Finnegan is one of the oldest & most-trusted Arkansas DME companies. By further expanding its interoperability with using SHARE (Arkansas’ only Statewide HIE), Finnegan Health Services is using SHARE to access a patient’s DME orders and results, especially from large enterprise healthcare systems. SHARE is providing the ability to securely share accurate patient health information with Finnegan Health Services, which can help to improve the speed, safety and quality of patient care while potentially cutting costs and time.

By utilizing SHARE, Finnegan Health Services will be able to enhance the way they provide quality medical products ordered by health care providers while improving patient care and enhancing the quality of peoples’ lives. Although Finnegan will not be able to push their patient’s health records into SHARE, they will be able to use the Virtual Health Record (VHR) to view a patients’ health record and get a more complete picture of their health from participating hospitals providers involved in their patients’ care. By also using SHARE Secure Messaging, Finnegan Health Services will be able to share clinical information— such as diabetic supplies prescriptions filled, urinary supplies prescriptions filled, wound care prescription supplies filled, etc. —through secure, encrypted email exchange with other providers. Most importantly, other providers can send Finnegan Health Services referrals securely and instantly that assist with transitions of care. They have been serving Arkansas and beyond since 1984.

About Finnegan Health Services:

Finnegan Health Services is the largest and oldest family owned durable medical equipment provider in Arkansas. We specialize in incontinence, urinary, and diabetic supplies. Finnegan Offers a Wide Variety of Medical Supply Products, Including, But Not Limited to:

• Incontinence Supplies: Child & adult diapers, pull-ups, pads, underpads/chux, wipes & gloves
• Urinary Supplies: Catheters, Foley catheters & drainage bags, condom catheters
• Diabetic Supplies: Testing supplies for diabetes & gestational diabetes
• Nutritional & Tube Feeding Supplies:  Simply Thick® food thickeners, pudding & formula
• Bathroom Safety Equipment: Shower & commode chairs, transfer benches & sprayers
• Respiratory & Tracheostomy Supplies: AeroChambers® & peak flow meters
• Wound Care Supplies: Basic & specialty dressings, including foam & hydrocolloid

For more information, visit: https://finneganhealth.com

 

SHARE is now collaborating with UAMS North Central Family Medicine Center that provides primary care medical services to patients of all ages. They offer treatment for acute medical conditions but also ongoing treatment for chronic conditions such as asthma, diabetes, hypertension and arthritis. They cover all stages of life from pediatric conditions to senior health care.

The clinic provides convenient diagnostic and support services on site and also are able to perform minor office surgical procedures in clinic as well as offer routine adult and pediatric immunizations. Their caring and compassionate staff serves an 11-county region that includes: Marion, Baxter, Fulton, Sharp, Searcy, Van Buren, Stone, Cleburne, Izard, Independence and White.

The data exchange services will also give UAMS North Central Family Medicine Center in eleven counties in Northern and North Central Arkansas, secure access to important information such as lab results, updated patient records and demographic information. This ensures every care provider in a patient’s chain of care has consistent and current information, and that their records are more secure and accessible than with paper files. Together, SHARE and UAMS North Central Family Medicine Center are working to change health care for the better for the residents of Northern and North Central Arkansas. The UAMS North Central Family Medicine Center is affiliated with White River Medical Center, which is also connected to SHARE. The clinic is also affiliated with the UAMS Medical Center and clinics.

About UAMS North Central Family Medicine Center:

The University of Arkansas for Medical Sciences North Central (UAMS North Central) is an outreach of the University of Arkansas for Medical Science (UAMS), serving Marion, Baxter, Fulton, Sharp, Searcy, Van Buren, Stone, Cleburne, Izard, Independence, and White counties. UAMS North Central has been a part of the statewide UAMS Regional Campuses since 2007, provides clinical care, health education services, and training for medical residents in primary care. The UAMS North Central mission is to improve the health of Arkansans by training health professionals and delivering patient-centered care in an eleven county area of north-central Arkansas. UAMS North Central opened the UAMS Family Medical Center in August 2018. The Family Medical Center has 24 exam rooms and multiple areas for team-based care, which includes physicians, nurses, pharmacists and other clinical professionals. The UAMS Family Medicine Residency Program in Batesville plans to receive our first residents in July 2019. The program will admit six residents per year until reaching a total of 18 residents in 2021. UAMS North Central was established by the Arkansas legislature in cooperation with UAMS in 2007. The center works in partnership with the University of Arkansas Community College at Batesville and Arkansas State University at Mountain Home. Each college continues to house several UAMS degree programs. In addition to its partnership with the local colleges, UAMS North Central works closely with the White River Medical Center in Batesville.

