Modified Meaningful Use

Meaningful Use Program Update History of Rulemaking and the Current State of MU MU Rulemaking Recap

• 2009 – ARRA/HITECH sets the stage • 2010 – Final Rule for Stage 1 MU • 2011 – first year of MU reporting • 2012 – Final Rule for Stage 2 MU • 2012 – first set of Stage 1 changes • 2013 – second set of Stage 1 changes • 2014 – Flexibility Rule • 2015 – Modified Stage 2 (2015-2017 Changes) and Stage 3 Rule MU Program Registration

200,000

• ~550,000 eligible providers have 180,000 registered for EHR incentive program 160,000 (~350,000 Medicare and ~185,000 49,051 61,098 Medicaid) 140,000 120,000 • About 85% of registered providers have received EHR incentive payments 100,000 80,000 • Lag since March 2015 reflects hold for 34,778 60,000 123,648 24,332 2015 modifications rule 113,658

40,000 Medicare Medicaid Eligible Eligible 54,062 48,623 13,274 Professionals Professionals Total 20,000 Professionals Paid 305,335 146,514 451,849 14,621 0 Total of Payments $8.16 Billion $3.94 Billion $12.1 Billion 2011 2012 2013 2014 2015 to Percent of Registered Professionals date Paid 86% 80% 84% Medicaid Eligible Professionals Stage 2 Payments Medicare Eligible Professionals Professionals Paid 51,115 Total of Payments $330 Million Ambulatory EHR Vendor Rankings • Vendors with the highest overall Medicare MU Market Share: 1. Epic Systems Corporation 2. Allscripts 3. eClinicalWorks LLC 4. NextGen Healthcare 5. GE Healthcare 6. Greenway Health, LLC 7. athenahealth, Inc. 8. Practice Fusion 9. McKesson 10. Community Computer Service Inc. Geographic Concentration of MU Statewide MU Adoption Example: CA NextGen’s Position

180,000 th • NextGen has maintained 4 for 160,000

overall attestations (currently 140,000 ~48,000) and has steadily 120,000 grown market share of 100,000 attestations year over year 80,000 60,000 • Approximately 30,000 unique 40,000

providers have successfully 20,000

attested for ~$870 million in 0 MU incentives using certified 2011 2012 2013 2014 2015 solutions from NextGen Epic Systems Corporation Allscripts Healthcare eClinicalWorks LLC NextGen Healthcare GE Healthcare Greenway Health LLC athenahealth Inc Practice Fusion McKesson Community Computer Service Inc MU Stage 2

• Stage 2 attestation Only 15% of previously numbers industry-wide successful Medicare have continued to be low Meaningful Users have • Stage 2 attestations attested to MU Stage 2 account for only 6% of overall attestations MU Stage 2

• Vendors with the highest Medicare MU Stage 2 market share: 1. Epic Systems Corporation 2. eClinicalWorks LLC 3. athenahealth, Inc. 4. Allscripts 5. Practice Fusion 6. Community Computer Service Inc. 7. Greenway Health 8. NextGen Healthcare 9. gMed Inc. 10. Eyefinity/OfficeMate Stage 2 Attrition

99.27% 45,000 93.29% 95.17% 100.00% • Stage 2 attrition refers 86.95% 88.14% to providers who were 40,000 90.00% scheduled to attest to 35,000 73.59% 80.00% 70.00% 30,000 Stage 2, but did not 58.22% 60.00% attest as scheduled 25,000 51.15% 50.00% • Many top ten vendors 20,000 40.00% struggled to get 15,000 27.59% providers to attest to 30.00% 10,000 Stage 2 20.00% 5,000 10.00% • ¾ of vendors have 0.00% attrition rates of 100% 0 0.00% (i.e., did not have any providers attest to Stage 2 despite being scheduled)

Stage 2 Attestations Attrition % Attrition Overall Attrition

60,000 42.17% 45.00% • Attrition here (black 55,454 35.95% 40.00% line) = providers who 50,000 35.20% 30.94% 35.00% 28.88% did nothing in 2014 40,000 30.00% 25.59% 24.04% 25.00% • Industry average for 30,000 27,509 18.31% 20.00% overall attrition is 67% 19,98018,600 20,000 15.00% 15,737 11,585 10.00% • All top ten vendors 6,603 7,721 10,000 4.05% 6,960 3,321 5.00% fare much better than 0.00% industry average 0 0.00% • NextGen’s attrition rate has not grown, despite challenges of attesting in 2014 Stage 1, 2013 Measures Stage 1, 2014 Measures Stage 2 Attestations Attrition Attrition Rate MU Flexibility

