1. TWS July 2011 Stimulation

2. TWS July 2011 The ARRA Stimulus Reimbursement from an ifa Customer Perspective

3. TWS July 2011 Stimulus Basics EP (Eligible Providers) must select either the Medicare OR Medicaid program Medicaid pays more ($63,750 vs. $44,000) ODs can only apply for the Medicare Program MDs can switch from selected program (Medicare/Medicaid) only once Must have 30% of services provided to Medicaid patients to qualify for Medicaid Program Note: EPs who work at multiple locations, but do not have EHR programs at all locations, must have 50% of their total patient encounters where EHR is available – meaningful use based on EHR location https://www.cms.gov/ehrincentiveprograms/

4. TWS July 2011 Who is eligible? Physicians, dentists, podiatrists, optometrists, and some chiropractors. Meaningful use year: 1/1/2011. Implementation of a small practice should ideally start no later than early 2011 to ensure meaningful use can be reported in the 2011 reporting year - as it takes time to train, install, and begin to demonstrate and report on 'meaningful use'. Payout Starts: Payments expected to begin May of 2011 according to final rules released July 13th, 2010.final rules Penalties/Deductions. Beginning in 2015 and accelerating in subsequent years, non- adopters who are not meaningfully using a Certified EHR, fee schedules will be reduced as follows: – 2015 - 1% Reduction – 2016 - 2% Reduction – 2017 - 3% Reduction – 2018 - 4% (Secretary of HHS Option if fewer than 75% of eligible professionals are not meaningfully using a certified EHR) – 2018 - 5% (Secretary of HHS Option if fewer than 75% of eligible professionals are not meaningfully using a certified EHR)

5. TWS July 2011 Who is eligible? Physicians, dentists, certified nurse mid-wife, nurse practitioners, and physician assistants practicing in a rural health clinic or Federally Qualified Health Clinic (FQHC). Eligible professionals cannot be hospital based, and patient volume must be comprised of at least 30% Medicaid patients. Meaningful use year: 1/1/2010. Implementation of an EHR for Medicaid providers should begin immediately. Payout Starts: Eleven states - Alaska, Iowa, Kentucky, Louisiana, Oklahoma, Michigan, Mississippi, North Carolina, South Carolina, and Tennessee opened registration on January 3rd, 2011 and four additional states (Texas, California, Missouri, and North Dakota) open in February 2011. The remaining states will roll out their Medicaid EMR incentive registration periods throughout spring and summer of 2011.

6. TWS July 2011 Payment Details MedicareMedicaidMedicareMedicaidMedicareMedicaidMedicareMedicaidMedicareMedicaid EHR Adopt. 2011 EHR Adopt. 2012 EHR Adopt. 2013 EHR Adopt. 2014 EHR Adopt. 2015 EHR Adopt. 2016 2011$$18,000 $21,250 2012$$12,000 $8,500 $18,000 $21,250 2013$$8,000 $8,500 $12,000 $8,500 $15,000 $21,250 2014$$4,000 $8,500 $8,000 $8,500 $12,000 $8,500 $12,000 $21,250 2015$$2,000 $8,500 $4,000 $8,500 $8,000 $8,500 $8,000 $8,500$21,250 2016$$0 $8,500 $2,000 $8,500 $4,000 $8,500 $4,000 $8,500 $21,250 2017$ $8,500 2018$ $8,500 2019$ $8,500 2020$ $8,500 2021$ $8,500 Total$44,000 $63,750 $44,000$63,750$39,000$63,750$24,000$63,750$0$63,750

7. TWS July 2011 Need User Id/Password: same as NPPES by provider, practice TIN #, IFA product # 30000002dnnlsaa, Medicare/Medicaid(not all states are ready)

8. TWS July 2011 Key dates for EHR incentives that have been released by the Centers for Medicare & Medicaid Services: Jan. 3, 2011 – Registration for the Medicare EHR incentive program begins. Jan. 3, 2011 –States that are ready (currently Alaska, Iowa, Kentucky, Louisiana, Oklahoma, Michigan, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) may launch their incentive programs for Medicaid providers. January 2011 – Some state agencies begin issuing Medicaid EHR incentive payments. April 2011 – Attestation for the Medicare EHR incentive program begins. May 2011 – Issuing of Medicare EHR incentive payments expected to begin. July 3, 2011 – Last day for eligible hospitals to begin their 90-day reporting period to demonstrate meaningful use for the Medicare EHR incentive program for federal FY 2011. Sept. 30, 2011 – Federal FY 2011 payment year ends at midnight for eligible hospitals and critical access hospitals (CAHs). Oct. 3, 2011 – Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 to demonstrate meaningful use for the Medicare EHR incentive program. Nov. 30, 2011 – Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for federal fiscal year 2011. Dec. 31, 2011 – Calendar 2011 payment year ends for eligible profession Dates

