Medicare & Medicaid EHR Incentive Program Final Rule

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1 Medicare & Medicaid EHR Incentive Program Final Rule Implementing the American Recovery and Reinvestment Act of 2009 Presented by: Kevin R. Burchill, Esq., FACHE Director Date: August 19, 2010

2 Overview American Recovery & Reinvestment Act (Recovery Act) February 17, 2009 Medicare & Medicaid Electronic Health Record (EHR) Incentive Program Notice of Proposed Rulemaking (NPRM) Display December 30, 2009 Publication January 13, 2010 Final Rule on Display July 13, 2010 Final Rule Published July 28, 2010

3 What Did and Did Not Change Did Change MU Criteria Clinical Quality Measures Hospital-Based EPs Medicaid acute care hospitals Medicaid patient volume Removed reporting period for adopt, implement or upgrade (Medicaid) All programs will start in 2011 More clarification throughout Did Not Change Adopted statutory provider eligibility and payment requirements MU Matrix Goals Hospital Definition EPs must demonstrate MU Clinical Quality Reporting Timeline

4 Changes to Provider Eligibility Due to recent legislation, hospital-based EPs are only those who see more than 90% of their patients in a hospital in-patient or ER setting Medicaid included critical access hospitals in its definition of acute care hospital (but incentive is like other acute care hospitals, not following the Medicare CAH formula)

5 Medicaid Patient Volume Medicaid EP participation hinges on patient volume requirements. Medicaid patient volume was significantly clarified Expanded definition of encounter to include any encounter for which Medicaid had any payment liability (e.g. premiums, co-pays, waivers) Allows States to define patient volume as just encounters or encounters plus patient panel (managed care), both or propose a new methodology

6 Meaningful Use: Process of Defining National Committee on Vital and Health Statistics (NCVHS) hearings HIT Policy Committee (HITPC) recommendations Listening Sessions with providers/organizations Public comments on HITPC recommendations Comments received from the Department and the Office of Management and Budget (OMB) Revised based on public comments on the NPRM

7 Meaningful Use Stage 1: Health Outcome Priorities* Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their health care Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information *Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America s Healthcare. Washington, DC: National Quality Forum; 2008.

8 Meaningful Use: Changes from the NPRM to the Final Rule NPRM Meet all MU reporting objectives 25 measures for EPs/23 measures for eligible hospitals Measure thresholds range from 10% to 80% of patients or orders (most at higher range) Final Rule Must meet core set /can defer 5 from optional menu set 25 measures for EPs/24 for eligible hospitals. Measure thresholds range from 10% to 80% of patients or orders (most at lower to middle range) Denominators To calculate the threshold, some measures required manual chart review Denominators No measures require manual chart review to calculate threshold Administrative transactions (claims and eligibility) included Measures for Patient-Specific Education Resources and Advanced Directives discussed but not proposed Administrative transactions removed Measures for Patient-Specific Education Resources and Advanced Directives (for hospitals) included

9 Meaningful Use: Changes from the NPRM to the Final Rule (cont d) NPRM States could propose requirements above/beyond MU floor, but not with additional EHR functionality Core clinical quality measures (CQM) and specialty measure groups for EPs Final Rule States flexibility with Stage 1 MU is limited to seeking CMS approval to require 4 public health-related objectives to be core instead of menu Modified Core CQM and removed specialty measure groups for EPs 90 CQM total for EPs 44 CQM total for EPs must report total of 6 35 CQM total for eligible hospitals and 8 alternate Medicaid CQM 5 CQM overlap with CHIPRA initial core set 15 CQM total for eligible hospitals 4 CQM overlap with CHIPRA initial core set

10 How were MU Core Objectives Selected? Overarching considerations Statutory requirements (e.g. e-prescribing, CQM, health information exchange) Foundational objectives (e.g. privacy and security and those that provide foundational data needed for other measures, like demographics, medication lists, etc.) Patient-centered Patient access (e.g. clinical summaries) Patient safety (e.g. drug-drug and drug-allergy features) Part of providers normal practice Looked at how the objectives aligned Feedback received from HIT Policy Committee and commenter's

11 Meaningful Use: Applicability of Objectives and Measures Some MU objectives are not applicable to every provider s clinical practice, thus they would not have any eligible patients or actions for the measure denominator. In these cases, the EP, eligible hospital or CAH would be excluded from having to meet that measure Example: Dentists who do not perform immunizations; Chiropractors do not e-prescribe

12 How Were Thresholds Selected 80%: Objective part of standard practice (e.g. maintain active medication list) Others: Defined on a case-by-case basis based on commenter or clearance feedback Example: e-prescribing set at 40% lowered from 75% to address concerns by commenter's regarding non-participation by pharmacies and patient preference

