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Meaningful Use - Modified Stage 2

Modified Stage 2, which was first introduced in a Proposed Rule by CMS in April 2015 and was finalized October 6, 2015, changes the structure of objectives and measures for Meaningful Use for 2015-2018.

Only providers attesting to MEDICAID will be doing Meaningful Use in 2017 and beyond. For those providers who have previously attested to MEDICARE for Meaningful Use and/or PQRS, these programs have been replaced by the new Quality Payment Program.

Highlights of Modified Stage 2-
- A 90 day reporting period in 2015, 2016, 2017, and 2018. This is any consecutive 90 days within the calendar year, and providers are not "locked in" to attesting to a fiscal quarter. 

-There are only 10 objectives of Modified Stage 2 of Meaningful Use, each of which are detailed in their own section below. 

This guide will walk you through each of the measures required for Modified Stage 2 of Meaningful Use including what is required, any corresponding Measure Calculation report in MacPractice, any available exclusions, and each of the options within MacPractice for recording the necessary information.

Contact MacPractice Support if you wish to attest to Meaningful Use so that we may enable the appropriate Abilities.

Required Abilities

*EMR/EHR Ability (Only way to record all structured data for Meaningful Use)

*PHI Portal set up (Objectives 8 and 9)

*Comprehensive ePrescribe (Objectives 2 and 4)

*Lab Requisition - either integration with an outside Lab company that sends structured data or the Other Labs ability (Required for structured data needed for certification)

Secure Direct Messaging address configured and vetted

*These are purchased abilities.

Actions outside of MacPractice

Security Risk Analysis (Objective 1)

Contact with a local Immunization Registry (Objective 10)

Contact with a local Public Health Agency (Objective 10)

External Resources
Modified Stage 2 Attestation Worksheet (via CMS)

Specification Sheets

Attestation Worksheet

Security Risk Analysis Tip Sheet

Patient Electronic Access Tip Sheet

Guide for Eligible Professionals Practicing in Multiple Locations

CMS EHR Incentive Programs website

Configuration
Configure each provider that will attest to Meaningful Use.

In the User Reference for the provider, check the "Is CPOE" checkbox, and enter a Start Date. This date should be when the user became a licensed healthcare professional. (Other users that are licensed healthcare professionals can also be set up as a CPOE user, which you will want to do if they are ever ordering prescriptions, lab tests, or radiology and imaging tests.) Select the year the provider started attesting to Meaningful Use. This will allow you to correctly configure additional information in the Reports ability.

Also set the First Year Attesting to the first year that this provider successfully attested to Meaningful Use. This will allow you to set up the next set of adjustments with the proper exclusions and supplemental information.


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In the Reports ability, select the "Measure Calculation Adjustments" folder in the sidebar. Use this to add in supplemental information not otherwise entered into MacPractice, note the exclusions a provider plans to claim on specific measures for the reporting period, and choose the federal and state holidays on which the provider and office staff are not available.

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Objective 1 - Protect Patient Health Information

Objective

Protect electronic protected health information (ePHI) created or maintained by the CEHRT through the implementation of appropriate technical capabilities.

Measure

Conduct or review a security risk analysis in accordance with the requirements in 45CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI created or maintained by CEHRT in accordance with requirements under 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP's risk management process.

Exclusions
None

MacPractice Report
There is no Measure Calculation report in MacPractice for this measure. Attesting to this is a simple yes/no answer that requires a "yes" to be considered accepted.

How
This measure is not recorded in MacPractice. When attesting to this measure, it is a simple yes/no question (which must be answered with a "yes" to submit a successful and accepted attestation). MacPractice highly recommends hiring an outside IT or security company to perform a security risk analysis for your office that provides a report of this analysis. This analysis should include things outside of your MacPractice software such as network and building security. For this reason, this is not something that MacPractice can assist with.

It is important to note that in audits that MacPractice has assisted with, this is the most common reason we have seen for failed audits. In the event your office does get audited, you must furnish proof of a Security Risk Analysis in the form of a report. For more information on what is accepted for a Security Risk Analysis, we suggest contacting CMS with any questions you may have, as we are unable to assist with this requirement in any way.

