Overview of MU Stage 2 Joel White, Health IT Now

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1 Overview of MU Stage 2 Joel White, Health IT Now 1

2 Agenda 1. Introduction 2. Context 3. Adoption Rates of HIT 4. Overview of Stage 2 Rules 5. Overview of Issues 6. Trend in Standards: Recommendations v. NPRM v. Final Rules 7. Next Steps 2

3 Context Provider adoption of HIT has improved significantly over the past two years (See Appendix). PPACA requires payment and delivery systems changes that can only be done well with robust and shared data (ACOs, medical homes). Low standards and lack of interoperability threaten these reforms. Technology and standards exist to support interoperability. Two rules released and three more expected shortly. Aggressive input is necessary to ensure the success of MU and other programs to lower costs and to improve quality, safety and health. 3

4 Regulatory Outlook Agency Rule Release Comments Due Final ONC EHR Functions: Standards and Certification Criteria for February 24 April June-August Meaningful Use Stage 2 NPRM 2012 What does an EHR have to do to be certified for use in the MU program? CMS Medicare and Medicaid: Meaningful Use Stage 2 NPRM Delay for 2011 adopters Incremental changes New core requirements New menu requirements Interoperability? February 23 April June-August 2012 ONC HIEs: Governance NPRM May July Summer Suggested standards for exchange of clinical information Participation requirements Security standards ONC Nationwide Health Information Network: Participation requirements Notice of Proposed Rule Making (ANPRM) May July Anticipated Late Spring 2012 HHS/OC R Privacy And Security HITECH Miscellaneous Rules April/May Unclear Unclear 4

5 MU Program $27 billion in total incentive payments; $3.1 billion to date. EPs - ~$44,000 Medicare; $63,750 Medicaid Hospitals can access both programs ($millions for both) Continuance of core and menu options: EPs EHs and CAHs Stage 1 Stage 2 Stage 1 Stage 2 Core Requirements Menu Options 5 of 10 3 of 5 5 of 10 2 of 4 Clinical Quality Measures CQM reported electronically. Can meet measures if reported through PQRS/HIQR and Joint Commission. 5

6 Stage 2 Rules Delays Stage 2 by one year for 2011 adopters. 6

7 Stage 2 Rules Makes payment adjustments (cuts) required by statute in 2015 dependent on a prior reporting period. Avoid penalty if provider demonstrates MU at least 3 months prior to end of CY or FY2014. Must meet registration and attestation requirements by July 1, 2014 (hospitals) and October 1, 2014 (EPs). Exceptions include providers who lack access to internet, new EPs or hospitals, and case-by-case exception. Fourth potential category for providers with limited engagement with patients and a lack of control over availability of EHR technology at practice location. Expands definition of Medicaid patient encounter to include CHIP funded Medicaid expansions. 12 additional children s hospitals would be made eligible. 7

8 Stage 2 Rules 1 2 Requirement Record patient demographics Record vital signs and chart changes Maintain up-to-date problem list of current and active diagnoses Stage 1 Standard More than 50% of patient demographic data must be recorded as structured data More than 50% of patients >2 years old must have height, weight and blood pressure recorded as structured data More than 80% of patients must have at least one entry recorded as structured data Stage 2 Standard More than 80% of all unique patients have demographics recorded as structured data. More than 80% of patients >3 years old must have blood pressure measured and all patients have height and weight recorded as structured data Incorporated in electronic patient summary Maintain an active medication list Maintain an active allergy list Record smoking status Provide patients with clinical summaries for each office visit More than 80% of patients have at least one entry recorded as structured data More than 80% of patients have at least one entry recorded as structured data More than 50% of patients age 13 or older have smoking status recorded as structured data Incorporated in electronic patient summary. Incorporated in electronic patient summary. More than 80% of patients age 13 or older have smoking status recorded as structured data Provide clinical summaries for more than 50% of all visits within Provide clinical summaries for more than 50% of all visits within 3 business days 24 hours (EP only) 7 Upon request, provide patients with an electronic copy of their health information More than 50% of requesting patients must receive an electronic copy within 3 business days Requirement eliminated. Incorporated as part of electronic/online access. 8 ERx More than 40% must be transmitted electronically More than 65% are compared to at least one drug formulary and transmitted electronically (EP only) 9 CPOE More than 30% of patients with at least one medication must have at least one medication ordered via CPOE More than 60% of medication, labs, and radiology orders are recorded using CPOE. No requirement to order electronically. 10 8

