Meaningful EHR Use- Details on the Final Rule

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1 Meaningful EHR Use- Details on the Final Rule Immunization Coalition December 9th, 2010 Amanda Parsons, MD, MBA Assistant Commissioner Primary Care Information Project NYC Department of Health & Mental Hygiene Primary Care Information Project 0

2 OBJECTIVES Learn about the recently release Meaningful Use rules Understand elements related to vaccinations Q & A Primary Care Information Project 1

3 OVERVIEW OF MEANINGFUL USE The American Recovery and Reinvestment Act (ARRA) authorizes CMS to offer financial incentives to physician & hospital providers who demonstrate meaningful use of an electronic health record (EHR). Meaningful Use is using a certified EHR technology to: 1) Improve quality, safety, efficiency, and reduce health disparities 2) Engage patients and families in their care 3) Improve care coordination 4) Improve population and public health 5) All the while maintaining privacy & security Primary Care Information Project 2

4 FIVE PILLARS OF MEANINGFUL USE 1) Improve quality, safety, efficiency, and reduce health disparities Provide access to comprehensive patient health data for patient s health care team Use evidence-based order sets and CPOE Apply clinical decision support at the point of care Generate lists of patients who need care and use them to reach out to patients 2) Engage patients and families Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health 3) Improve care coordination Exchange meaningful clinical information among professional health care team 4) Improve population and public health Submit immunization, syndromic surveillance and reportable disease data to public health agencies 5) Ensure privacy and security protection for personal health information Protect confidential information through operating policies, procedures, and technologies Provide transparency of data sharing to patient Primary Care Information Project 3

5 THE VISION FOR MEANINGFUL USE Each stage gets progressively harder to drive toward the ultimate goal 3 Stages of Meaningful Use Improved quality of care Stage 3 Stage 2 Stage 1 Primary Care Information Project 4

6 MEANINGFUL USE IMPACT ON ELIGIBLE PROFESSIONALS- CMS ESTIMATES Medicare 477,750 eligible non-hospital-based Medicare professionals in 2011 Of these, ~95,500 would also be eligible for Medicaid (assume they ll choose Medicaid instead) + Medicaid 44,100 Medicaid-only eligible providers in 2011 = 521,850 total eligible providers nationwide Primary Care Information Project 5 5

7 AGENDA Meaningful Use eligibility Incentive payments Meaningful Use measures Immunization specific Primary Care Information Project 6

8 Meaningful Use Eligibility Medicare Eligible Professional: Doctor of medicine or osteopathy, doctor of dental surgery or dental medicine, doctor of podiatry, doctor of optometry or a chiropractor Can t be hospital based (90% services furnished inpatient or ED) Medicaid Eligible Professional: Physicians, nurse practitioner, certified nurse-midwife, or dentist and physician assistants who work at a PA-led FQHC or RHC site Can t be hospital based Must meet one of the following criteria: Have a minimum 30% Medicaid patient volume Have a minimum 20% Medicaid patient volume, and is a pediatrician Practice predominantly in a FQHC or RHC and have a minimum 30% patient volume attributable to needy individuals If eligible for both the Medicare and the Medicaid incentive programs, can only participate in one program, not both. If practicing in multiple locations, at least 50% patients must be treated in locations that have certified EHRs are used meaningfully. Primary Care Information Project 7

9 AGENDA Meaningful Use eligibility Incentive payments Meaningful Use measures Immunization specific Primary Care Information Project 8

10 OVERVIEW OF PAYMENTS Medicare Payments are proportional to Medicare allowed charges (75% of total of allowed charges up to a cap each year, including capitation and copayments) Up to $44,000 over 5 years Payments increased by 10% for physicians practicing in a Health Professional Shortage Area Must participate by 2012 to receive the maximum incentive payment If you are eligible for both Medicare and Medicaid incentives, you must select one Medicaid Payments are fixed and not proportional to Medicaid billings. Up to $63,750 over 6 years If pediatricians qualify at 20%, only eligible for 67% (2/3) of payments Must participate by 2016 to receive the maximum incentive payment Primary Care Information Project 9

