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

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Performance Measures, 2013

Although The CMS Stage 2 Rule Exit Disclaimer: You Are Leaving www.ihs.gov details the rubrics for Stage 2, the document also includes changes for Stage 1 that went into effect for FY/CY 2013. See below for more information. (Note that these changes are not retroactive to FY/CY 2011 or 2012.)

For CY 2013, EPs must:

  • Meet 13 core performance measures.
  • Meet 5 performance measures from a menu set of 10 (at least one of the 5 has to be a public health measure).
  • Report on 6 clinical quality measures - 3 core or alternate core measures and 3 measures from the menu set (CQMs have no performance targets).

For FY 2013, EHs must:

  • Meet 12 core performance measures.
  • Meet 5 performance measures from a menu set of 10 (at least one of the 5 has to be a public health measure).
  • Report on all 15 clinical quality measures (CQMs have no performance targets).

The following Stage 1 changes also went into effect for participation year 2013. (The 2011-2012 requirements are listed for comparison purposes.)

  • Stage 1 Core Measure: Computerized Provider Order Entry (CPOE) - New measure added
    • 2011 - 2012: More than 30 percent of all unique patients with at least one medication in their medication list admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) have at least one medication order entered using CPOE.
    • 2013: More than 30 percent of medication orders created by the EP during the EHR reporting period are recorded using CPOE.
  • Stage 1 Core Measure: Electronic Prescribing - New exclusion added
    • 2011 - 2012: Any EP who writes fewer than 100 prescriptions during the EHR reporting period is excluded.
    • 2013: In addition to the existing exclusion from 2011 - 2012, a new exclusion allows for when the EP does not have a pharmacy within his/her organization and no pharmacies accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period.
  • Exchange of Key Clinical Information: No longer required
    • 2011 - 2012: Perform at least one test of certified EHR technology's capacity to exchange key clinical information electronically.
    • 2013: This test is no longer required for EPs or EHs in Stage 1.
  • Report Clinical Quality Measures: No longer a separate objective
    • 2013: Although CMS has removed the standalone objective that requires providers to attest that they plan to report on clinical quality measures, EPs and EHs still need to report on CQMs to achieve MU.

Helpful Resources

Listed below are links that may prove useful in achieving Stage 1 MU in 2013.