Learn more about UAMS North Central Family Medicine Center at: https://uamsfamilymedcenters.com/

 

SHARE is now sending real-time event notifications to over 50 Arkansas Hospitals on their patients that have been readmitted to another facility within 30 days.

• Assisting in Lowering Readmission Rates
• Identifying High Risk Patients
• Assisting in Lowering Potential Payment Penalties

Little Rock, Arkansas – November, 2018   The only statewide HIE in Arkansas, State Health Alliance for Records Exchange (SHARE), is now sending 30-day readmission notifications in real-time across the State to assist hospitals in combatting readmissions. The 30-day readmission notification project allows hospitals to receive a secure message notification when a patient that discharged from their facility, was readmitted into any SHARE participating hospital within a 30-day timeframe. This assists hospitals in lowering readmissions, identifying high risk patients which in turn could lover their potential payment penalties.

In order for a hospital to participate and receive 30-day readmission notifications they must send ADT (Admit, Discharge and Transfer) data to SHARE.  SHARE uses very specific message types in order for the facility to receive the information they want without a lot of outliers. 

ADT notifications are a way to ensure hospitals and providers have the information necessary to navigate occasionally rocky transitions of care and stay up-to-date on a patient’s status for post-hospital follow-up, if needed.

By keeping hospitals and providers aware of a patient’s condition as they move across the continuum of care, SHARE can enable better informed clinical decisions, reduce costs related to readmissions, and address potential health concerns or threats to patient safety as soon as possible.   Gaining access to clinical patient data at discharge via SHARE has the potential to reduce 30-day same-cause hospital readmissions and furthermore avert the potential costs of readmissions.

If your hospital is interested in receiving 30-day readmissions on your patients, contact SHARE today. 

About State Health Alliance for Records Exchange (SHARE):

SHARE’s Mission is to advance secure connectivity and serve as a sustainable, interoperable data exchange platform for health-related operations.

SHARE’s Vision is to provide a mechanism through which individuals, health care providers, and health organizations can electronically share health-related information to facilitate and strengthen the delivery of healthcare throughout Arkansas. This is designed to lead to improved patient care, informed individual health decisions, better public health outcomes, and cost-effective use of healthcare resources. SHARE is expected to achieve broad acceptance, credibility, and access by employing advanced technologies that ensure efficiency, privacy, and security and continuously evolve to serve Arkansans more effectively.

Did you know that over 60 million Americans live in rural and frontier communities? Rural communities are wonderful places to live and work, but these communities also have unique healthcare needs, which is why the National Organization of State Offices of Rural sets aside the third Thursday of every November – November 15, 2018 to celebrate National Rural Health Day!

SHARE is now collaborating with medical and dental clinics at Boston Mountain Rural Health Centers in Northern and Northwest Arkansas.  SHARE is providing access to daily reports when their patients are admitted and discharged from the Emergency Room and Inpatient Encounter Discharges in the last 24 hours.

Boston Mountain Rural Health Centers offer comprehensive medical services to ensure patients receive all the medical services needed. They offer a number of diagnostic tests and services within their medical clinics in Marshall, Clinton, Southside (Bee Branch), Center Ridge, Yellville, Mountain View, Huntsville, Green Forest, Jasper, and Deer, Arkansas.

Boston Mountain Rural Health Centers includes over 36 primary care, behavioral health, dentistry and specialty providers with offices in eight counties in Northern and Northwest Arkansas. The data exchange services from SHARE will provide secure access to important information such as lab results, updated patient records and demographic information. This ensures every care provider in a patient’s chain of care has consistent and current information, and that their records are more secure and accessible than with paper files. Together, SHARE and Boston Mountain Rural Health Centers are working to change health care to better serve the residents of Northern and Northwest Arkansas.

