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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Performance Measures, 2014-15

In anticipation of new CEHRT capabilities in 2014, CMS has decided to change some of the 2011-13 Stage 1 requirements so that they align better with the new technology. EPs and EHs must meet these new requirements to be eligible to collect an EHR incentive payment for Stage 1, 2014.

To allow for implementation of the new 2014 CEHRT, all participants, regardless of their stage, will only have to report on a three-month period in 2014. (States have the option of limiting this reporting period to the quarters with the FY/CY or to any consecutive 90-day period.)

EPs must:

  • Meet 13 core performance measures.
  • Meet 5 performance measures from a menu set of 9.
  • Report on 9 clinical quality measures (CQMs) from 3 of 6 National Quality Strategy Domains (CQMs have no performance targets). Note that, beginning in 2014, providers beyond their first year of MU must report Medicare CQMs electronically to CMS. Reporting options for Medicaid CQMs vary by state.

EHs must:

  • Meet 11 core performance measures.
  • Meet 5 performance measures from a menu set of 10.
  • Report on 16 clinical quality measures from 3 of 6 National Quality Strategy Domains (CQMs have no performance targets).

The following changes also go into effect for Stage 1, 2014, in addition to the 2013 Stage 1 Changes.

Record Vital Signs: The measure includes an age change (from two and older to three and older), and the previous exclusion has been split into four exclusions to allow EPs more flexibility. The new measure and exclusions are listed below.

  • More than 50 percent of all unique patients seen by the EP or admitted to the EH's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have blood pressure (for patients age three and over only) and height/length and weight (for all ages) recorded as structured data.
  • Any EP who:
    • Sees no patients three years or older is excluded from recording blood pressure;
    • Believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them;
    • Believes that height and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure; or
    • Believes that blood pressure is relevant to their scope of practice, but height and weight are not, is excluded from recording height and weight.

Patient Electronic Access (View/Download/Transmit): New Measure

  • More than 50 percent of all unique patients seen by the EP or who are discharged from the inpatient or emergency department (POS 21 or 23) of an EH or CAH are provided timely online access to their health information (within four business days after the information is available to the EP or 36 hours of discharge for EH).
  • This new measure will replace the following objectives:
    • EPs/EHs: Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, medication allergies, discharge summary, procedures) upon request.
    • EHs: Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request.
    • EPs: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within four business days of the information being available to the EP.

Helpful Resources

Listed below are links that may prove useful in achieving Stage 1 in 2014.