Additional Resources
The Office of the National Coordinator for Health Information Technology (ONC), HHS Office for Civil Rights (OCR), and HHS Office of General Counsel (OCG) have collaborated to create a number of tools, guides, and additional resources for security risk assessment:

Doing A Proper Risk Analysis video with Healthcare Scene

Security Risk Assessment Tool and Video on healthit.gov

Template for a Do It Yourself Security Risk Analysis

- meaningfuluseexperts.com

- hipaasecurenow.com

- hipaaone.com 


Objective 2- Clinical Decision Support

Objective

Use clinical decision support to improve performance on high-priority health conditions.

Measure

- Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point of patient care for the entire reporting period. If not related to clinical quality measures, the clinical decision support interventions must be related to high-priority health conditions

- Measure 2: Implement the functionality for drug-drug and drug-allergy interaction checks for the entire reporting period.

Exclusions
There are no exclusions for the first measure. For the second measure, a provider who writes fewer than 100 medication orders during the reporting period is excluded.

 

MacPractice Report

There is no MacPractice report for this measure. If both measures are implemented, the provider will simply attest "yes" to these.

How
- For the first measure, clinical decision support interventions can be created and enabled in References> Clinical Decision Rule.

- For the second measure, The use of Comprehensive ePrescribe is what allows a user to enable drug-drug and drug-allergy interaction checks in MacPractice. This must be purchased and the checks must be enabled through your entire reporting period to answer "yes" in your attestation.

Objective 3- Computerized Provider Order Entry (CPOE)

Objective

Use computerized provider order entry for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.

Measure 1

More than 60 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry.

Measure 2

More than 30 percent of laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry.

Measure 3

More than 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using computerized provider order entry.

Exclusions

Measure 1: Any EP who writes fewer than 100 medication orders during the EHR reporting period.

Measure 2: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period.

Measure 3: Any EP who writes fewer than 100 radiology orders during the EHR reporting period.

MacPractice Report

CPOE Measure

How
The most important factor in meeting this measure is to mark your MacPractice users as CPOE. To do this, go to the References ability and select Users in the sidebar and check Is CPOE, then enter the start and end dates. Because this report is based off of the user being a CPOE, MacPractice highly recommends that each person in your office has their own login user. It will not be acceptable to mark users such as Front Desk, Room 1, Room 2, Server, etc. as CPOE users, because the software has no way of knowing which person (CPOE or not) is logged into that computer.

The Start Date can be as far back as the day the user became a licensed healthcare professional. If you have any questions on whether a user should legally be marked as CPOE, CMS has created an FAQ over this topic.

Once a user is marked as CPOE, prescriptions, labs orders, and radiology/imaging orders entered by that user will increase your percentages in the CPOE Measure report.

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For Medication orders 
-

Denominator: All prescriptions entered in the ePrescribe ability (or manually in the Current Medications folder in the Rx ability with an Ordered date added) within the filtered date range with medication orders entered.

Numerator: Any medication order that was entered into MacPractice as the First Record of Order by a user that is marked as CPOE (with a start date before the date of the medication entry).

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For Laboratory and Radiology/Imaging orders 
-

Denominator: The number of orders of the types Laboratory and Radiology/Imaging respectively.

Numerator: Orders created by a CPOE user (with a CPOE start date before the Ordered Date). The "First record of order" box must be checked on the orders themselves, which should happen by default when the orders are created.

Work flow for offices with Lab Interfaces that import test results
Offices that have an interface (with Quest, Shiel, LabCorp, a local hospital, or any other outside laboratory) for their Laboratory test results to automatically import into MacPractice still must create an order in MacPractice for the CPOE measure requirements. These orders are essentially a placeholder order, created by a CPOE user, that waits with a status of "Pending Results". Once the lab tests come back and are brought into MacPractice from the import folder for your interface, the results will tie themselves to the open order, changing the order status to "Results Available".

Objective 4 - Electronic Prescribing

Objective

Generate and transmit permissible prescriptions electronically (eRx).