On-site services include:

• Preventative, acute, chronic, episodic for adults and pediatrics
• X-rays (can also refer out)
• Lab drawing services (can also refer out)
• Pulmonary function testing (spirometry) to measure how well the lungs take in and release air
• Electrocardiogram (EKG) to check for problems with the electrical activity of your heart
• Diabetes education
• Health screenings, education, and prevention
• Annual physicals for adults and children
• School and sports physicals
• Minor surgery to remove lumps and moles
• Stitches for cuts
• Wellness visits and case management
• Referral to specialty care
• Prescription medication assistance
• Assistance in applying for insurance
• Chronic case management
• Food bags
• Wellness centers
• Children’s immunizations
• Adult vaccines (flu, pneumonia)

Special areas of medical expertise include:

• Family Practice
• Women’s Health
• Pediatrics
• Dentistry
• Diabetes Self-Management
• Mental Health/Substance Abuse

About Boston Mountain Rural Health Center:

Established in 1994, Boston Mountain Rural Health Center (BMRHC) is a family and community health center with ten medical clinics and four dental clinics located in medically underserved areas of Northwest and North Central Arkansas. They offer a wide range of services for insured, uninsured, and underinsured patients. The highly trained doctors, dentists, and healthcare professionals at BMRHC are committed to providing comprehensive medical and dental services to all Arkansas residents in the following counties regardless of their ability to pay: Searcy, Van Buren, Madison, Newton, Carroll, Marion, Stone, and Conway.

If a patient cannot pay for health services, BMRHC offers a discounted fee program for patients that qualify. In addition, BMRHC prescription medication assistance programs can help their patients obtain the medicine they need at a price they can afford. At BMRHC, it is their mission to provide high quality, accessible, affordable, patient-centered health care to improve the well-being of patients in the communities they serve. Make them your patient-centered medical home today. To schedule an appointment, call the location you wish to visit or request an appointment onlineThey also offer translation services for 36 languages.

For more information, visit: https://www.bmrhc.net/

 

 

 

 

 

SHARE is now sharing patients results with MHC in a phased approach.

• Phase I: Admission, Discharge and Transfers (ADT) notifications are sent based on the patient’s home of record for all Mercy Hospitals in Arkansas (7 Hospitals) and Missouri (14 Hospitals)
• Phase II: Connect Mercy hospitals and clinics to SHARE sending Continuity of Care Documents (CCDs)
• Phase III: Seamlessly deliver patient health information (Laboratory Results, Radiology Reports and Transcribed Documents) across each state’s boarder based on the patient’s home of record

Little Rock, Arkansas – November, 2018 The only statewide HIE in Arkansas, State Health Alliance for Records Exchange (SHARE), is now connected to Missouri Health Connection (MHC) exchanging admission, discharge and transfer (ADT) notifications for patients who live in either state during a phased approach of connection.

This landmark announcement comes after the two health information exchanges are successfully exchanging ADTs with all Mercy Hospitals in Arkansas and Missouri. This is an important achievement to the benefit of patients in both states. It is a great milestone for both SHARE and MHC and we’re happy to implement a solution that allows healthcare providers and hospitals to connect across state borders and SHARE patient results in a HIPAA compliant, secure environment, says Angie Bass, President and CEO, MHC.

By connecting with our border state, Missouri Health Connection will help to improve transitions of care (TOC) for patients who cross the state line. Our collaboration as neighboring states will help providers and hospitals better communicate with one another to better coordinate patient care, and assist in reduction of readmission rates regardless of state borders.

Natural disasters, like tornados in Arkansas and Missouri, present challenges to health systems and providers not only in areas directly impacted, but also to those in neighboring regions who treat patients displaced by the catastrophe. One of the greatest issues: access to patient records. With proper connections, Health Information Exchanges play key role in transmitting patient data. With this connection, both HIE’s will be able to seamlessly deliver patient health information (CCDs, Laboratory Results, Radiology Reports and Transcribed Documents) across each state’s boarder based on the patient’s home of record.

As the healthcare landscape continues to transform, HIEs may play a key role in providing data that fuels innovation. SHARE and MHC are working together to contribute to these innovation efforts such as population health initiatives, identifying potential social determinants of health, potential natural disasters and assisting with payer relations, among other efforts, says Anne Santifer, Executive Director, SHARE.