13 Meaningful Use Stage 1 Core Set Health Outcomes Policy Priority Improving quality, safety, efficiency, and reducing health disparities Stage 1 Objective Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines Implement drug-drug and drug-allergy interaction checks EP Only: Generate and transmit permissible prescriptions electronically (erx) Record demographics: preferred language, gender, race, ethnicity, date of birth, and date and preliminary cause of death in the event of mortality in the eligible hospital or CAH Maintain up-to-date problem list of current and active diagnoses Stage 1 Measure More than 30% of unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital or CAH have at least one medication entered using CPOE The EP/eligible hospital/cah has enabled this functionality for the entire EHR reporting period More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology More than 50% of all unique patients seen by the EP or admitted to the eligible hospital or CAH have demographics as recorded structured data More than 80% of all unique patients seen by the EP or admitted to the eligible hospital or CAH have at least one entry or an indication that no problems are known for the patient recorded as structured data

14 Meaningful Use Stage 1 Core Set (cont d) Health Outcomes Policy Priority Improving quality, safety, efficiency, and reducing health disparities Stage 1 Objective Maintain active medication list Maintain active medication allergy list Record and chart vital signs: height, weight, blood pressure, calculate and display BMI, plot and display growth charts for children 2-20 years, including BMI Record smoking status for patients 13 years old or older Implement one clinical decision support rule and the ability to track compliance with the rule Report clinical quality measures to CMS or the States Stage 1 Measure More than 80% of all unique patents seen by the EP or admitted to the eligible hospital or CAH have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data More than 80% of all unique patents seen by the EP or admitted to the eligible hospital or CAH have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data For more than 50% of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital or CAH, height, weight, and blood pressure are recorded as structured data More than 50% of all unique patients 13 years or older seen by the EP or admitted to the eligible hospital or CAH have smoking status recorded as structured data Implement one clinical decision support rule For 2011, provide aggregate numerator, denominator, and exclusions through attestation; For 2012, electronically submit clinical quality measures

15 Meaningful Use Stage 1 Core Set (cont d) Health Outcomes Policy Priority Stage 1 Objective Stage 1 Measure Engage patients and families in their healthcare Improve care coordination Ensure adequate privacy and security protections for personal health information Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures), upon request Hospitals Only: Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request EPs Only: Provide clinical summaries for each office visit Capability to exchange key clinical information (ex: problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities More than 50% of all unique patients of the EP, eligible hospital or CAH who request an electronic copy of their health information are provided it within 3 business days More than 50% of all patients who are discharged from an eligible hospital or CAH who request an electronic copy of their discharge instructions are provided it Clinical summaries provided to patients for more than 50% of all office visits within 3 business days Performed at least one test of the certified EHR technology s capacity to electronically exchange key clinical information Conduct or review a security risk analysis per 45 CFR (a)(1) and implement updates as necessary and correct identified security deficiencies as part of the EP s, eligible hospital s or CAH s risk management process

16 Meaningful Use Stage 1 Menu Set Health Outcomes Policy Priority Improving quality, safety, efficiency, and reducing health disparities Stage 1 Objective Implement drug-formulary checks Hospitals Only: Record advance directives for patients 65 years old or older Incorporate clinical lab-test results into certified EHR technology as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach EPs Only: Send reminders to patients per patient preference for preventive/follow-up care Stage 1 Measure The EP/eligible hospital/cah has enabled this functionality and has access to at least one internal or external drug formulary for the entire EHR reporting period More than 50% of all unique patients 65 years old or older admitted to the eligible hospital or CAH have an indication of an advance directive status recorded More than 40% of all clinical lab test results ordered by the EP, or an authorized provider of the eligible hospital or CAH, for patients admitted during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period

17 Meaningful Use Stage 1 Menu Set (cont d) Health Outcomes Policy Priority Engage patients and families in their health care Improve care coordination Stage 1 Objective EPs Only: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within 4 business days of the information being available to the EP Use certified EHR technology to identify patientspecific education resources and provide those resources to the patient, if appropriate The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral Stage 1 Measure More than 10% of all unique patients seen by the EP are provided timely (available to the patient within 4 business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP s discretion to withhold certain information More than 10% of all unique patients seen by the EP or admitted to the eligible hospital or CAH are provided patient-specific education resources The EP, eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital or CAH The EP, eligible hospital or CAH who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals

18 Meaningful Use Stage 1 Menu Set (cont d) Health Outcomes Policy Priority Improve population and public health 1 Stage 1 Objective Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice Hospitals Only: Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Stage 1 Measure Performed at least one test of the certified EHR technology s capacity to submit electronic data to immunization registries and follow-up submission if the test is successful (unless none of the immunization registries to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) Performed at least one test of certified EHR technology s capacity to provide submission of reportable lab results to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) Performed at least one test of certified EHR technology s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically)

