Meaningful Use of Computers in Medicine. How Will NICUs Fit In?

Transcription

1 Meaningful Use of Computers in Medicine How Will NICUs Fit In? Willa H. Drummond, MD, MS (Informatics) Professor of Pediatrics & Physiology University of Florida College of Medicine

2 Disclosures Relevant financial relationships Nothing to disclose FDA Nothing to disclose

3 Seven years ago... Within 10 years, every American must have a personal electronic medical record. That's a good goal for the country to achieve. The federal government has got to take the lead in order to make this happen.. George W. Bush, April 26,

4 ARRA Legislation ( Stimulus Bill ) American Recovery & Reinvestment Act Passed & signed; Feb 2009 Anticipated HIT budget $45 Billion Final Meaningful Use Incentive Criteria Published - July Months Later! STIMULUS Bill incentives 2011 Fiscal Year. Thus, so do the MU timelines. Hospitals 2011 Fiscal Year started in October, 2010 Lead time was very short (2.5 months!) Usual development time for software upgrades, testing<> installation is about 18 months.

5 Timeline for Meaningful Use (What took so long?) Certification Process NPRM Released Final Rule Released (60 days to draft final rule) Federal process to recognize certification entities established (60 days after effective date) Significant number of products certified (6 months after first entity recognized) Vendor places hospital on schedule (6 month wait time) Achieve meaningful use for the first time (90 day reporting period) Mar 2010 May 2010 July 2010 Sep 2010 Nov 2010 Jan 2011 June 2011 July Dec 2011 Jan June 2012 July Dec 2013 Jan Mar 2014 Comments on NPRM due (60 days) Final Rule effective (60 days after release) First certification entities recognized by federal government (60 days after established) Hospitals select products and establish contracts (6 month process) Installation (18 to 24 month process) T Incentive Program To Start FY 2011 FINAL RULE Amount of incentive drops for newly eligible hospitals FY 2014 Penalties begin FY 2015

6 Historical Look at Spending in Health IT Total Federal Health IT Spending (through ONC ) before the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act: $300,000,000 Total expected gross outlays through HITECH (up to): $45,000,000,000 15,000% increase >>>>>> Breathe... 6

7 Meaningful Use - DOB July, page document for the Final Rule Only discusses STAGE ONE 15 core requirements, 10 menu requirements Quality Measures are not Pediatric appropriate Eligibility Based on Medicare/Medicaid Patients 20% to 30% Medicaid patient encounters Inpatient physicians, some with > 50% Medicaid patients..are excluded from incentive payments. Infants under age 2 are also excluded (both Inpatient and Outpatient) NEED for Advocacy and Advising Office of the National Coordinator ( ) Center for Medicare and Medicaid Services ( ) Multiple Standards and Policy Agencies AAP Child Health Informatics Center (CHIC)

8 Mission and Goals The Meaningful Use framework will be about the goals of care, not the technology. The HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters. David Blumenthal, MD National Coordinator, ONCIT

9 Meaningful Use Example

10 Meaningful Use - Objectives Improve quality, safety, efficiency and reduce disparities Engage patients Improve coordination of care Ensure privacy & security of PHI Improve population health and interact with public health programs

11 Stage Focus Date Range Stage 1 Electronic data capture, track & communicate key conditions, clinical decision support (CDS), quality measure & public health data reporting Starting in 2011 Stage 2 Expands on Stage 1, covers disease management dimensions, information exchange in the most structured format possible (CPOE and diagnostic study results like Labs & Rads) Stage 3 Promotes improvements in quality, safety & efficiency as well as population health, focuses on CDS for national high priority conditions & Patient self-management tools (Subject to great change & many refinements) Starting in 2013 Starting in 2015

12 What is MU & Who determines it? The three basic requirements for Meaningful Use as defined in the new law, include: Use of certified EHR technology. Electronic exchange of health information Use EHR to report clinical and process-based quality measures Medicare & Medicaid patient mix defines eligibility.

13 Vendor Certification Processes Two Certification Programs Temporary certification program to test and certify Complete EHRs and/or EHR Modules (until Q1 2012) To Assure availability of Certified EHR Technology in time to meet MU incentives (for 2012 and beyond). Permanent certification program to replace the temporary certification program Separate the responsibilities for performing testing and certification Introduce accreditation requirements Establish requirements for certification bodies. 3 Certifying Agencies approved 12/ Certified products as of Oct 1, 2010 Still a Work in Progress.

14 HITECH's Framework for MU $$$s Blumenthal D. N Engl J Med Feb 4;362(5):382-5.

15 MU Operational Plans: Regional Extension Centers (RECs) $650 million funded by the HITECH Act Creating a network of ~70 Regional Health Information Technology Extension Centers Focusing initially on primary care providers in small practices Assists and advises physicians and hospitals in gaining Meaningful Use of EHRs. HITECH regional readiness is uneven.