9. TWS July 2011 15 Core Measures 5 of 10 Menu items Public Health (Smoking, Disease) Medication Contraindications Electronic Billing Stimulus Basics

10. TWS July 2011 https://www.cms.gov/ehrincentiveprograms/ Core and Menu Set Measures Eligible Professional Core Measures (1) Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. (2) Implement drug-drug and drug-allergy interaction checks. (3) Maintain an up-to-date problem list of current and active diagnoses. (4) Generate and transmit permissible prescriptions electronically (eRx). (5) Maintain active medication list.

11. TWS July 2011 (6) Maintain active medication allergy list. (7) Record all of the following demographics: – (A) Preferred language, (B) Gender, (C) Race, (D) Ethnicity, (E) Date of birth (8) Record and chart changes in the following vital signs: – (A) Height, (B) Weight, (C) Blood pressure, (D) Calculate and display body mass index (BMI), (E) Plot and display growth charts for children 2–20 years, including BMI (9) Record smoking status for patients 13 years old or older. (10) Report ambulatory clinical quality measures to CMS or, in the case of Medicaid EPs, the States. Core and Menu Set Measures Eligible Professional Core Measures (continued)

12. TWS July 2011 https://www.cms.gov/ehrincentiveprograms/ Core and Menu Set Measures Eligible Professional Core Measures (Continued) (11) Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. (12) Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, medication allergies) upon request. (13) Provide clinical summaries for patients for each office visit. (14) Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically (15) Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

13. TWS July 2011 Menu Set (5 of 10) (1) Implement drug formulary checks. (2) Incorporate clinical lab-test results into EHR as structured data. (3) Generate patient lists by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. (4) Send patient reminders per patient preference for preventive/follow-up care. (5) Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP.

14. TWS July 2011 Menu Set (continued) (6) Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. (7) The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. (8) The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. (9) Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice. (10) Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.

15. TWS July 2011 Office Staff – Collect/record appropriate demographics Clinical Staff – eRx training – Enter patient medications, allergies, smoking status, diagnosis code Staff Training

16. TWS July 2011 Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Core Measure 1: CPOE

17. TWS July 2011 More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE DENOMINATOR: Number of unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period. NUMERATOR: The number of patients in the denominator that have at least one medication order entered using CPOE. EXCLUSION: EPs who write fewer than 100 prescriptions during the EHR reporting period would be excluded from this requirement. EPs must enter the number of prescriptions written during the EHR reporting period in the Exclusion box to attest to exclusion from this requirement. The resulting percentage (Numerator ÷ Denominator) must be more than 30 percent in order for an EP to meet this measure. Core Measure 1: CPOE

18. TWS July 2011 Compliance and Tracking Computerized Provider Order Entry (CPOE) stimulus compliance tracking is represented by item 6 on the Stimulus Statistics Dashboard. Compliance is achieved through the processes outlined in the eRx document (HT-0060).

19. TWS July 2011 Implement drug-drug and drug-allergy interaction checks. The EP has enabled this functionality for the entire EHR reporting period. No exclusion. Core Measure 2: Drug Contraindications

20. TWS July 2011 Compliance and Tracking Drug-drug and drug-allergy checking is automatic in the ifa eRx module. The criteria for tracking this requirement is met by recording active medication allergies in ifa. Compliance is documented in area three of the Stimulus Statistics Dashboard. It is achieved through the processes outlined in the eRx document (HT-0060). Core Measure 2: Drug Contraindications

21. TWS July 2011 Attestation Requirements YES / NO Eligible professionals (EPs) must attest YES to having enabled drug-drug and drug-allergy interaction checks for the length of the reporting period to meet this measure. Core Measure 2: Drug Contraindications

22. TWS July 2011 Core Measure 3: Problem List Objective Maintain an up-to-date problem list of current and active diagnoses. Measure More than 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data. ExclusionNo exclusion.