11 Meaningful Use Payment: Medicare Participation in the Medicare EHR Incentive Program can begin as early as 2011 or as late as Incentives end in Penalties for not meeting Meaningful Use begin in 2015 (1% in 2015, 2% in 2016, and 3% in 2017) Primary Care Information Project 10

12 AMBULATORY CARE PROPOSED MEDICARE MEANINGFUL USE PAYMENTS Medicare Runs from Physicians are eligible for payments equal to 75% of total Medicare billings, with a yearly cap (phased down from $18,000 in year 1), up to $44,000 Payments are based solely on achieving meaningful use- No upfront payment for adopting, implementing or upgrading EHRs Paid over 5 years, up to 5 payments (if adopt later or achieve meaningful use later, both the # of payments and the amount per payments drops) Primary Care Information Project 11

13 Meaningful Use Payment: Medicaid Medicaid EHR Incentive programs are voluntarily offered by individual states and may begin as early as 2011 or as late as Incentives end in Primary Care Information Project 12

14 AMBULATORY CARE PROPOSED MEDICAID MEANINGFUL USE PAYMENTS Medicaid Runs from Providers whose adult patient mix includes at least 30% Medicaid beneficiaries (pediatrics 20%) (either managed care or fee-for-service) are eligible for up to $63,750 2 types of payments First payment is based on adopting, implementing or upgrading EHR (up to $21,250 for this first payment) Remaining 5 payments are based on achieving meaningful use Up to 6 payments, paid over 6 years (if adopt later/achieve meaningful use later, # of payments available decreases, but not the amount per payment) Primary Care Information Project 13

15 PROPOSED STAGES OF MEANINGFUL USE TIMELINE First Payment Year CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 and later** 2011 Stage 1 Stage 1 Stage 2 Stage 2 TBD 2012 Stage 1 Stage 1 Stage 2 TBD 2013 Stage 1 Stage 2 TBD 2014 Stage 1 TBD 2015 and later* TBD *Avoids payment adjustments only for EPs in Medicare EHR Incentive Program **Stage 3 criteria of meaningful use or a subsequent update to criteria if one is established Primary Care Information Project 14

16 AGENDA Meaningful Use eligibility Incentive payments Meaningful Use measures Immunization specific Primary Care Information Project 15

17 OVERVIEW OF MEANINGFUL USE MEASURES 1) Meaningful Use Objective Measures divided into a core set and a menu set. Core set has 15 measures- must do all 15 Menu set has 10 measures- must choose 5 Must choose at least one population or public health measure 2) As part of the core set, providers will be required to report Clinical Quality Measures to CMS Need to report 6 quality measures 3 core (or use the alternate core quality measures) plus 3 measures from a set of 38 additional measures 3) There are 3 methods by which measures can be reported EHR calculated- denominators only include patients whose records are in EHR Counting- denominators include all patients, regardless if in EHR or not Attestation- providers will attest to whether or not they comply Primary Care Information Project 16

18 YOU WILL BE REPORTING ON 2 TYPES OF MEASURES 1) Meaningful Use objectives Core-must report all 15 Menu- must select 5 of 10, including at least 1 public health measure One of the Core 15 is Report ambulatory clinical quality measures to CMS or the States 2) Clinical Quality Measures Core- must report 3 (3 alternates provided if denominator is 0) Menu- must report 3 of 38 (non-zero denominators) If none apply, need to attest to that Report these through attestation in 2011, but transmission starting in 2012 Measure practices process Measure clinical outcomes & processes Primary Care Information Project 17

19 MEANINGFUL USE MEASURES (CORE + MENU SET) 1) Submit all 15 Meaningful Use CORE SET Measures Counting (all pts seen) CPOE erx Vitals smoking status clinical summaries EHR calculation (EHR pts seen) Demographics problem list med list med allergy list health info Quality Measures * Yes/No attestation drug-drug/allergy checks CDSS exchange info protect PHI and + 2) Submit 5 of 10 MENU SET Measures Counting (all pts seen) lab results Reminders access to health info med reconciliation summary of care EHR calculation (EHR pts seen) patient education Yes/No attestation lists of patients drug/formulary immunization registries syndromic surveillance Primary Care Information Project 18