About State Health Alliance for Records Exchange (SHARE):

SHARE’s Mission is to advance secure connectivity and serve as a sustainable, interoperable data exchange platform for health-related operations.

SHARE’s Vision is to provide a mechanism through which individuals, health care providers, and health organizations can electronically share health-related information to facilitate and strengthen the delivery of healthcare throughout Arkansas. This is designed to lead to improved patient care, informed individual health decisions, better public health outcomes, and cost-effective use of healthcare resources. SHARE is expected to achieve broad acceptance, credibility, and access by employing advanced technologies that ensure efficiency, privacy, and security and continuously evolve to serve Arkansans more effectively.

For more information, visit:  SHAREarkansas.com

 

 

 

 

About Missouri Health Connection (MHC):

MHC, a private, non-profit, statewide health information exchange network, is one of the largest HIE’s in the United States that provides a secure and private electronic platform to electronically share health information.  Since January 2014, the MHC network has been providing the electronic exchange of health records enabling physicians to quickly and securely access patient health records while treating their patients which has improved the quality of health care delivery by coordinating care, reducing preventable errors and avoiding treatment duplication.  MHC’s network includes more than 109 hospitals, hundreds of clinics and more than 7,000 physicians treating more than 15 million patients.

For more information, visit:  https://missourihealthconnection.org

 

Transitions of care (TOC) refers to the movement of patients between healthcare providers, settings and home as their condition and care needs change. The State Health Alliance for Records Exchange (SHARE) is Arkansas’ only statewide Health Information Exchange (HIE). Connecting to HIE’s like SHARE can enable providers to work as a team by having consistent up to date information during transitions of care of their patient population.

1. Access to a more complete health record

HIE’s are connected to many other local and national healthcare providers. Being connected to SHARE can allow real time updates on patients that receive care at another hospital or clinic connected to SHARE. Currently SHARE is connected to over 1,500 Arkansas Hospitals and Practices, over 90 Hospitals in Missouri and Oklahoma, and 24 HIE’s across the US.

 

 

2. Reduce readmission rates

Connecting to HIE’s can allow hospitals to track patients and eliminate any miscommunication that may occur during transitions of care. SHARE offers 30-day readmission notifications which allow hospitals to receive a secure message when a patient that discharges from their facility, was readmitted into any SHARE participating hospital within a 30-day timeframe.

3. Receive patient information in real time

No more time consuming phone calls to other physicians or waiting on a fax. You can send patient information in real time using SHARE. HIE data is digitally shared, meaning that the most up to date information is available as soon as it is uploaded. This contributes to the timeliness of the information needed during transitions of care.

 

 

4. Send and receive information using a secure network

 

SHARE complies with all Federal and state privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and the Arkansas Personal Information Protections Act, which are designed to protect information. Providers can ensure their patients privacy when sending and receiving critical data needed during the transitions of care process.

 

5. Eliminate the hassle and cost of transporting medical records

 

HIE’s take some of the burden off providers having to send patient information through mail, courier or fax. Using HIE’s like SHARE enables providers to view all of their patient’s information in the same place without sifting through piles of paperwork or logging into multiple hospitals or provider systems. Healthcare providers can query SHARE and pull up patient records into their local electronic medical records (EMR) system via a Continuity of Care Document (CCD).

 

On Friday October 19, 2019 SHARE attended and exhibited to 178 provider practices in Benton, Arkansas.  Comprehensive Primary Care Plus (CPC+) program. CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.

CPC+ includes two primary care practice tracks with advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S..). CPC+ includes two primary care practice tracks with advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S..). The care delivery redesign ensures practices in each track have the setup to deliver better care to result in a healthier patient population.

 The multi-payer payment redesign gives practices greater financial resources and flexibility to make appropriate investments to improve the quality and efficiency of care, and reduce unnecessary health care utilization. CPC+ provides practices with a robust learning system, as well as actionable patient-level cost and utilization data feedback, to guide their decision making. 