9 Stage 2 Rules Requirement Stage 1 Standard Stage 2 Standard Implement drug-drug and drug-allergy interaction checks Functionality must be enabled Functionality must be enabled 11 Implement capability to electronically exchange key clinical information among providers and patient-authorized entities Must perform at least one test Eliminated requirement. 12 Clinical Decision Support Implement one clinical decision support rule and track compliance with that rule Implement five clinical decision support rules related to 5 or more clinical quality measures 13 Privacy and Security Conduct a security risk analysis, implement security updates and correct identified issues Conduct a security risk analysis, implement security updates and correct identified issues, including data at rest Clinical Quality Measures Report on 3 core or alternate core measures and 3 additional measures. Provide aggregate numerator and denominator through attestation (2011) and electronic submission (2012) NEW Report on 12 (24) CQMs and one additional domain measure OR report 11 core measures and one menu option OR report under the PQRS EHR reporting option. More than 10 percent of medication orders are tracked using an electronic medication admission record. (EH and CAH only) 16 NEW A secure message was sent using the electronic messaging function of the EHR by more than 10 percent of unique patients. (EP only) 17 9

10 Stage 2 Rules Menu Items Requirement Stage 1 Stage Implement drug formulary checks System must be implemented and clinician must be able to access at least one formulary Lab results More than 40% of clinical lab results are in positive/negative or numerical format and stored as structured data Generate list of patients by specific condition for use in quality Generate one list of patients with a specific condition. improvement, reduction of disparities, research or outreach. Use EHR technology to identify patient-specific education More than 10% of patients are provided patient-specific resources as provide to patients as appropriate. education resources. Move to core requirement. More than 55% of all clinical lab tests are incorporated as structured data. Move to core requirement. Move to core requirement Perform medication reconciliation Provide summary of care record for patients referred or transitioned to another provider. Submission of electronic immunization data Submission of electronic syndromic surveillance data. Submission of electronic reportable lab results. Perform med reconciliation for more than 50% of transitions of care Summary of care records are provided for at least 50% of patient transitions or referrals. Must perform at least one test of data submission and follow-up submission to immunization registries. Must perform at least one test of data submission and follow-up submission to public health agencies. Must perform at least one test of data submission and follow-up submission to public health agencies. Move to core requirement. Perform medication reconciliation for more than 65 percent of transitions of care. Move to core. Must meet both requirements: 1. provide a summary of care for 65% of transitions or referrals; and 2. transmit summary of care record to a recipient with no organizational affiliation and who uses a different certified technology vendor than the sender for more than 10 percent of transitions or referrals. Move to core requirement. Successful ongoing submission of electronic immunization data to a registry or reporting system for entire EHR reporting period. Move to core requirement. Successful ongoing submission of electronic syndromic surveillance data to a public health agency for entire EHR reporting period. (EH only). Move to core requirement. Successful ongoing submission of electronic reportable laboratory results to a public health agency for entire EHR reporting period. (EH only). 10