20 CLINICAL QUALITY MEASURES MUST BE SUBMITTED FOR 2011 AND 2012 REPORTING PERIODS Choose 3 Core Measures 1. BP control 2. Smoking screening & Cessation 3. Weight screening Alternate Core Measures 1. Weight assessment 2. Influenza immunization (Pts >50 years old) 3. Childhood immunization and + Choose 3 (Examples of the 38 clinical quality measures) 1. HbA1C> 9 2. LDL < BP < 140/90 4. ACE or ARB in HF 5. Beta-blocker in hx of CAD or MI 6. Pts >50 yrs old w/ influenza vaccine 7. Pts > 65 yrs old w/ pneumovax vaccine 8. Breast CA screening 9. Colorectal CA screening 10.Antiplatelet therapy in CAD 11.Beta-blocker in HF +LVSD 12.Anti-depression medication in new episode of depression 13.Others. 07/10 SOURCE: HIT Policy Committee; HCI HIT team analysis Primary Care Information Project 19

21 AGENDA Meaningful Use eligibility Incentive payments Meaningful Use measures Immunization specific Primary Care Information Project 20

22 OBJECTIVE MEASURE MENU SET- IMMUNIZATION REGISTRY DATA SUBMISSION Objective: Measure: Exclusions: Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law & practice Perform at least 1 test of certified EHR technology s capacity to submit electronic data to immunization registries & follow up if the test is successful (unless none of the immunization registries to which the EP submits such information has the capacity to receive the information electronically An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically Primary Care Information Project 21

23 IMMUNIZATION REGISTRY DATA SUBMISSION- ADD L INFO Additional information The test to meet the measure must involve actual submission of information to a registry or immunization information system, in one exists. Simulated transfers are not acceptable The transmission of actual patient information is not required for the purpose of a test. The use of test information about a fictional patient would satisfy this objective If multiple EPs are using the same certified EHR technology in a shared physical setting, testing would only have to occur once for a given certified EHR technology An unsuccessful test to submit electronic data to immunization registries will be considered valid & would satisfy the objective If the test is successful, then the EP should institute regular reporting in accordance to applicable law & practice The transmission of immunization information must use the standards from 45 CFR (k) Primary Care Information Project 22

24 CLINICAL QUALITY MEASURES- ALTERNATE CORE: INFLUENZA VACCINE Influenza Vaccination for Pts> 50 years Measure: % of patients aged 50 years old and older who received an influenza immunization during the flu season (Sept to Feb) Denominator: All active patients >49 years old in the EHR Exclusions: TBD Primary Care Information Project 23

25 CLINICAL QUALITY MEASURES- ALTERNATE CORE: CHILDHOOD IMMUNIZATION STATUS Childhood Immunization Status Measure: % of patients 2 years or older who have 4 th DTAP, 3 IPV, 2 HiB, 3 Hep B, 1 VZV, 4 PCV, 2 Hep A, 2 or 3 RV, and 2 flu vaccines by their 2 nd birthday (NQF 0038) Denominator: All active patients aged 2 or over Exclusions: TBD Primary Care Information Project 24

26 CLINICAL QUALITY MEASURES- MENU: PNEUMONIA VACCINATION Pneumonia Vaccination for Pts> 65 years Measure: % of patients 65 and older as of Jan 1 of the measurement year who have ever received a pneumococcal vaccine (NQF 0043) Denominator: All active patients aged 65 or over Exclusions: TBD Primary Care Information Project 25

27 Thank you, from the PCIP & NYC REACH teams Primary Care Information Project 26 26

28 UNUSED SLIDES SOURCE: Final Rule Primary Care Information Project 27

29 CALCULATING MEDICAID VOLUMES/ELIGIBILITY States will be able to select their methodology: Potential Option 1- Encounter volume Total # Medicaid pt encounters All pt encounters treated over any 90-day period from previous year Potential Option 2- Medicaid panel Total # Medicaid patients in provider panel All patients in provider panel For EPs applying for Medicaid incentives working at FQHC/RHC: Providers must demonstrate that 50% of their patient encounters occur at the FQHC or RHC over a 6 month period and 30% of their patient volume qualify as needy (Medicaid, uninsured, free care, sliding scale) Medicaid dual eligibles count, as well as Family Health Plus, but Child Health Plus does not You can use practice or clinic level data if all eligible professionals at the clinic use this methodology and all see Medicaid patients (must have auditable data source) Primary Care Information Project 28

