The NC Medicaid EHR Incentive Program

1. The NC Medicaid EHR Incentive Program Presented by: Rachael Williams, Program Manager Layne Roberts, Data Specialist

3. The Basics… Eligible Provider Type? Certified EHR Technology? Medicaid Patient Volume Threshold? EPs – 30%* EHs – 10% *Exception for Peds & FQHC/RHCs

5. Statewide

6. The first milestone on this journey is AIU.

7. Meaningful Use is the goal. AIU

8. Nation’s Conceptual Approach to MU Stage 3: Improved Outcomes 2016 Stage 2: Advanced Clinical Processes 2014 Stage 1: Data capture and sharing 2012

10. Medicare Penalties • Medicare EPs who are not meaningful users will be subject to a payment adjustment beginning on January 1, 2015 • The payment adjustment is 1% per year and is cumulative for every year that an EP is not a meaningful user. • Medicare EPs must demonstrate meaningful use prior to the 2015 calendar year in order to avoid the adjustments. More information can be found here: www.cms.gov/Regulations-and-guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetforEP.pdf

12. Meeting Stage 1 MU (for EPs/EHs) 13 Core Measures 5 Menu Measures 6 CQMs Meaningful Use NOTE: EHs will submit their MU data to CMS prior to attesting on the NC Medicaid Incentive Payment System (NC-MIPS). EPs will submit MU data directly through NC-MIPS. 5

13. For EPs 15 for EHs Report on ALL core measures or Report exclusions where the measure doesn’t pertain to your practice

14. Report on 5 out of 10 menu measures and One of the 5 must be a public health measure … Once DPH allows electronic submission of data 5 public health

15. EP CQM Formula 3 Core CQMs (report even if zero) 3 Additional CQMs (choose 3 out of 38) 0 to 3 Alternate CQMs (1 for every core zero, if applicable) 6 to 9CQMs EHs need to attest to all 15 CQMs 15

16. Stage 1 Changes – Patient Volume • Medicaid-enrolled, regardless of payment liability • Can now include Medicaid expansion programs funded by Title 21 funds (MCHIP) • More flexibility for the 90-day PV reporting period • More flexibility for the six-month PV reporting period for practicing predominantly

17. Stage 1 Changes - Measures • Two core measures are no longer required • Reporting CQMs • Exchanging key clinical information • Three core measures were changed to give providers more flexibility in demonstrating MU: • CPOE • eRx • Vital Signs

18. Here’s the numbers… • Sweet data slides.

19. Paid Providers 3,118 EPs $69,253,792 74 EHs $66,567,879 Eligible professionals (EPs) Eligible hospitals (EHs) $135,821,671

20. Paid Providers 3,118 EPs 74 EHs

21. Paid Providers In Towns & Cities with Populations of under 50,000 EPs EHs

22. Paid Providers In Towns & Cities with Populations of 50,000+ EPs EHs

23. Paid EHs

24. Paid EPs

25. Payments to EPs for AIU & MU # of payments

26. Payments to EHs for AIU & MU

27. Number of Days Between AIU and MU Payments Mean = 399 days Mean = 392 days EHs EPs

28. mu data

32. Meeting Stage 2 MU Stage 2 MU for EPs 16 Core Measures 3 Menu Measures 17 Core Measures 3 Menu Measures 16 of 29 CQMs 9 of 68 CQMs MU! MU! Stage 2 MU for EHs 5

33. EPs/EHs select CQMs from at least three of these six domains: 1. Patient and Family Engagement 2. Patient Safety 3. Care Coordination 4. Population and Public Health 5. Efficient Use of Healthcare Resources 6. Clinical Processes/Effectiveness -EPs are required to electronically submit this information to the state from their EHRs through the state-designated NC HIE. -EHs will submit their CQMs to CMS.