16 Which Health Care Professionals Are Eligible for MU Incentives? Under the HITECH Act, an eligible professional is defined as, a physician, as defined in section 1861(r) of the Social Security Act; which includes: Physician Excludes Hospitalists Dentists Podiatrists Optometrists Chiropractors

17 Medicare & Medicaid Services: EHR Incentive Program Defines Eligible Hospitals (EH) & Eligible Professionals (EP) Establishes payment years & reporting periods Creates 3 Stages of implementation; Provides details on Stage 1 Goals & requirements for 2011 and Includes hospitals, but.. Inpatient Physicians (IPs) are bystanders in the mandate... Excluded from financial incentive eligibility, Few adequate computer tools exist for complex venues, No pediatric-designed Inpatient systems yet exist, and; Babies & Toddlers were excluded.

18 What is required for MU? Provider Must use the certified EHR as the primary record of care for patients Reports certain clinical quality measures to CMS (or the State under Medicaid) Provides certain attestations regarding EHR use.

19 How will physicians prove MU? Demonstration of Meaningful Use and information exchange may be satisfied by: An attestation (2011) ~ like IRS forms Submission of claims with appropriate coding After code sets are stabilized during ICD10 roll-out in 2013 Electronic reporting of clinical quality measures Increasing percentages at each stage Quality measures now are challenged as not data based Or as unlikely to change behavior, or improve care (e.g. the smoking question)

20 Eligibility Under Medicaid: Providers Any Provider with a National Provider Identifier Who over a continuous, representative 90-day period in the calendar year prior to reporting: Has at least 30% of all patient encounters as Medicaid patients; or, Is a PEDIATRICAN and has at least 20% of all patient encounters with Medicaid patients

21 Being a Pediatrician is an Advantage: Medicare providers will have $ penalties as early as 2015 for failing to meet MU criteria No MU penalties (after 2015) for Medicaid participants Proposes implementation schedules and MU criteria for 2013 are in the public comment period Comment Deadline for 2013 MU criteria is 2/28/2011 ( Please speak your minds & voice your opinions re excluding infants and children < 2 years old, and inpatient docs...today.

22 Medicaid Providers Users of Certified EHR Technology in 2011 Do NOT need to demonstrate Attestation ONLY! Registration requires State CMS office readiness. Earliest Payment: Register: January 2011 Attest: April 2011 Payment: May 2011

23 MU Registration Began Jan 3, 2011 Registration is Administered by the Centers for Medicare & Medicaid Services (CMS). State by State Basis As of Februqry 2011 (about 2 dozen) states were ready to process incentive applications. Florida was not First checks have already been sent out, in Nebraska..

24 Core Set Use CPOE Denominator: Unique patients with at least one medication Numerator: Number of patients with at least one medication order in CPOE Goal: >30%

25 Core Set Drug-Drug & Drug-Allergy Check Functionality enabled 100% of the time Unintended Consequences: Physician workarounds for over-alerting and alert fatigue eprescribing Denominator: permissible prescriptions Numerator: prescriptions transmitted electronically using the EHR Goal: >40%

26 Core Set Record Demographics Date of Birth (needs Time), Preferred Language, Gender, Race, Ethnicity, (2010 census definitions) Denominator: Unique patients Numerator: Patients with recorded demographics Goal: >50%

27 Core Set Recording of Smoking Status Denominator: Unique Patients >= 13 years Numerator: patients with recorded smoking status Goal: >50%

28 Core Set Clinical Decision Support Implement one CDS rule Report Ambulatory Clinical Quality Measures 2011 attestation 2013 electronic submission 2015 under development

29 Core Set Electronic Copy of Health Information Diagnostic test results, problem list, medication list, medication allergy list Denominator: All unique patients who requested a copy Numerator: Patients who received a copy within 3 business days Goal: >50%

30 Core Set Clinical Summary May include updated medication list, test results, procedures and instructions Denominator: All unique patients Numerator: Patients who received a Clinical Summary within 3 business days Goal: >50%

31 Core Set Capability to exchange key clinical information Perform 1 test of EHR s capacity to exchange electronically Protect EHR information Security risk analysis, implement security, correct deficits

32 2011 Menu Set - select 5 of *Implement drug-formulary checks Functionality enabled and access to 1 or more or formularies 2. *Incorporate lab results >40% of laboratory results are incorporated in EHR 3. *Patient List by condition Generate at least 1 report of patients with a specific condition * Possibly could apply to NICU Inpatients

33 2011 Menu Set - select 5 of Preventive or Follow-Up Care >20% of patients >=65 years or <=5years received an appropriate reminder 5. *Timely Electronic Access >10% of unique patients are provided electronic access to health information within 4 business days Providers may withhold information * Possibly could apply to NICU Inpatients

34 MU Measurement Even though incentives are paid by Medicare or Medicaid, the requirements for MU apply to ALL patients.??? MU measurements are based on a percentage of ALL patients

35 Measure Reporting Rules for Kids Pediatricians required to report 3 core measures 3 alternate core measures If the denominator is 0 for any core measure, replace with alternate core measures If the denominator is 0 for all core and alternate core measures, then report on 3 of the additional measures Is this kid over or under 2? Does he count as a person?