• Many vendors ranking 14,000 high in Stage 2 attrition, 12,000 but low in overall 10,000 attrition, rank high in MU 8,000

Flexibility attestations 6,000

• NextGen anticipated low 4,000

Stage 2 attestations as 2,000 we supported clients in their opting to take 0

advantage of the e-MDs SRSsoft Allscripts McKesson Compulink

flexibility rule AllMeds Inc ACOM Health GE Healthcare GE Practice Fusion Practice HealthTronics Inc HealthTronics MedInformatix Inc MedInformatix Merge Healthcare Merge

• Vendors who did not Inc Solutions Altos Cerner Corporation Cerner eClinicalWorks LLC eClinicalWorks Eyefinity/OfficeMate NextGen Healthcare NextGen Meditab Software Inc Software Meditab support their clients’ use LLC Health Greenway AmazingCharts.com Inc AmazingCharts.com Varian Medical Systems Medical Varian Intermountain Healthcare Intermountain Intuitive Medical Software Medical Intuitive Epic Systems Corporation

of the flexibility rule had Inc Systems Software MPN BioMedix Vascular Solutions Vascular BioMedix Aprima Medical Software Inc Software Medical Aprima

higher attrition rates Integrated Practice Solutions Inc UT MD Anderson Cancer Center Cancer Anderson MD UT Elekta - IMPACMedical Systems…

Stage 2 Scheduled, Stage 1 2013 Measures Stage 2 Scheduled, Stage 1 2014 Measures Stage 1 Scheduled, 2013 Measures Modified Stage 2 Summary of Final Rule for Modified Stage 2 and Stage 3

• CMS has released one final rule for both modified Stage 2 and Stage 3 – these combined rules: • Simplify reporting by reducing number of objectives and eliminating core/menu structure • Get all providers onto the same stage of MU • Focus MU on interoperability and advanced EHR usage in Stage 3 • Aligns with new MACRA law with respect to HITECH penalties • EHR reporting based on a calendar year for all providers (EPs and EHs) • Relieve burden on patient engagement rules temporarily MU Stages based on 1st Year MU Reporting Periods

• 90 Days all first-time attesters 2016 • Full year all returning attesters

• 90 Days first-time attesters • 90 Days providers exercising Stage 3 option 2017 • All others full year

2018 • Full year for all Medicare EHR Incentives Medicaid EHR Incentives Medicaid EHR Incentive Program Modified Stage 2 and Stage 3 Objectives Modified Stage 2 and Stage 3 Objectives Objective #1 – Protect Health Information Security Risk Analysis

• Security Risk Analysis must be completed for each reporting period Security Risk Analysis Security Risk Analysis Security Risk Analysis What is the SRA Requirement?

• Based in both HITECH (meaningful use) and HIPAA Security Rule [45 CFR 164.308(a) (1)] • Requires accurate and thorough written assessment outlining potential risks and vulnerabilities, security policies and procedures, and corrective actions • Practice must update SRA each year, documenting the completion of previous corrective actions, along with any new risks and related actions • The SRA answers some basic questions concerning electronic protected health information (ePHI): • Where is ePHI stored and used? • How is it currently protected? • Is protection adequate? (Risks)

• P - Physical safeguards • A - Administrative safeguards • T - Technical safeguards A Simplified SRA Solution for MU and HIPAA

Next Gen Healthcare has partnered with HIPAA One to offer hands-on assistance and online tools to help you meet your Security Risk Assessment (SRA) obligations and reduce risk to your practice:

• HIPAA One® license and training • Network vulnerability scan • Education on security rules under MU and HIPAA • Review of existing SRA • Service packages to support client’s specific SRA needs: – Silver – self-directed; remote training on HIPAA One tool – Gold – Guided SRA (remote) – Platinum – Comprehensive onsite SRA w/ physical walk-through Objective #10 – Public Health Reporting Public Health Reporting

One objective, 3 measures: • Measure Option 1 – Immunization Registry Reporting: The EP is in active engagement with a public health agency to submit immunization data. (May be counted 1 time) • Measure Option 2 – Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data. (May be counted 1 time) • Measure Option 3 – Specialized Registry Reporting: The EP is in active engagement to submit data to a specialized registry. (May be counted two times) Achieving ‘Active Engagement’

• Modified Stage 2 rules require “active engagement” with public health or specialized registry (as opposed to “ongoing submission” per the old rule) • Option 1: The EP is registered to submit data with the agency, registration was completed within 60 days after the start of the EHR reporting period; and the EP is awaiting invitation to begin testing and validation. • Option 2: The EP is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the agency within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure. • Option 3: The EP has completed testing and validation and is submitting production data. Public Health Reporting

One objective, 3 measures: • Measure Option 1 – Immunization Registry Reporting: The EP is in active engagement with a public health agency to submit immunization data. • Measure Option 2 – Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data. • Measure Option 3 – Specialized Registry Reporting: The EP is in active engagement to submit data to a specialized registry.