34. Stage 2 Core Measures

35. Stage 2 Menu Measures EPs: EHs:

36. New Stage 2 Core Objectives For EPs Only For EHs Only Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR) Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge from the hospital • Use secure electronic messaging to communicate with patients on relevant health information • Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP

37. Emphasis on HIE • For more than 10% of transitions and referrals, EPs, eligible hospitals, and CAHs that transition or refer their patient to another setting of care or provider of care must provide a summary of care record electronically. • The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care must either a) conduct one or more successful electronic exchanges of a summary of care record with a recipient using technology that was designed by a different EHR developer than the sender's, or b) conduct one or more successful tests with the CMS-designated test EHR during the EHR reporting period.

38. Public Health • Required Core Measures: • NCIR • Electronic lab reporting • Optional Menu Measures: • Syndromic Surveillance • Cancer Registry • Other disease registries

39. NC Medicaid’s Preparation for MU • Stage 1 MU • NC-Medicaid Incentive Payment System (NC-MIPS) • Manual key-in of aggregate data • Stage 2 MU • NC HIE as conduit for exchange and electronically reporting: • Immunizations; • Reportable labs; • Patient information to cancer and disease registries; and, • Clinical quality measures (Quality Reporting Document Architecture I/III)

40. FAQs for Stage 2 • What happens if I switch systems during my MU reporting period? • How do I onboard new providers? • For the Stage 2 Toolkit, visit www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

41. From CMS’ FAQs: For meaningful use Stage 2's transitions of care and referrals objective, in what ways can I meet the second measure that requires more than 10% of the summary care records I provide for transitions of care and referrals to be electronically transmitted? An EP, eligible hospital, or CAH could use 3 distinct approaches (which could also be used in combination) to meet this measure.  The first two rely solely on the use of CEHRT, while the third is slightly different. • For the first two approaches, this measure can only be met if the EP, eligible hospital, or CAH uses the capabilities and standards included as part of its Certified EHR Technology (CEHRT) to electronically transmit summary care records for transitions of care and referrals  (specifically those capabilities certified to the certification criterion adopted by ONC at 45 CFR 170.314(b)(2) “transitions of care – create and transmit transition of care/referral summaries,” which specifies standards for data content and transport).  • For the third approach, the EP, eligible hospital, or CAH must use its CEHRT to create a summary care record for transitions of care and referrals, but instead of using a transport standard specified in ONC’s certification criterion at 45 CFR 170.314(b)(2) (included as part of its CEHRT) to electronically transmit the summary care record, the EP, eligible hospital, or CAH may use a NwHIN Exchange participant to facilitate the electronic transmission to the recipient. 

42. From CMS’ FAQs: If multiple eligible professionals or eligible hospitals contribute information to a shared portal or to a patient's online personal health record (PHR), how is it counted for meaningful use when the patient accesses the information on the portal or PHR? This answer is relevant to the following meaningful use measure: For Eligible Professionals: If an eligible professional sees a patient during the EHR reporting period, the eligible professional may count the patient in the numerator for this measure if the patient (or an authorized representative) views online, downloads, or transmits to a third party any of the health information from the shared portal or online PHR.  For Eligible Hospitals and Critical Access Hospitals:The same would apply for an eligible hospital or CAH if a patient is discharged during the EHR reporting period. The respective eligible professional, eligible hospital, or CAH must have contributed at least some of the information identified in the Stage 2 final rule to the shared portal or online PHR for the patient.  However, the respective provider need not have contributed the particular information that was viewed, downloaded, or transmitted by the patient. Although availability varies by state and geographic location, some Health Information Exchanges (HIEs) provide shared portal or PHR services. If a provider uses an HIE for these services to make information available to patients, in order to meet meaningful use requirements the provider must use an HIE that is certified as an EHR Module for that purpose.  The HIE must be able to verify whether a particular provider actually contributed some of the information identified in the Stage 2 final rule to the shared portal or PHR for a particular patient. If a provider elects to use the HIE for these shared portal or PHR services, the provider must include the HIE’s certification number as part of their attestation.