23. TWS July 2011 Compliance and Tracking Compliance is achieved through standard ifa data entry processes (ICD Diagnosis). Compliance is documented in area one of the Stimulus Statistics Dashboard Core Measure 3: Problem List

24. TWS July 2011 Attestation Requirements NUMERATOR / DENOMINATOR DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who have at least one entry or an indication that no problems are known for the patient recorded as structured data in their problem list. The resulting percentage (Numerator ÷ Denominator) must be more than 80 percent in order for an EP to meet this measure. Core Measure 3: Problem List

25. TWS July 2011 Generate and transmit permissible prescriptions electronically (eRx). Threshold: 40% Denominator: All permissible prescriptions Numerator:Number prescribed electronically Core Measure 4: eRx

26. TWS July 2011 Compliance and Tracking Electronic prescription stimulus compliance tracking is represented by item 14 on the Stimulus Statistics Dashboard. Compliance is achieved through the processes outlined in the eRx document (HT-0060). Core Measure 4: eRx

27. TWS July 2011 Objective: Maintain active medication list. Measure: More than 80 percent of all unique patients seen by the EP have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data. Exclusion: No exclusion. Core Measure 5: Active Medication List

28. TWS July 2011 Maintaining a patient’s active medication list is achieved through standard data entry procedures in ifa (History Complete). This data can be populated in the Medications, Systemic Medications or Eye Medications areas. Compliance is documented in area two of the Stimulus Statistics Dashboard Core Measure 5: Active Medication List

29. TWS July 2011 Attestation Requirements NUMERATOR / DENOMINATOR DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who have a medication (or an indication that the patient is not currently prescribed any medication) recorded as structured data. The resulting percentage (Numerator ÷ Denominator) must be more than 80 percent in order for an EP to meet this measure. Core Measure 5: Active Medication List

30. TWS July 2011 Objective: Maintain active medication allergy list. Measure: More than 80 percent of all unique patients seen by the EP have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data. Exclusion: No exclusion. Core Measure 6: Medication Allergies

31. TWS July 2011 Compliance Tracking The criteria for tracking this requirement is met by recording active medication allergies in ifa. Compliance can be tracked by monitoring item 3 in the Stimulus Dashboard. Compliance is achieved either through the processes outlined in the eRx document (HT-0060) or by entering medication allergy data in the patient record. Core Measure 6: Medication Allergies

32. TWS July 2011 Attestation Requirements NUMERATOR / DENOMINATOR DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: Number of unique patients in the denominator who have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data in their medication allergy list. The resulting percentage (Numerator ÷ Denominator) must be more than 80 percent in order for an EP to meet this measure Core Measure 6: Medication Allergies

33. TWS July 2011 Core Measure 7: Demographics. 1.Preferred lang. 2.Gender 3.Race 4.Ethnicity 5.Date of birth

34. TWS July 2011 Compliance is achieved by entering data in the requisite fields in the demographics area. Core Measure 7: Demographics Compliance can be tracked by monitoring item 4 in the Stimulus Dashboard.

35. TWS July 2011 Attestation Requirements DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who have all the elements of demographics (or a specific exclusion if the patient declined to provide one or more elements or if recording an element is contrary to state law) recorded as structured data. The resulting percentage (Numerator ÷ Denominator) must be more than 50 percent in order for an EP to meet this measure. Core Measure 7: Demographics

36. TWS July 2011 Objective Record and chart changes in the following vital signs: (A) Height (B) Weight (C) Blood pressure (D) Calculate and display body mass index (BMI) (E) Plot and display growth charts for children 2-20 years, including BMI Measure For more than 50 percent of all unique patients age 2 and over seen by the EP, height, weight, and blood pressure are recorded as structured data. ExclusionAny EP who either see no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice. Core Measure 8: Vital Signs

37. TWS July 2011 Vital signs can be entered in the Special Exam section of ifa. BMI is calculated automatically and displayed in the top right window. Growth charts and patient graphs can be viewed by using the associated buttons in the Admin Data section. Compliance is documented in area seven of the Stimulus Statistics Dashboard. Core Measure 8: Vital Signs

38. TWS July 2011 Attestation Requirements DENOMINATOR: Number of unique patients age 2 or over seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who have at least one entry of their height, weight and blood pressure are recorded as structured data. EXCLUSION: An EP who sees no patients 2 years or older would be excluded from this requirement. Additionally, an EP who believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice would be excluded from this requirement. EPs must select NO next to the appropriate exclusion, then click the APPLY button in order to attest to the exclusion. The resulting percentage (Numerator ÷ Denominator) must be more than 50 percent in order for an EP to meet this measure. Core Measure 8: Vital Signs

39. TWS July 2011 Core Measure 9: Smoking Status ObjectiveRecord smoking status for patients 13 years old or older. Measure More than 50 percent of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data. ExclusionAny EP who sees no patients 13 years or older.

