HIT Incentives: Issues of Concern to Hospitals in the CMS Proposed Meaningful Use Rule

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1 HIT Incentives: Issues of Concern to Hospitals in the CMS Proposed Meaningful Use Rule Lori Mihalich-Levin, J.D. Senior Policy Analyst Jennifer Faerberg Director, Health Care Affairs

2 Understanding Meaningful Use AAMC Teleconferences: 2-3:30 ET February 4: Hospital Issues February 11: ONC Standards and Misc. Issues Comments on both the CMS and ONC rules are due March 15, 2010 COMMENTS ARE IMPORTANT!! 2

3 Agenda for Today s Call 1. Meaningful use functionality measures 2. Quality measures 3. Multiple hospitals under single CCN 4. Charity care issues 5. Discharge data sources 6. Hospital-based eligible professionals 7. Anything else? 3

4 Have you met IT functionality? CMS proposes 3 Stages of requirements Right now, only have details for Stage 1 proposed requirements Reporting is by attestation through secure mechanism Hospitals must meet all 23 measures 4

5 Proposed Stages of Meaningful Use By Payment Year First Payment Payment Year Year for EP or Hospital ** 2011 Stage 1 Stage 1 Stage 2 Stage 2 Stage Stage 1 Stage 1 Stage 2 Stage Stage 1 Stage 2 Stage Stage 1 Stage * Stage 3 * Avoids payment adjustments only for EPs in the Medicare EHR Incentive Program. ** Stage 3 criteria of meaningful use or a subsequent update to the criteria if one is established Source: Federal Register, Table 1 (p. 1854) 5

6 Meaningful Use Reporting Periods? First payment year (i.e. 1 st year a hospital receives payment): Any continuous 90-day period Subsequent payment years: Entire FFY 6

7 7 Medicare Meaningful Use Reporting Period for FY 2011:

8 Meaningful Use Functionality Objective Use of CPOE for orders (any type) directly entered by authorizing provider (for example, MD, DO, RN, PA, NP) Measure CPOE is used for at least 10 percent of all orders 8

9 Meaningful Use Functionality Objective Implement drug-drug, drugallergy, drug-formulary checks Measure The eligible hospital has enabled this functionality 9

10 Meaningful Use Functionality Objective Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT Measure At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry or an indication of none recorded as structured data 10

11 Meaningful Use Functionality Objective Maintain active medication list Measure At least 80 percent of all unique patients admitted by the eligible hospital have at least one entry (or an indication of none if the patient is not currently prescribed any medication) recorded as structured data 11

12 Meaningful Use Functionality Objective Maintain active medication allergy list Measure At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry (or an indication of none if the patient has no medication allergies) recorded as structured data 12

13 Meaningful Use Functionality Objective Record demographics (preferred language, insurance type, gender, race, ethnicity, date of birth, date and cause of death in the event of mortality) Measure At least 80 percent of all unique patients admitted to the eligible hospital have demographics recorded as structured data 13

14 Meaningful Use Functionality Objective Record and chart changes in vital signs Measure For at least 80 percent of all unique patients age 2 and over admitted to the eligible hospital, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20 14

15 Meaningful Use Functionality Objective Record smoking status for patients 13 years old or older Measure At least 80 percent of all unique patients 13 years old or older admitted to the eligible hospital have smoking status recorded 15

16 Meaningful Use Functionality Objective Incorporate clinical lab-test results into EHR as structured data Measure At least 50 percent of all clinical lab tests results ordered by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data 16

17 Meaningful Use Functionality Objective Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach Measure Generate at least one report listing patients of the eligible hospital with a specific condition 17

18 Meaningful Use Functionality Objective Report hospital quality measures to CMS or the States Measure For 2011, an eligible hospital would provide the aggregate numerator and denominator through attestation For 2012, electronically submit the measures 18

19 Meaningful Use Functionality Objective Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules Measure Implement five clinical decision support rules relevant to the clinical quality metrics the eligible hospital reports 19

20 Meaningful Use Functionality Objective Check insurance eligibility electronically from public and private payers Measure Insurance eligibility checked electronically for at least 80 percent of all unique patients admitted to an eligible hospital 20

21 Meaningful Use Functionality Objective Submit claims electronically to public and private payers Measure At least 80 percent of all claims filed electronically by the eligible hospital 21

22 Meaningful Use Functionality Objective Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies, discharge summary, and procedures), upon request Measure At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours 22

23 Meaningful Use Functionality Objective Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request Measure At least 80 percent of all patients who are discharged from an eligible hospital and who request an electronic copy of their discharge instructions and procedures are provided it 23

24 Meaningful Use Functionality Objective Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically Measure Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information 24

25 Meaningful Use Functionality Objective Perform medication reconciliation at relevant encounters and each transition of care Measure Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care 25

26 Meaningful Use Functionality Objective Provide summary care record for each transition of care and referral Measure Provide summary of care record for at least 80 percent of transitions of care and referrals 26

27 Meaningful Use Functionality Objective Capability to submit electronic data to immunization registries and actual submission where required and accepted Measure Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries 27

28 Meaningful Use Functionality Objective Capability to provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received Measure Performed at least one test of certified EHR technology capacity to provide electronic submission of reportable lab results to public health agencies (unless none of the public health agencies to which eligible hospital submits such information have the capacity to receive the information electronically) 28

29 Meaningful Use Functionality Objective Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice Measure Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically) 29