Measure

More than 50 percent of all permissible prescriptions, or all prescriptions, written by the provider are queried for a drug formulary and transmitted electronically using CEHRT.

Exclusions
- Any provider who writes fewer than 100 permissible prescriptions during the EHR reporting period

- Any provider who does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the provider's practice location at the start of his/her EHR reporting period.

MacPractice Report
Electronic Prescribing Measure

How
The use of ePrescribe in MacPractice will help you record and send these prescriptions as required.

Denominator: All prescriptions written by the provider that meet one of the following conditions: a) Destination type is Electronic Retail or Electronic Mail Order and the DEA Schedule is None b) Destination type is Print and the DEA Schedule is None c) Destination type is Print, Fax or None and the pharmacy type is Electronic.

Numerator: Total prescriptions with the destination type of Electronic Retail or Electronic Mail Order.

There are two reporting options for Modified Stage 2. Providers will choose to attest with numbers from either report, and are not required nor permitted to submit both. The first report will only count permissible prescriptions. The second report counts controlled substances in the denominator. Even if you prescribe controlled substances, you are still allowed to attest with numbers from the first report that does not include them.

Objective 5 - Health Information Exchange

Objective

The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral.

Measure

The EP that transitions or refers their patient to another setting of care or provider of care must (1) use CEHRT to create a summary of care record; and (2) electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals.

Exclusions

Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period.

MacPractice Report

Summary of Care Measure

How

Denominator: All instances of a referral of the type Transition To. This means that if you multiple Transition To referrals on the same patient, they will appear multiple times in the denominator.

Numerator: A Summary of Care document (CDA) must be made available for the referral electronically via a direct address. This can be done either on the Clinical tab in the Patient ability or in EHR. You must first select the incident itself that you wish to export and then either export it to an existing referral for the patient or add a new referral to the patient at that time.

Exported from the Clinical Tab
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Exported from EHR

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A patient will be added to the numerator of the report only if you transmit the summary to another provider's secure direct address. Summaries that are just printed out will NOT count towards the numerator.

If you have difficulties finding providers that you refer your patients to who have secure direct addresses to send summaries to, CMS has posted this FAQ regarding this situation. They allow the summaries to be sent to a third party. MacPractice has no further information on this since it's outside of our software, so we recommend contacting CMS for questions regarding these third parties. (CMS can be reached at 888-734-6433.)

Objective 6 - Patient Specific Education

Objective

Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient.

Measure

Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period.

Exclusions

Any EP who has no office visits during the EHR reporting period.

MacPractice Report

Patient Education Measure

How

Denominator: All unique patients seen within the filtered date range.

Numerator: The patient must have a Patient Education added to their account within the same year as your reporting period.

Patient Education records can be added to a patient in two ways. The first involves creating custom Patient Education Resources in References. Once the Patient Education Resources are created, they can be added to any patient who meets all of the qualifications on their Clinical tab in the Patients ability or in an EHR form.

In the Clinical Tab

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In an EHR Form

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In addition to creating Patient Education Resources in References, MacPractice has added an InfoButton Standard to Allergies, Problems, Medications, and Labs on a patient's clinical tab and EHR summary. The use of this will also count as providing the education to the patient. Remember to check the "Gave Resource to Patient" button at the bottom of the window to add the education to the patient's account.

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Objective 7- Medication Reconciliation

Objective

The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant performs medication reconciliation.

Measure

The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP.

Exclusions

Any EP who was not the recipient of any transitions of care during the EHR reporting period.

MacPractice Report

Medication Reconciliation Measure

How

Denominator: Patient must meet one of the following conditions to be included in the report:

A) An incident with the First Encounter box checked, which also must include an office visit code.
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B) Electronic receipt of a transition of care document to your office from another office using an EHR capable of sending these. The document must then be tied to an incident, and that incident's ledger must also include an office visit code.

C) A patient coming into your office with a list of their current medications, which will then need to be entered in as a list to reconcile. (For this case, the act of entering in a list to reconcile and reconciling will add the patient to the denominator and numerator at the same time.)

Numerator: You must perform a medication reconciliation in EHR or EMR. You must be sure to go through the Reconcile process, and not just add Medications manually or check the No Medications checkbox.