An EP previously scheduled to be in Stage 2 in 2015 must meet 2 measures An EP previously scheduled to be in Stage 1 in 2015 must meet 1 measure All EPs must meet 2 measures in 2016 and 2017. Public Health Reporting

NextGen® Clinical Registry Service • Choose from several available specialty registries • Utilizes one connection from NextGen® Share to all available registries • Simplified implementation process (self-installed through NextGen® Share)

Note: This is a not replacement for syndromic or immunization interfaces at this time Specialty Registries Available Through NextGen Share

• Pricing based on what individual registry charges (most charge subscription, some charge installation/participation fee) Additional Specialty Registries

• These registries are available to clients outside of NextGen Share • Clients will work directly with the registries to submit data • American Urological Association / AQUA • American Academy of Neurology / Axon • American College of Emergency Physicians / CEDR • American Board of Family Medicine / PRIME • American College of Rheumatology / RISE • American Society of Nuclear Cardiology / ImageGuide • Academy of Dermatology / DataDerm • Diabetes Collaborative Registry • American College of Cardiology / PINNACLE • American Academy of Ophthalmology / IRIS Alternate Exclusion 2016 Table: Measures and Exclusions for Modified Stage 2

2016 MU Reporting from NextGen® Health Quality Measures (HQM) HQM for 2016

• All clients auto-enrolled in 2016 MU Program • Released on April 8th, 2016 • All providers pre-configured for full year reporting • If in first year will need to change reporting period to 90 days

• Redundant, Duplicative, Topped Out measures: • Remain in HQM for monitoring purposes • Numbering in place for ‘reportable’ objectives Payment Adjustments Based on performance in 2016….

• New participants who successfully demonstrate meaningful use for 90 days will avoid the payment adjustment in CY 2017 if the EP successfully attests by October 1, 2016, and will avoid the payment adjustment in CY 2018 if the EP successfully attests by February 28, 2017 • Returning participants who successfully demonstrate meaningful use will avoid the payment adjustment in CY 2018 if the EP successfully attests by February 28, 2017 Based on performance in 2017….

• New participants who successfully demonstrate meaningful use for 90 days will avoid the payment adjustment in CY 2018 if the EP successfully attests by October 1, 2017 Meaningful Use and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) MIPS and MU

• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law in April, includes new Medicare Merit-Based Incentive Payment System (MIPS) • Taken together with final MU rules, MIPS does the following: • Sunsets meaningful use, PQRS, and VBM penalties after 2018 • Consolidates programs and associated penalties into a new payment system that will assess physicians in four categories

• Quality measures (30%) • Resource use/cost (30%) • Clinical practice improvement activities (15%) • Meaningful use of a certified EHR (25%)

MIPS Scores (0-100) will be compared to benchmarks and used to determine positive/negative payment adjustments MIPS: Merit-based Incentive Payment System

Positive/Negative adjustments based on benchmarked MIPS score… Who Participates?

Years 1 and 2:  Physicians (MD/DO and DMD/DDS)  PAs and NPs  Clinical nurse specialists  Certified registered nurse anesthetists Who Participates?

Years 3 and beyond: (may expand to include)  Physical therapists  Occupational therapists  Speech-language pathologists  Audiologists  Nurse midwives  Clinical social workers  Clinical psychologists  Dietitians/Nutritional professionals Still Relevant?

MU remains relevant…  As a percentage of your MIPS score  As a means of participating in quality improvement programs and reporting quality metrics  As a set of behaviors to support clinical improvement, patient engagement/consumerism, care coordination

…even after the incentives and penalties are gone MU Resources for NextGen Healthcare Clients Complimentary Webinars

• Meaningful Use: Modified Stage 2 (Complimentary) • Meaningful Use: Question and Answer Session (Complimentary) • New webinars coming soon! • Meaningful Use page in Success Community For More Information

• 2016 CMS Program Requirements • CMS Educational Resources • CMS FAQs • CMS Fact sheet on MACRA • CMS presentation MACRA/MIPS • CMS presentation on MIPS/Advancing Care Hardship Exceptions

• Providers may apply for hardship exceptions to avoid the payment adjustments • Hardship exceptions are granted on a case-by-case basis • Information on how to apply for a hardship exception is posted on the CMS EHR Incentive Programs website Any Questions?