43. Attesting for Program Year 2014 • All program participants are granted a one-time 90-day MU reporting period in 2014 to allow time to upgrade to the new 2014 certification standards • Visit ONC’s Health IT Product List to see if your certified EHR technology is compliant with the 2014 certification standards • Look for the ‘14E’ • Update the CEHRT number on CMS’ R&A Portal

44. Register your intent with DPH within 60 days of starting your 2014 MU reporting period • For EHs, Medicare sets your attestation schedule for more information regarding attestation schedules, see the next slides. • Keep all documentation for at least six years post-payment in case of audit • Visit our website at http://www.ncdhhs.gov/dma/provider/ehr.htm

45. Remember… Attest early!

46. Examples of Attestation ScenariosScenario 1: EH attests with Medicaid 1st and then attests with Medicare in 2012. For Medicaid Participation: Attest to AIU the first payment year, then attest to 365 days of MU for each of the following payment years (payment years 2 and 3). Further explanation: If the EH attests with Medicaid first in 2012 and would like to attest with Medicare in the same year, the EH will attest to AIU during its first payment year in the NC Medicaid EHR Incentive Program, and will then attest to 90 days of MU with Medicare. Because Medicare requires an EH to attest to 90 days of MU during its first payment year, when the EH comes back to attest with Medicaid (in payment years 2 and 3), it will be attesting to 365 days of MU for both Medicaid & Medicare. The EH will NOT attest to 90 days of MU with Medicaid, but will skip from AIU to 365 MU. **Note that 2014 is a 3-month reporting period for all hospitals to allow for system upgrades.

47. Examples of Attestation ScenariosScenario 2: EH attested with Medicaid in 2011 and then attests with Medicare for the first time in 2012. For Medicaid Participation: Attest to AIU in the first payment year, attest to 90 days of MU in the second payment year, and attest to 365 days of MU in the third payment year. Further Explanation: If the EH attested with Medicaid in 2011 and waits until 2012 to attest with Medicare, it attested to AIU for its first payment year with the NC Medicaid EHR Incentive Program. When the EH comes back to attest for its second payment year with Medicaid in 2012, it will attest to 90 days of MU. When the EH comes back to attest for its third year with Medicaid, it will attest to 365 days of MU. **Note that 2014 is a 3-month reporting period for all hospitals to allow for system upgrades.

48. Examples of Attestation ScenariosScenario 3: EH attests with Medicare 1st and then attests with Medicaid in 2012. For Medicaid Participation: Attest to 90 days of MU for the first payment year, then attest to 365 days of MU for each of the following payment years (payment years 2 and 3). The EH will attest to Medicare first each year. Further explanation: If the EH first attested with Medicare, and would like to attest with Medicaid in the same year, the EH will follow the Medicare reporting requirements when attesting with Medicaid. This means, if the EH reported 90 days of MU with Medicare in 2012, it will report 90 days of MU in 2012 with Medicaid as well – even if 2012 is its first payment year with the Medicaid EHR Incentive Program. Furthermore, after its first year of participation, the EH will attest to 365 days of MU for every additional year it participates with Medicaid (payment years 2 and 3). If the EH attests with Medicare first, the EH will NOT attest to AIU for the Medicaid program. **Note that 2014 is a 3-month reporting period for all hospitals to allow for system upgrades.

49. Examples of Attestation ScenariosScenario 4: EH attested with Medicare in 2011 and wishes to attest with Medicaid for the first time in 2012. For Medicaid Participation: Attest to 365 days of MU for the first payment year and beyond (payment years 1, 2, and 3). Further Explanation: If the EH successfully attested with Medicare in 2011 and waits until 2012 to attest with Medicaid for the first time, it will be required to attest to 365 days of MU with Medicaid, in keeping with the consecutive attestation schedule with Medicare. If the EH attests with Medicaid a year after attesting with Medicare, it will NOT attest to AIU or 90 days MU with Medicaid. Instead, it will attest to 365 days of MU for every year of its participation in the Medicaid Incentive Program (payment years 1, 2, and 3). **Note that 2014 is a 3-month reporting period for all hospitals to allow for system upgrades.