In EHR

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In EMR

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Objective 8- Patient Electronic Access

Objective

Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP.

Measure 1

More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information.

Measure 2

For an EHR reporting period in 2017, more than 5 percent of unique patients seen by the EP during the EHR reporting period (or his or her authorized representatives) view, download or transmit to a third party their health information during the EHR reporting period.

Exclusions (Measure 2 only)

Any EP who neither orders nor creates any of the information listed for inclusion as part of the measures; or conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period.

MacPractice Report

View, Download, Transmit

How
Both measures will require the use of the Patient Portal set up for your MacPractice database. Without the Patient Portal on your MacPractice account, the act of exporting the summaries will not count.

Denominator: All unique patients seen within the filtered date range.

Numerator:

Measure 1: For measure 1, a patient is added to the numerator if the office exports a clinical summary to that patient via the patient portal within 4 days of their office visit procedure date, as well as within 4 days of any change or addition to any clinical information on the patient's file.

***A New clinical summary must be exported to the portal within 4 business days each time any change or addition to clinical information on a patient is made. This is not limited to office visits and can include things like adding an allergy, filling a prescription, changing an address, and so on. If you miss exporting the summary within 4 business days of any change, that patient will remain in your denominator and there will be no way to ever get them back into the numerator for that reporting period.***

The export of this summary can be done in several areas of MacPractice. If you would like to do it as part of billing, there is a simple checkbox that will prompt you to export the summary when you create an insurance claim.

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With this box checked, you will get a second prompt after your claim printing window. From here, you can export to the portal and opt weather to physically print the summary as well.

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You can also export summaries from the Clinical tab in the Patients ability. Select the incident that contains the office visit code in the ledger, then select To Patient from the Export Incident menu in the upper right corner of the Clinical screen. This will bring up the same clinical summary preview window shown above, where you can export and print the summary.

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Finally, summaries can be created and exported in the EHR ability. Select the incident that includes the office visit code, then select To Patient from the Export Incident menu. You will see the prompt to export and print the summary.

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The next step is vital and necessary regardless of how the clinical summary is exported. You must set up the patient with Portal Access in the Patient tab AND save them with the "Relationship to Patient" set as "Self". This must be done prior to or within four business days following the office visit or change to clinical information. If you are just exporting without setting up an actual Portal User for your patients, you are not really providing electronic access. This will require a work flow change for many offices, as this measure is time sensitive and you will not be able to go back and increase your percentage if this report does not meet the required 50% at the end of your attestation period. MacPractice highly recommends running this report at least twice a week to monitor and watch for changes in your numbers. Doing so will allow you to 'catch' the patients that are removed from the numerator and allow you enough time to export them an updated summary within 4 days of your changes.

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Measure 2: The patient (or their authorized representative) must log into the Patient Portal with the username and password created by the office and either view, download, or transmit their clinical summary. 

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Objective 9- Secure Messaging

Objective

Use secure electronic messaging to communicate with patients on relevant health information.

Measure

For an EHR reporting period in 2017, for more than 5 percent of unique patients seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the EHR reporting period.

Exclusion

Any EP who has no office visits during the EHR reporting period; or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period.

MacPractice Report

Secure Electronic Messaging Measure

How
This measure requires the setup and use of the Patient Portal.

Denominator: All unique patients that were seen within the filtered date range.

Numerator: A patient will be added to the numerator if they or their authorized representative receive a message from a provider user.

Patients can be set up with a Patient Portal User on the Portal Access tab. Once this is set up, providers will be able to search by their name or portal username within the Messaging ability to send them a secure message.
NOTE: The message that the patient or their authorized representative receives from the office MUST be sent by a user in MacPractice that is a provider. Messages sent from front desk staff, billing staff, etc. do not count towards the numerator of this report.

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Objective 10 - Public Health and Clinical Data Registry

Objective

The EP is in active engagement with a public health agency to submit electronic public health data from CEHRT except where prohibited and in accordance with applicable law and practice.

Measure 1 - Immunization Registry Reporting

The EP is in active engagement* with a public health agency to submit immunization data.

