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What are the MU Reporting Requirements in 2016?

Updated: August 2016

Providers that are participating in the EHR Incentive Program for the first time will report using the Modified Stage 2 requirements for 90 consecutive days. They will need to report on all measures as required, with special accommodations for measure that were not required previously for Stage 1 providers. Providers participating in their second year or beyond are required to report on Modified Stage 2 for the full calendar year. They will have to report on all measures as required. (See Table 1. below.)

Proposed Changes to Reporting

In July 2016, CMS proposed changes to the rule and are gather public comments here.

CMS Proposes a 90-day reporting period for 2016 for all participants and may eliminate reporting entirely for clinical decision support (CDS) and computerize physician order entry (CPOE) requirements in the 2017 and 2018 reporting years.

Streamlining Stages

Since Meaningful Use began, there have been the idea of stages. When a clinician started participating in Meaningful Use, they would start by reporting on Stage 1 measures, then move to Stage 2 and finally to Stage 3.

The modified rule changes this, essentially abolishing the idea of stages, and instead aligning clinicians to report on the same set of measures, which are being called the “Modified Stage 2 Measures.”  The Modified Stage 2 Measures are a reduced set of the Stage 2 Core and Menu measures. The modified rules abolish the idea of “core” and “menu” measures, reduce the number of measures a provider has to report on, and make a few measures easier to meet.

Eligible Providers in Stage 1 in 2016 will need to report on 10 core objectives, including one consolidated public health reporting objective with 3 measure options.

Eligible Providers in Stage 2 in 2016 will need to report on 10 core objectives including one consolidated public health reporting objective with 3 measure options.

What do you need to do in 2017? See the FAQ. 


Table 1. List of objectives and measures required for reporting 2016 MU

Objective

Measure

Exclusion

Objective 1:

Protect patient health information

Measure: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI created or maintained in 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.

Objective 2:

Clinical decision support

For providers to meet the objective they must satisfy both of the following measures:

Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to a provider’s scope of practice or patient population, the clinical decision support interventions must be related to high priority health conditions.

Measure 2: The provider has enabled and implemented the functionality for drugdrug and drugallergy interaction checks for the entire EHR reporting period.

Exclusion for Measure 2: Any provider who writes fewer than 100 medication orders during the EHR reporting period.

Objective 3:

Computerized provider order entry

A provider, through a combination of meeting the thresholds and exclusions (or both), must satisfy all three measures for this objective.

Measure 1: More than 60 percent of medication orders created by the provider during the EHR reporting period are recorded using computerized provider order entry.

Measure 2: More than 30 percent of laboratory orders created by the provider during the EHR reporting period are recorded using computerized provider order entry.

Measure 3: More than 30 percent of radiology orders created by the provider during the EHR reporting period are recorded using computerized provider order entry.

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

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

Objective 4:

Electronic prescribing

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

Exclusions: Any provider who meets the following criteria:

·        Writes fewer than 100 permissible prescriptions during the EHR reporting period; or

·        Does not have a pharmacy within his or her organization and no pharmacies accept electronic prescriptions within 10 miles of the provider’s practice location at the start of his or her EHR reporting period.

Objective 5:

Health information exchange

Measure: Providers who transition or refer 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.

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

Objective 6:

Patient-specific education

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 provider during the EHR reporting period.

Exclusion: Any provider who has no office visits during the EHR reporting period.

Objective 7:

Medication reconciliation

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

Exclusion: Any provider who was not the recipient of any transitions of care during the EHR reporting period.

Objective 8:

Patient electronic access (view, download, and transmit)

Measure 1: More than 50 percent of all unique patients seen by the provider 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 provider’s discretion to withhold certain information.

Measure 2: For an EHR reporting period in 2016, at least one patient seen by the provider during the EHR reporting period (or patientauthorized representative) views, downloads, or transmits his or her health information to a third party during the EHR reporting period.

Exclusion for Measure 1: Any provider who neither orders nor creates any of the information listed for inclusion as part of the measures except for “Patient Name” and “Provider’s name and office contact information.”

Exclusion for Measure 2: Any provider who meets the following criteria:

·        Neither orders nor creates any of the information listed for inclusion as part of the measures except for “Patient Name” and “Provider’s name and office contact information”; 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.

Objective 9:

Secure messaging

Measure: For an EHR reporting period in 2016, for at least one patient seen by the provider during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patientauthorized representative), or in response to a secure message sent by the patient (or the patientauthorized representative) during the EHR reporting period.

Exclusion: Any provider who has no office visits during the EHR reporting period, or any provider 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.

Objective 10:

Public health reporting

Providers in 2016 must meet two of the following three measures:

Measure Option 1 – Immunization Registry Reporting: The provider is in active engagement with a public health agency to submit immunization data.

Measure Option 2 – Syndromic Surveillance Reporting: The provider is in active engagement with a public health agency to submit syndromic surveillance data.

Measure Option 3 – Specialized Registry Reporting:The provider is in active engagement to submit data to a specialized registry.

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

·        Does not administer any immunizations to any of the populations for which data is collected by its 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 from the provider at the start of the EHR reporting period.

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

·        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 providers 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 providers at the start of the EHR reporting period.

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

·        Does not diagnose or treat any disease or condition associated with, or collect relevant data that is collected 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 provider is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.

Under the Modified Stage 2 Measures:

Providers no longer need to report on:

  • Problem List (Stage 1 Core)
  • Medication List (Stage 1 Core)
  • Allergy List (Stage 1 Core)
  • Demographics (Stage 2 and Stage 1 Core)
  • Vital Signs (Stage 2 and Stage 1 Core)
  • Smoking Status (Stage 2 and Stage 1 Core)
  • Structured Lab Results (Stage 2 Core, Stage 1 Menu)
  • Patient Lists (Stage 2 Core, Stage 1 Menu)
  • Reminders (Stage 2 Core, Stage 1 Menu)
  • Clinical Summaries (Stage 2 Core)
  • Electronic Notes (Stage 2 Menu)
  • Imaging Results (Stage 2 Menu)
  • Family Health History (Stage 2 Menu)

Some measure were adjusted to be easier to meet:

  •  Secure Messaging Measures
  •  Patient Electronic Access Measures