36 Additional Measures = 0 for NICU % of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) and prior myocardial infarction (MI) that were prescribed beta-blocker therapy. % of patients 65 years of age and older who have ever received a pneumococcal vaccine. % of women years of age who had a mammogram to screen for breast cancer. % of adults years of age who had appropriate screening for colorectal cancer. % of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy. % of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD (LVEF < 40%) and who were prescribed betablocker therapy. The % of patients 18 years of age and older who were diagnosed with a new episode of major depression,.pediatric-appropriate treated with antidepressant health medication, concerns and who remained on an antidepressant medication treatment. Meaningful Quality Reporting Measures for Pediatrics are limited. Reporting Measures are of little use to sub-specialists Many measures could have been expanded to include Ignoring infants health is ignoring our future. % of patients aged 18 years and older with a diagnosis of primary open angle glaucoma (POAG) who have been seen for at least 2 office visits who have an optic nerve head evaluation during one or more office visits within 12 months. % of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.

37 MU: Demographics & Opinions WHAT ARE PHYSICIANS THINKING?

38 23% Do Not Intend To Pursue Stimulus Incentives Source: Texas Medical Association survey, 2009

39 23% Do Not Intend To Pursue Stimulus Incentives Source: Texas Medical Association survey, 2009

40 17% Do Not Plan On An EMR Source: Texas Medical Association survey, 2009

41 What s the Problem With EMRs? 38% 50% 13% 12% 32% 31% 27% 23% 6% Source: TMA survey, 2009

42 So what to do? Certified EHR talk to your vendor! National Provider Identifier get yours, if necessary Assess Your Medicaid Population Your Inpatients may boost the hospital s overall eligibility Hospital-based practices, NICUs, PICUs and their physicians, may suffer rapid implementations of software systems not designed to support the teamwork-based, real-time critical workflow for infants. Source and nature of rewards for NICU and Hospitalist docs is unclear. Prepare for negotiations ahead.

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49 Much Thanks To Many Sources Medicare and Medicaid Programs; Electronic Health Record Incentive Program - Notice of Proposed Rule Making. Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology - Interim Final Rule Diamond L, Bates M. Quality Metrics Requirements for Obtaining Meaningful Use: Developing a Plan for Implementation. (HIMSS web site) Minnesota health: HIMSS: One stop for all ARRA information ONC: CMS: Tennessee Office of ehealth Initiatives California Center for Connected Health Dr. Joseph Schneider, Past-Chair, AAP Council on Clinical Information Technology Dr. Eugenia Marcus, Past Vice-Chair, AAP COCIT Ms. Joy Kuhl, Alliance for Pediatric Quality/HL7 Peds SIG Ms. Beki Marshall & Ms. Jennifer Mansour, AAP Council Staff Extrordinaire Dr. Chris Lehmann, Founding Director, AAP Child Health Informatics Center (CHIC)

50 Acronyms Dictionary AQA Ambulatory Care Quality Alliance LINK ARRA American Recovery and Reinvestment Act (a.k.a. the stimulus bill ) LINK CCHIT Certification Commission on Health Information Technology CDS Clinical Decision Support LINK, Text Book (link) CPOE Computerized Provider Order Entry CPI Continuous Process Improvement EH - Eligible Hospital as defined by the CMS EHR Incentive Program (Internal Link) EHR Electronic Health Record EP Eligible Provider as defined by the CMS EHR Incentive Program (Internal Link) HIE Health Information Exchange HIT Health Information Technology HITECH - Health Information Technology for Economic and Clinical Health Act HQA Hospital Quality Alliance (LINK) IFR Interim Final Rule LINK MU Meaningful Use LINK NACHRI National Association of Children s Hospitals and Related Institutions NPRM Notice of Proposed Rule Making LINK NQF National Quality Forum LINK ONC The Office of the National Coordinator for Health Information Technology LINK PHI Protected Health Information LINK PI Process Improvement LINK PQRI Physician Quality Reporting Initiative LINK QuIIN Quality.. RECs Regional Extension Centers RHQDAPU Reporting Hospital Quality Data for Annual Payment Update LINK