11 Stage 2 Rules Requirement Stage 1 Stage 2 27 Send reminders to patients per patient preference for preventative and follow up care Provide patients with timely electronic access to their health information. More than 20% of patients aged 65 or older or 5 or younger must be sent appropriate reminders. More than 10% of patients must be provided with electronic access to information within 4 days of update within EHR. Move to core requirement. More than 10% of all unique patients who had a visit within past 24 months were sent a reminder, per patient preference. (EP only) Move to core requirement. More than 50% of patients are provided online access to their health information within 4 days after available to the provider (within 36 hours of hospital discharge), subject to the EP's discretion to withhold NEW 30 NEW 31 NEW 32 NEW NEW 33 NEW 34 NEW 35 More than 10% of all unique patients view, download or transmit to a third party their health information. (NEW) More than 50% of all patients 65 years and older admitted to an inpatient department have an advance directive noted as structured data. (EH only). More than 40 percent of all scans and tests whose result is an image are accessible through the EHR. More than 20 percent of all unique patients have a structured data entry for one or more first degree relatives. More than 10 percent of hospital discharge medication orders are compared to at least one drug formulary and transmitted electronically. (EH only) Successful ongoing submission of electronic syndromic surveillance data to a public health agency for entire EHR reporting period. (EP only) Successful ongoing submission of cancer case information to a cancer registry for entire EHR reporting period. (EP only) Successful ongoing submission of specific case information to a specialized registry for entire EHR reporting period. (EP only) 11

12 Issues Standards Trend has been to lower standards throughout comment process. Interoperability Lost one year of interoperability with one year delay. Even in 2014, interoperability will be limited. We will have secure in a specific transition of care or referral. Bad actors who block information exchange allowed to continue for two more years. MU tools not sufficient to promote success in Shared Savings Program (ACOs). Patient Access Patient access via online access much simpler, and reflects demand. Clinical Quality Framework CQM framework needs to be assessed. Focus should be on outcomes, not process. Electronic reporting makes sense. Alignment with PQRS, Hospital reporting programs welcome. 12

13 Trend: NPRM vs. Final Standards All Measures 45% Drop for EPs 39% Drop for EHs Improve Care Coordination 69% Drop for EPs 69% Drop for EHs EP Stage 1 NPRM EP Stage 1 Final EH Stage 1 NPRM EH Stage 1 Final EP Stage 1 NPRM EP Stage 1 Final EH Stage 1 NPRM EH Stage 1 Final Source: HITN Calculations based on a composite index of standards. 13

14 Next Steps Need to aggressively pursue standards that improve care, quality, safety and costs. Regulatory Comment process White Paper Technical and political issues resolution Calls/meetings to resolve core problems Submission of Comments Regulatory Advocacy Grassroots Coordination with other organizations Legislative Advocacy Oversight Hearings Congressional Briefings Introduction of Legislation 14

15 Contacts: HITN Joel White Grant Olson Executive Director VP, Public and Media O: O: C: C: Jim Bialick VP, Technology and Public Policy O: C: (858)

16 HITN APPENDIX A: Provider Adoption and Payments 16

17 Physician Adoption of EHRs Source: CMS 17

18 Participation Source: CMS. Data accessed on January 23, 2012 at 18

19 Following Dollars to Adopters/Users 19

20 HITN APPENDIX B: Trend in Specific Standards 20

21 Trend: NPRM vs. Final Standards Improving quality, safety, efficiency, and reducing health disparities. 42% Drop for EPs 33% Drop for EHs 21 EP Stage 1 NPRM EP Stage 1 Final EH Stage 1 NPRM EH Stage 1 Final

22 Trend: NPRM vs. Final Standards CPOE Requirements for EPs 80% 60% 30% EP Stage 1 NPRM EP Stage 1 Final EP Stage 2 NPRM 22

23 Trend: NPRM vs. Final Standards Generate and transmit permissible prescriptions electronically (erx). 75% 65% 40% EP Stage 1 NPRM EP Stage 1 Final EP Stage 2 NPRM 23

24 Trend: NPRM vs. Final Standards Perform medication reconciliation at relevant encounters and each transition of care for EPs 80% 50% menu 65% EP Stage 1 NPRM EP Stage 1 Final EP Stage 2 NPRM 24

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