Measure 2- Syndromic Surveillance Reporting
The EP is in active engagement* with a public health agency to submit syndromic surveillance data.


Measure 3 - Specialized Registry Reporting
The EP is in active engagement* to submit data to a specialized registry.

Exclusions

Measure 1: Any EP meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP- 

- Does not administer any immunizations to any of the populations for which data is collected by their jurisdiction’s immunization registry or immunization information system during the EHR reporting period;

- Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or

- Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the EHR reporting period

Measure 2: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP- 

- Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system;

- Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or

- Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs as of 6 months prior to the start of the EHR reporting period.

Measure 3: Any EP meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the EP-

- Does not diagnose or treat any disease or condition associated with, or collect relevant data that is required by a specialized registry in their jurisdiction during the EHR reporting period;

- Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or

- Operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.

 


*Active Engagement Option 1 - Completed Registration to Submit Data: The EP registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.

*Active Engagement Option 2 - Testing and Validation: The EP is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.

*Active Engagement Option 3 - Production: The EP has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

MacPractice Report
There are no Measure Calculation reports for these measure. Attesting to this is a simple yes/no answer that requires a "yes" to be considered accepted.

How
Measure 1
With the proper setup, the HL7 immunization files required by immunization registries will be automatically exported to a folder that you choose in Preferences. In the HL7 Preferences, use the green plus button to create a new path. Then set up a folder in the Server Path for Outgoing HL7 Messages. Once this is set, move to the Outgoing tab and check the box next to Immunization Registry.

NOTE: MacPractice Support can only assist with setting up data export for this measure. It is up to you and your office staff to contact local Immunization Registries to see if they can accept these files and if so, maintain contact and submission with them.

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Measure 2
There is a report in MacPractice designed to collect this format of data and generate the necessary files for submission to PHAs. This can be found in Reports under the Clinical folder. Running the Syndromic Surveillance Export report and using the Export button at the bottom will generate the files and save them in a folder that you set up in HL7 Preferences.

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NOTE: MacPractice Support can only assist with setting up data export for this measure. It is up to you and your office staff to contact local Public Health Agencies to see if they can accept these files and if so, maintain contact and submission with them.

Measure 3
MacPractice does not currently have the ability to generate the necessary electronic files for reporting to specialized registries, as there is no industry wide standard for doing so. Every registry that exists has the potential to collect different data in different formats which means a unique process for each request we receive. This is something that we will consider adding on a case by case basis as requested and required. CMS has published a new FAQ regarding this measure, allowing providers to be excluded from this measure for 2015 if they are excluding from the first two.

CQM Reporting
In addition to the 10 Objectives reviewed above, Meaningful Use requires that providers report on 9 CQMs (Clinical Quality Measures). These can be found in the Clinical Quality Measures (2014) folder in the Reports ability. Unlike the Core and Menu Set Measures, there are no required percentages for any of these reports, meaning you could have a 0% and this will not count against you or prevent you from achieving Meaningful Use; however, each report must have a denominator. They merely want to make sure that they are collecting this data from attesting providers.

For the most part, the Meaningful Use program is lenient in that they allow a provider to choose 9 of these reports that apply to their practice and have a denominator. There is one rule that they have made in order to collect a variety of data: Your chosen reports must be from at least 3 of the 6 different domains. A list of the domains and the measures that fall under each of them is at the end of this document.

For attestations in 2015-2017, CMS will continue to allow for manual entry of your CQM numbers into the attestation site just as you manually enter in your numbers for the main objectives and measures of Meaningful Use. Though electronic upload of files for CQM reporting is optional now, in 2018, electronic upload of these files will be required.

Once you choose a report and run it for your attesting period, you will have the option to export these reports in either QRDA Category 1 or QRDA Category 3 files. Both file formats will be accepted by CMS for electronic upload and submission. The difference in the two is that QRDA Category 1 will create a file for each patient in the report, and QRDA Category 3 will create one file for the entire report data.

Domains and Measures
Patient and Family Engagement

Patient Safety Care Coordination Population/Public Health Efficient Use of Healthcare Resources Clinical Process/Effectiveness
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