Providers and care coordinators in the program can use the Health Information Exchange (HIE)  to be notified in the last 24 hours of when their Medicare patients have been admitted/discharged from the emergency department (ED) and inpatient discharged in real-time, see more here : https://sharearkansas.com/providers/comprehensive-primary-care-plus-cpc.

 

There are 2,900 primary care practices currently participating in Comprehensive Primary Care Plus (CPC+) in 18 regions: Arkansas, Colorado, Hawaii, Greater Kansas City Region of Kansas and Missouri, Louisiana, Michigan, Montana, Nebraska, North Dakota, Greater Buffalo Region of New York, North Hudson-Capital Region of New York, New Jersey, Ohio and Northern Kentucky Region, Oklahoma, Oregon, Greater Philadelphia Region of Pennsylvania, Rhode Island, and Tennessee. (List)

See more here about CPC+ initiative: https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus/

 

The OCH Health System is a regional safety-net healthcare provider serving both urban and rural communities throughout the Ozarks. The Hospital is located in Gravette, Arkansas, and clinics located in Missouri and Oklahoma is dedicated to providing advanced healthcare in Northwest Arkansas, West Oklahoma and Missouri through inpatient and outpatient services as well as community outreach. OCH Health System provides acute inpatient, outpatient, and long-term care services, behavioral health, cancer, cardiac, emergency, neurology, respiratory, recuperative, and women's health care; and nutrition counseling, pain management, pediatrics, radiology, surgery, therapy, rehabilitation, urology, weight reduction, wound healing, and mammography services, as well as services for ear, nose, and throat problems.

The following Hospital and Clinics are integrating with SHARE to exchange Continuity of Care (CCDs) to improve transitions of care and improve the quality of care they provide.

Rural Locations

• Gravette Hospital & 24 Hour Emergency Room
• OCH of Gravette Clinic
• OCH of Gravette Specialty Clinic
• OCH Anderson Rural Health Clinic
• OCH Goodman Family Clinic
• OCH Noel Clinic
• OCH Pineville Medical Clinic
• OCH Polk County Clinic
• OCH Jasper County Clinic (Carthage)
• OCH Jay Family Medicine Clinic
• OCH Wellpointe Family Medical Clinic (Marshfield)
• OCH Southwest City Community Clinic
• OCH Sparta Clinic
• OCH Lawrence County Clinic (Mt. Vernon)
• OCH Webster County Clinic (Rogersville)
• Webb City Community Health Clinic

Urban Locations

• OCH Behavioral Health Clinic (Springfield)
• OCH Evergreen Clinic (Springfield)
• OCH Pain Clinic at Evergreen (Springfield)
• OCH Christian County Clinic (Nixa)

About OCH of Gravette

At the OCH Health System, they take pride in standing out. They are simply not a traditional healthcare system, here’s why:

They care. They are an organization that takes pride in what they do, how they do it, and who they serve. They are dedicated to providing care to a high percentage of governmental and uninsured patients and strongly believe in helping the underserved.

Their culture is contagious. Patients who have only visited them once can immediately feel how the OCH Health System is unique. Their hospital staff treats patients like patients, not like numbers in a system. At the OCH Health System, every employee is member of their hospital family and they work hard to extend that relationship to every patient who walks through their door.

Learn more about OCH of Gravette here: https://www.ocholine.com

 

 

 

 

 

 

 

 

 

 

 

 

 

The pace of change in healthcare is rapid, and even more far reaching change may be on the way.  Washington Regional realizes the importance of exceeding expectations for comprehensive healthcare services from birth through end of life care.  Every plan they make, every action they implement, is driven by the desire for quality and is focused on the following central beliefs:

• Providing outstanding clinical quality
• Being good financial stewards
• Providing a rewarding place for our employees to work
• Building, nurturing and preserving a strong partnership with the physician community

A vital component in Washington Regional’s quest for quality is the constant investment in their people, facilities, and technologies. Washington Regional believes that the best outcomes for their patients can be achieved when they coordinate care across a broad scale, from clinics and hospitals to home care, rehabilitation, social services, and pharmacy services.  Quality is their passion and energies will remain dedicated to it. If there is a constant in healthcare, it is change.  They are proud of the ability to adapt in a way that benefits their patients.