30 Meaningful Use Payment: Medicaid Medicaid EHR Incentive programs are voluntarily offered by individual states and may begin as early as 2011 or as late as Incentives end in Primary Care Information Project 29

31 Medicaid Payment Year 1 Providers must demonstrate that they have adopted, implemented or upgraded certified EHR technology Providers also must demonstrate that they (or someone else) has covered 15% of net allowable charges Incentives cover 85% of net average allowable costs related to EHR purchase, updates, training, implementation, and maintenance (excludes any discounts or technology donations received), capped at $25,000 for payment year 1 and $10,000 for Years 2-6 Provider is responsible for 15% of net average allowable costs (15% x $25K = $3750 in year 1; $1500 in years 2-6) Allowable costs include costs associated with: Purchase, support services implementation, integral related training, upgrade,costs of operating, maintaining, and using No reporting period for this requirement. It simply has to be accomplished before they attest to that fact to the State. The first year a Medicaid provider demonstrates meaningful use the EHR reporting period is 90 days. Do I need to save receipts and turn in items? Medicaid providers may be required to produce receipts or documentation in support of their attestation of the first year incentive for adoption, implementation or upgrading of certified EHR technology. All providers should keep documentation that they have and are using certified EHR technology in case of future audit. Primary Care Information Project 30

32 AMBULATORY CARE PROPOSED MEDICAID MEANINGFUL USE PAYMENTS Medicaid Runs from Providers whose adult patient mix includes at least 30% Medicaid beneficiaries (pediatrics 20%) (either managed care or fee-forservice) are eligible for up to $63,750 2 types of payments First payment is based on adopting, implementing or upgrading EHR (up to $21,250 for this first payment) Remaining 5 payments are based on achieving meaningful use Up to 6 payments, paid over 6 years (if adopt later/achieve meaningful use later, # of payments available decreases, but not the amount per payment) Primary Care Information Project 31

33 OBJECTIVE CORE MEASURES 1/3 SOURCE: Final Rule Primary Care Information Project 32

34 OBJECTIVE CORE MEASURES 2/3 SOURCE: Final Rule Primary Care Information Project 33

35 OBJECTIVE CORE MEASURES 3/3 SOURCE: Final Rule Primary Care Information Project 34

36 OBJECTIVE MENU MEASURES 1/3 SOURCE: Final Rule Primary Care Information Project 35

37 OBJECTIVE MENU MEASURES 2/3 SOURCE: Final Rule Primary Care Information Project 36

38 OBJECTIVE MENU MEASURES 3/3 SOURCE: Final Rule Primary Care Information Project 37

39 CLINICAL QUALITY MEASURES 1/4 SOURCE: Final Rule Primary Care Information Project 38

40 CLINICAL QUALITY MEASURES 2/4 SOURCE: Final Rule Primary Care Information Project 39

41 CLINICAL QUALITY MEASURES 3/4 SOURCE: Final Rule Primary Care Information Project 40

42 CLINICAL QUALITY MEASURES 4/4 SOURCE: Final Rule Primary Care Information Project 41

43 HOW TO LEARN MORE ABOUT MEANINGFUL USE Current PCIP Participants Sign up to have your membership roll over at end of two-year PCIP agreement Speak to a PCIP staff member or Fill out agreement at REACH table New Members Fill out application at NYCREACH.org More Information NYCREACH.org March PCIP Bulletin Stop by REACH table with questions! Primary Care Information Project 42

44 Meaningful Use Payment: Medicare Participation in the Medicare EHR Incentive Program can begin as early as 2011 or as late as Incentives end in For year 1, physicians will qualify based on any 90-day reporting period Later years will require reporting on full year A Payment Year is a calendar year. Physicians who attest to Meaningful Use and bill Medicare for $24,000 should receive full payment of $24,000 once they meet this threshold If you bill less than $24,00, you will receive a pro-rated payment equal to 75% of charges after the payment year has closed Source: Accenture, 2010 Primary Care Information Project 43