40. TWS July 2011 Stimulus Tracking and Compliance Compliance is achieved through entering smoking status in ifa in the Demographics area or in Social History. Compliance can be tracked by monitoring item 8 in the Stimulus Dashboard. Core Measure 9: Smoking Status

41. TWS July 2011 Attestation Requirements NUMERATOR / DENOMINATOR / EXCLUSION DENOMINATOR: Number of unique patients age 13 or older seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator with smoking status recorded as structured data. EXCLUSION: An EP who sees no patients 13 years or older would be excluded from this requirement. EPs must enter ‘0’ in the Exclusion box to attest to exclusion from this requirement. The resulting percentage (Numerator ÷ Denominator) must be more than 50 percent in order for an EP to meet this measure. Core Measure 9: Smoking Status

42. TWS July 2011 Objective: Report ambulatory clinical quality measures to CMS. Measure: Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS. Exclusion: No exclusion. Core Measure 10: CQM

43. TWS July 2011 Attestation Requirements YES / NO Eligible professionals (EPs) must attest YES to reporting to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS to meet the measure. Core Measure 10: CQM

44. TWS July 2011 Objective: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. Measure: Implement one clinical decision support rule. Exclusion: No exclusion. Core Measure 11: CDS

45. TWS July 2011 Attestation Requirements YES / NO Eligible professionals (EPs) must attest YES to having implemented one clinical decision support rule for the length of the reporting period to meet the measure. Core Measure 11: CDS

46. TWS July 2011 Core Measure 12: Electronic Copy Objective Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request. Measure More than 50 percent of all patients who request an electronic copy of their health information are provided it within 3 business days. ExclusionAny EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period.

47. TWS July 2011 Compliance is achieved by using the ECPP module. Compliance can be tracked by monitoring item 10 in the Stimulus Dashboard. Core Measure 12: Electronic Copy

48. TWS July 2011 Attestation Requirements DENOMINATOR: Number of patients of the EP who request an electronic copy of their electronic health information four business days prior to the end of the EHR reporting period. NUMERATOR: Number of patients in the denominator who receive an electronic copy of their electronic health information within three business days. EXCLUSION: An EP who has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period would be excluded from this requirement. EPs must enter ‘0’ in the Exclusion box to attest to exclusion from this requirement. The resulting percentage (Numerator ÷ Denominator) must be more than 50 percent in order for an EP to meet this measure. Core Measure 12: Electronic Copy

49. TWS July 2011 Core Measure 13: Clinical Summaries Objective: Provide clinical summaries for patients for each office visit. Measure: Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days. Exclusion:Any EP who has no office visits during the EHR reporting period.

50. TWS July 2011 Compliance can be achieved through the use of the Eye Care Patient Portal or through Clinical Summaries button when a paper copy is provided. Compliance can be tracked by monitoring item 15 on the Stimulus Dashboard. Core Measure 13: Clinical Summaries

51. TWS July 2011 Attestation Requirements DENOMINATOR: Number of unique patients seen by the EP for an office visit during the EHR reporting period. NUMERATOR: Number of patients in the denominator who are provided a clinical summary of their visit within three business days. EXCLUSION: EPs who have no office visits during the EHR reporting period would be excluded from this requirement. EPs must enter ‘0’ in the Exclusion box to attest to exclusion from this requirement. The resulting percentage (Numerator ÷ Denominator) must be more than 50 percent in order for an EP to meet this measure. Core Measure 13: Clinical Summaries

52. TWS July 2011 Core Measure 14: Exchange Clinical Information Objective: Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results), among providers of care and patient authorized entities electronically. Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information. Exclusion: No exclusion.

53. TWS July 2011 Attestation Requirements YES / NO Eligible professionals (EPs) must attest YES to having performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information during the EHR reporting period to meet this measure. Core Measure 14: Exchange Clinical Information

54. TWS July 2011 Objective: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process. Exclusion: No exclusion. Core Measure 15: Protect Electronic Health Information

55. TWS July 2011 Attestation Requirements YES / NO Eligible professionals (EPs) must attest YES to having conducted or reviewed a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implemented security updates as necessary and corrected identified security deficiencies prior to or during the EHR reporting period to meet this measure. Core Measure 15: Protect Electronic Health Information