Washington Regional’s Mission, Vision, and Values

Mission

Washington Regional is committed to improving the health of people in communities they serve through compassionate, high quality care, prevention and wellness education.

Vision

To be the leading healthcare system in Northwest Arkansas — the best place to receive care and the best place to give care.

Values

To treat others – patients and their families, visitors, physicians, and each other – as we would want to be treated.

 

Learn more about Washington Regional at: https://www.wregional.com/main/about-us.aspx

 

 

SHARE Value/Benefit to Hospitals

• The hospital referral network is able to securely communicate between providers using SHARE’s Direct Trust Secure Messaging to send Continuity of Care Documents (CCDs).

 

• Hospitals use SHARE to send Immunizations, Syndromic Surveillance Data, Electronic Laboratory Reporting, Cancer Reporting to Arkansas Department of Health which assists with Interoperability Program Public Health Objective 6 (listed below). This allows hospitals to meet this objective and be eligible to receive $63,750 in total per Medicaid Eligible Professional (EP) or $43,480 in total per Medicare EP (depending on patient population) in 2018.

 

• SHARE assists hospitals in meeting Health Information Exchange Interoperability Program Objective 5 (listed below) by providing a summary of care record (CCD) for hospital transition of care (TOC) or referral. This allows hospitals to meet this objective and be eligible to receive $63,750 in total per Medicaid EP or $43,480 in total per Medicare EP (depending on patient population) in 2018.

 

• Hospital referral clinics connected to SHARE are able to see the longitudinal record of a patient that was seen by other facilities throughout the State.

 

• Hospital providers are able to access a patient record through the Virtual Health record to view patient summaries and results – (query based exchange) or query SHARE for your patients results– CCDs (Query and Response using xds.b or xca protocol).

 

• Clinics throughout the State will receive a daily report from SHARE connected hospitals. The clinics participating in Arkansas Medicaid Patient Centered Medical Home (PCMH) receive daily reports when a patient is admitted and discharged from the Emergency Departments and/or an Inpatient admission. These daily reports are sent in real-time to clinic care coordinators in their email.

 

Data Types Sent/Receive: CCDs, Admission, Discharge and Transfers (ADT), Radiology Reports, Transcribed Documents, Laboratory Reports and Immunizations

 

SHARE Sending to Referral Partners: SHARE receives CCD/HL-7 messages from hospitals. CCD/HL-7 messages include ADT’s, Radiology Reports, Laboratory Reports, and Transcribed Documents. Transcribed documents include discharge summaries and progress notes and other reports that supports clinics around Arkansas.

Hospital Objectives and Measures for 2018

Updated: June 2018

 

Stages of Promoting Interoperability Programs: First Year Demonstrating Meaningful Use

The Centers for Medicare & Medicaid Services (CMS) established the Promoting Interoperability Programs (formally named the EHR Incentive Programs) in 2011 to encourage eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) to adopt, implement, upgrade and successfully demonstrate meaningful use of certified electronic health record technology (CEHRT).

NOTE: The last year an EP, eligible hospital, or CAH could begin receiving Medicare incentive payments was 2015. The last year an EP, eligible hospital, or CAH could begin receiving Medicaid incentive payments was 2016. In 2016, Section 602 of the Consolidated Appropriations Act of 2016 added subsection (d) hospitals in Puerto Rico as eligible hospitals under the Medicare program, and extended the participation timeline for these hospitals.

The Medicare and Medicaid PI Programs were designed to measure the use of CEHRT in three stages:

Stage 1 established requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information.

Stage 2 expanded upon the Stage 1 criteria with a focus on advancing clinical processes and ensuring that the meaningful use of EHRs supported the aims and priorities of the National Quality Strategy. Stage 2 criteria encouraged use of CEHRT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible.

In October 2015, CMS released the  Medicare and Medicaid Programs Electronic Health Record Incentive Program–Stage 3 and Modifications to Meaningful Use in 2015 through 2017 final rule, which modified Stage 2 requirements to streamline reporting requirements on measures that had become redundant, duplicative, or topped out.

Stage 3 was established in 2017 as a result of the 2015 final rule and focuses on using CEHRT to improve health outcomes. The table on the next page outlines the appropriate stages of the PI Programs based on providers’ first year demonstrating meaningful use.