The Centers for Medicare and Medicaid Services has issued four new Frequently Asked Questions covering aspects of the electronic health records meaningful use program, including substantial new guidance on the Stage 2 transitions of care measures:

Question: For the meaningful use Stage 2's transitions of care and referrals objective, in what ways can the second measure be met that requires more than 10% of the summary care records provided for transitions of care and referrals to be electronically transmitted in the Electronic Health Records (EHR) Incentive programs?

Answer: An EP, eligible hospital, or critical access hospital (CAH) could use three approaches) to meet this measure. 

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 the Office of the National Coordinator (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.  However, 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 Nationwide Health Information Network (NwHIN) Exchange participant to facilitate the electronic transmission to the recipient.  The NwHIN Exchange is now known as “eHealth Exchange” and a list of participants can be found at http://www.healthewayinc.org/index.php/exchange/participants

The following are more detailed explanations of each permitted approach.  We also emphasize that regardless of the way an EP, eligible hospital, or CAH chooses to transmit the summary of care record, such a transmission will only count in the numerator if it is received by the provider to whom the sending provider is referring or transferring the patient.

1. Use of the transport standard capability required for certification – the primary Direct Project specification (the Applicability Statement for Secure Health Transport) hereafter referred to as simply “Direct”.  This specification is required by ONC to meet the CEHRT definition and every EP, eligible hospital, and CAH, must have EHR technology that is capable of electronically transmitting a summary care record for transitions of care and referrals according to it. To count electronically transmitted summary care records in their numerator, EPs, eligible hospitals, or CAHs:

• Must use their CEHRT’s “Direct” capability (whether provided as an integrated part of their EHR technology or combined with another service provider). If an EHR technology developer uses another service provider (for example, an Health Information Exchange organization (HIE) or Health Information Service Provider (HISP)) to achieve certification for Direct, an EP, eligible hospital, CAH can only count in their numerator electronically transmitted summary care records using that certified configuration. In other words, if an EP, eligible hospital, or CAH, sought to use a different service provider that was not certified with their EHR for Direct, that service provider would not be part of their CEHRT and, thus, any Direct transmissions using that service provider would not count toward the numerator.

• May use, if their CEHRT includes it, the “Direct + XDR/XDM for Direct Messaging” transport capability which enables EHR technology to include additional metadata and communicate with SOAP-based systems.

2. Use of the SOAP-based optional transport standard capability permitted for certification.  As part of certification, ONC permits EHR technology developers to voluntarily seek certification for their EHR technology’s capability to perform SOAP-based electronic transmissions.  EHR technology developers who take this approach would enable their customers to also use this approach to meet the measure. To count electronically transmitted summary care records in their numerator, EPs, eligible hospitals, or CAHs:

• May use their CEHRT’s “SOAP-based” capability (again if their EHR technology has been certified for it). The SOAP-based standard ONC adopted for certification is a baseline on top of which an EHR technology developer may add more advanced exchange capabilities (i.e., query). An EP, eligible hospital or CAH using an EHR technology certified to that SOAP baseline may count electronic transmissions in the numerator that utilize more advanced exchange capabilities even if those capabilities were not included when the EHR technology was certified.

3. Use of CEHRT to create a summary care record in accordance with the required standard (i.e., Consolidated CDA as specified in 45 CFR 170.314(b)(2)), and the electronic transmission is accomplished through the use of an eHealth Exchange participant who enables the electronic transmission of the summary care record to its intended recipient.  Thus, EPs, eligible hospitals, or CAHs who create standardized summary care records using their CEHRT and then use an eHealth Exchange participant to electronically transmit the summary care record would be able to count all of those transmissions in their numerator. EPs, eligible hospitals, and CAHs, do NOT themselves need to become an eHealth Exchange participant in order to use this option.  Rather, it is sufficient and acceptable to use the exchange services of a third party organization, like a health information exchange entity, that is an eHealth Exchange participant.

For this third approach, the regulation also permits an EP, eligible hospital, or CAH to count in their numerator instances where a summary care record for transitions of care or referrals was received via electronic exchange facilitated in a manner consistent with the governance mechanism ONC establishes for the nationwide health information network.  ONC has not yet established a governance mechanism for the nationwide health information network.  Until ONC establishes such a governance mechanism, this specific option will not be available.

Question: When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward the measure, or can they have other titles as long as their job functions are those of medical assistants?

Answer: If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a medical assistant but carries a more specific title due to either specialization of their duties or to the specialty of the medical professional they assist, he or she can use the CPOE function of CEHRT and have it count towards the measure.  This determination must be made by the eligible provider based on individual workflow and the duties performed by the staff member in question. Whether a staff member carries the title of medical assistant or another job title, he or she must be credentialed to perform the medical assistant services by an organization other than the employing organization. Also, each provider must evaluate his or her own ordering workflow, including the use of CPOE, to ensure compliance with all applicable federal, state, and local law and professional guidelines.

Question: For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, how should an eligible professional (EP), eligible hospital, or critical access hospital (CAH) attest if the certified EHR vendor uses 2011 edition Certified EHR Technology for the first part of 2013 and 2014 edition Certified EHR Technology for the remainder of 2013?

Answer: If an EP, eligible hospital or CAH switches from 2011 edition Certified EHR Technology to 2014 Edition Certified EHR Technology during the program year, the data collected for the selected menu objectives and quality measures should be combined from both of the EHR systems for attestation.  The count of unique patients does not need to be reconciled when combining from the two EHR systems. If the menu objectives and/or clinical quality measures used are also being changed when switching certified editions, the menu objectives and/or quality measures collected from the EHR system that was used for the majority of the EHR reporting period should be reported.

Question: The specifications for Denominator 2 for measure CMS64v2 do not produce an accurate calculation according to the measure’s intent. When will a correction to this clinical quality measure (CQM) be published?

Answer: The Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs  Stage 2 final rule (77 FR 54056) states that updates to the CQM specifications may be published annually approximately 6 months prior to the beginning of the calendar year (CY) for which the data would be collected (e.g., for the EHR reporting periods in CY 2014, approximately 6 months in advance of the beginning of CY 2014). A correction for this measure will be included in the next annual update, to be published in CY 2014.

Within the logic for Denominator 2, there is a missing “OR” operator in the Risk Assessment Logic between count >= 3 and count = 2.  This omission may result in cases incorrectly excluded from the denominator.  This missing “OR” operator in Denominator 2 creates a situation where 3+ risk factors AND a High Density Lipoprotein (HDL) laboratory result of >60 mg/dL will cause the patient to not fall into Denominator 2, which is an error. The issue would only impact cases when a patient’s Framingham Risk Score is not recorded in the EHR.  

The exact impact on the performance calculation for Denominator 2 is unknown.  Since the CQM asks for either the data to calculate risk or a pre-calculated Framingham Risk Score, the result will not be miscalculated in denominator 2 if there is a Framingham score already in the EHR system.
It  is highly recommended that eligible professionals (EPs) implementing this CQM record a Framingham Risk Score as outlined in the U.S. Department of Health & Human Services’ Third Report of the National Cholesterol Education  Program (NCEP) (2002, p. III-4 – III-5)  to ensure accurate performance calculation:  http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf.

In addition, CMS has updated five meaningful use FAQs: 8908, 3077, 8896, 8898 and 8900, available here.

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