45 OBJECTIVES OF AMBULATORY "MEANINGFUL EHR USE" OVER TIME (1/3) Stage 3 State 2 Stage 1 07/10 1. Improve quality, safety, efficiency, and reduce health disparities SOURCE: Final Rule Core Set Use CPOE for 30% of medication orders Implement drug-drug & drug-allergy Generate and transmit 40% permissible prescriptions electronically (erx) Record key demographics for 50% of patients Maintain an up-to-date problem list of current and active diagnoses for 80% of patients Maintain active medication and allergy list for 80% of patients Record and chart changes in vital signs for 50% of patients Record smoking status for 50% of pts > 13 years Implement one clinical decision rules relevant to clinical quality measures Report selected quality measures to CMS Menu set Implement drug-formulary checks Incorporate 50% of lab-test results into EHR as structured data Generate lists of patients by specific condition to use for quality improvement outreach Send reminders for preventive/follow up care to 20% of patients >65 yrs or less than 5 yrs old DRAFT Use evidence-based order sets Manage chronic conditions using patient lists and decision support Record family medical history Manage chronic conditions using patient lists Provide clinical decision support at the point of care Check insurance eligibility electronically for 80% of patients Submit 80% claims electronically to public and private payers DRAFT Achieve minimal levels of performance on quality, safety, and efficiency measures Implement clinical decision support for national high priority conditions Medical device interoperability Multimedia support (e.g. x- rays) Primary Care Information Project 44

46 OBJECTIVES OF AMBULATORY "MEANINGFUL EHR USE" OVER TIME (2/3) 2. Engage patients and families Stage 1 Core Set Provide patients with timely electronic access to their health information (lab results, problem list, medication lists, allergies) 1 Provide clinical summaries for 50% of all office visits within 3 business days Stage 2 Access for all patients to a PHR populated in real time with health data Offer secure patientprovider messaging Provide access to patientspecific educational resources in common primary languages Incorporate data from home monitoring devices Stage 3 Patients have access to selfmanagement tools Electronic reporting on experience of care 3. Improve care coordination Core Set Capability to electronically exchange key clinical information ( problem list, medication list, allergies, test results) among providers of care and patient-authorized entities Menu set Perform medication reconciliation at 80% relevant encounters and transitions of care 3 Retrieve and act on electronic prescription fill data Share an electronic summary care record for every transition in care (place of service, consults, discharge) Perform medication reconciliation at each transition of care from one health care setting to another Access comprehensive patient data from all available sources SOURCE: Final rule Primary Care Information Project 45

47 OBJECTIVES OF "MEANINGFUL USE" OVER TIME (3/3) 4. Improve population and public health 5. Ensure adequate privacy and security protection for personal health information 2011 Menu Set Electronically transmit data to immunization registries where required and accepted 1 Electronically transmit syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice Core Set Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities 2013 Receive immunization histories and recommendations from immunization registries 1 Receive health alerts from public health agencies Provide sufficiently anonymized electronic syndrome surveillance data to public health agencies with capacity to link to personal identifiers Use summarized or deidentified data when reporting data for population health purposes (e.g. public health, quality reporting, and research), where appropriate, so that important information is available with minimal privacy risk 2015 Use of epidemiologic data Automated real-time surveillance (adverse events, near misses, disease outbreaks, bioterrorism) Clinical dashboards Dynamic and Ad hoc quality reports Provide patients, on request, with an accounting of treatment, payment, and health care operations disclosures Protect sensitive health information to minimize reluctance of patient to seek care because of privacy concerns SOURCE: Final rule Primary Care Information Project 46

48 NYC REACH WILL HELP YOU GET TO MEANINGFUL USE Step 1 (July Sept) Step 2 (Oct- Nov) Step 3 (Jan 11-onwards) NYC REACH Providers Implementation support Bidirectional lab interface MU research MU education Vendor oversight Labs & erx Attend seminars, webinars Read materials Request patient portal Ensure correct software version Support tickets Conduct & analyze MU assessments Remediate issues Start on site visits MU education MU EMR trainings MU Reports Select incentive program Fill out our assessment tool Prepare for onsite visits (gather?s) Select measures Application support documents Onsite visits & issue remediation MU EMR trainings MU Reports Learning Preparation Submission Participate in onsite visits Joint preparation of submission (document compilation etc..) Primary Care Information Project 47

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