30 Meaningful Use Functionality Objective Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities Measure Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1) and implement security updates as necessary 30

31 Quality Measure Reporting Report on 35 quality measures FY 11 reporting via attestation numerator/denominator exclusions ALL patients FY 12 reporting, if CMS has capability, via EHR Measures required for EHR incentive and current pay-for-reporting program must only be submitted once through EHR program 31

32 Quality Measure Reporting Issues: Proposed measures have not been tested or validated for EHR submission (Stroke, VTE and ED scheduled for spring) Volume of measures and timeline Not all measures can be calculated by hospitals (risk adjusted readmission rates) Creating parallel reporting programs What measures should be dropped from the list and why? 32

33 Multiple Hospitals under Single CCN CMS proposes to identify a hospital: By Medicare provider number (CCN) Thus, multi-campus systems will only receive one set of incentive payments (and more likely to reach discharge cap ) (Anyone else with this issue?) 33

34 Multiple Hospitals under Single CCN Potential problems with this policy? Doesn t foster widespread EHR use Doesn t reflect deployment costs Installation & training are by site and EHR needs differ by site Penalties for entire system, even if just one campus isn t a meaningful user 34

35 Multiple Hospitals under Single CCN Possible solutions? Multi-pronged approach that includes: Distinct CCN Presence of an ED Distinct state hospital license RAC program documentation request limits are per campus TIN + first 3 digits of ZIP code where physically located 35

36 Medicare Incentives to Hospitals What is the hospital payment formula? [(Base amount + Discharge related amount) x Medicare share] x Transition factor 36

37 Charity Care Issues Hospital Incentives [(Base amount + Discharge related amount) x Medicare share] x Transition factor Medicare Share: Numerator: total estimated Part A and C inpatient days Denominator: total estimated inpatient days adjusted to exclude any charges attributable to charity care 37

38 Charity Care Issues Where to Get Charity Care Charges?: Medicare: use charges reported on Line 19 of revised Worksheet S-10 of the hospital cost report Medicaid: state may use S-10 or other auditable data source Final version of Worksheet S-10 not yet released Note: hospitals providing greater proportions of charity care receive higher EHR payments 38

39 Charity Care Concerns Don t know what final instructions will say What data to use for preliminary payments? What data to use for hospitals whose FY starts 1/1/2010? Track your state s decision on this particularly important because aggregate amount gets calculated prospectively for Medicaid Other concerns? 39

40 Discharge Data Sources Under Medicare & Medicaid formulas, hospitals receive $200 per discharge from 1,150 23,000 th discharge CMS proposes to use discharge data from hospital FY that ends during FY prior to payment year Need clarification on: Do total discharges include nursery discharges? Other questions? 40

41 Hospital-Based Eligible Professional Issues Statutory language regarding a hospital-based EP: An EP who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination... shall be made on the basis of site of service and without regard to any employment or billing arrangement between the eligible professional and any other provider. 41

42 Site of Service Inpatient setting Hospital outpatient settings care furnished to registered hospital outpatients: Outpatient setting in main provider On-campus and off-campus provider based department of the hospital Entities having provider-based status 42

43 Site of Service Codes Look to place of service (POS) codes on physician claims: 21: Hospital inpatient 22: Outpatient hospital 23: Emergency room, hospital 43

44 Substantially all Defined as: Furnishing at least 90% of services in a hospital setting, either inpatient or outpatient Determination made annually based on EP s claims from prior year For Medicare incentive: Medicare claims For Medicaid incentive: o Medicaid claims o Medicaid managed care: encounter data or equivalent 44

45 How many hospital-based EPs? CMS estimates: 27% of Medicare EPs 12-13% of family practitioners under Medicare CMS concern: disincentive for hospitals to invest in outpatient EHR systems Future rulemaking: broader definition of hospital care to include outpatient services? UHC-AAMC Faculty Practice Solutions Center estimates 38% of faculty qualify as hospitalbased 45

46 % Respondents Faculty Often Fund All Phases of EHR Adoption at Provider-Based Clinics 100% Who funds the costs of an EHR? 75% 50% 25% Hardware Software Implementation Maintenance 0% Hospital Clinical Services Other EHR Funding Sources Clinical services defined as funding from the faculty practice, medical school, or department. Totals for each phase may exceed 100% because multiple funding sources could be selected. Source: AAMC Survey of EHR implementation at Academic Clinics, N=38 Data restricted to institutions with provider-based clinics that reported EHR funding sources.

47 Clinical Services Fund the Majority of EHR Costs in Provider-Based Clinics Average Percent Contributed by Each Funding Source Other, 1.5% Hospital, 38.5% Clinical Services, 60.0% *Clinical services defined as funding from the faculty practice, medical school, or department. Source: AAMC Survey of EHR implementation at Academic Clinics, N=30 Includes institutions with provider-based clinics that reported percent of EHR funding.

48 Request for Comment We seek comment as to whether EPs are using qualified EHR of the hospital in ambulatory care settings. Your concerns?? Potential solutions?? 48

49 Helpful HIT Web Resources: ONC: CMS: AAMC: FACA Blog: 49

50 Interested in more frequent updates? Join our Health IT list serv by sending a blank (leave the subject line and body blank) to (You will receive a confirmation to confirm your subscription; please respond to this as instructed in the message or your subscription will not be complete.) 50

51 Call Replay Information: Available for 7 days after each call Dial : Passcode:

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