19 Future Stages Intend to propose 2 additional Stages through future rulemaking. Future Stages will expand upon Stage 1 criteria. Stage 1 menu set will be transitioned into core set for Stage 2 Administrative transactions will be added CPOE measurement will go to 60% Will reevaluate other measures possibly higher thresholds Stage 3 will be further defined in next rulemaking

20 States Flexibility to Revise Meaningful Use States can seek CMS prior approval to require 4 MU objectives be core for their Medicaid providers: Generate lists of patients by specific conditions for quality improvement, reduction of disparities, research or outreach (can specify particular conditions) Reporting to immunization registries, reportable lab results and syndromic surveillance (can specify for their providers how to test the data submission and to which specific destination)

21 Meaningful Use for EPs who Work at Multiple Sites An EP who works at multiple locations, but does not have certified EHR technology available at all of them would: Have to have 50% of their total patient encounters at locations where certified EHR technology is available Would base all meaningful use measures only on encounters that occurred at locations where certified EHR technology is available

22 MU for Hospitals that Qualify for Both Medicare & Medicaid Payments Applies to sub-section (d) and acute care hospitals Attest/Report on Meaningful Use to CMS for the Medicare EHR Incentive Program Will be deemed meaningful users for Medicaid (even if the State has CMS approval for the MU flexibility around public health objectives)

23 Clinical Quality Measures (CQM) Overview 2011: EPs, eligible hospitals and CAHs seeking to demonstrate Meaningful Use are required to submit aggregate CQM numerator, denominator, and exclusion data to CMS or the States by attestation. 2012: EPs, eligible hospitals and CAHs seeking to demonstrate Meaningful Use are required to electronically submit aggregate CQM numerator, denominator, and exclusion data to CMS or the States.

24 CQM: Eligible Professionals Core, Alternate Core, and Additional CQM sets for EPs EPs must report on 3 required core CQM. If the denominator of 1or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures EPs also must select 3 additional CQM from a set of 38 CQM (other than the core/alternate core measures) In sum, EPs must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures

25 CQM: Core Set for EPs NQF Measure Number & PQRI Implementation Number NQF 0013 NQF 0028 NQF 0421 PQRI 128 Clinical Quality Measure Title Hypertension: Blood Pressure Measurement Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention Adult Weight Screening and Followup

26 CQM: Alternate Core Set for EPs NQF Measure Number & PQRI Implementation Number NQF 0024 NQF 0041 PQRI 110 NQF 0038 Clinical Quality Measure Title Weight Assessment and Counseling for Children and Adolescents Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older Childhood Immunization Status

27 CQM: Additional Set for EPs 1. Diabetes: Hemoglobin A1c Poor Control 2. Diabetes: Low Density Lipoprotein (LDL) Management and Control 3. Diabetes: Blood Pressure Management 4. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) 6. Pneumonia Vaccination Status for Older Adults 7. Breast Cancer Screening 8. Colorectal Cancer Screening 9. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD 10. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 11. Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment 12. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 13. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 15. Asthma Pharmacologic Therapy 16. Asthma Assessment 17. Appropriate Testing for Children with Pharyngitis 18. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer 19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

28 CQM: Additional Set for EPs (cont d) 20. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 21. Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies 22. Diabetes: Eye Exam 23. Diabetes: Urine Screening 24. Diabetes: Foot Exam 25. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol 26. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation 27. Ischemic Vascular Disease (IVD): Blood Pressure Management 28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 29. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement 30. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) 31. Prenatal Care: Anti-D Immune Globulin 32. Controlling High Blood Pressure 33. Cervical Cancer Screening 34. Chlamydia Screening for Women 35. Use of Appropriate Medications for Asthma 36. Low Back Pain: Use of Imaging Studies 37. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control 38. Diabetes: Hemoglobin A1c Control (<8.0%)

29 CQM: Eligible Hospitals and CAHs 1. Emergency Department Throughput admitted patients Median time from ED arrival to ED departure for admitted patients 2. Emergency Department Throughput admitted patients Admission decision time to ED departure time for admitted patients 3. Ischemic stroke Discharge on anti-thrombotics 4. Ischemic stroke Anticoagulation for A-fib/flutter 5. Ischemic stroke Thrombolytic therapy for patients arriving within 2 hours of symptom onset 6. Ischemic or hemorrhagic stroke Antithrombotic therapy by day 2 7. Ischemic stroke Discharge on statins 8. Ischemic or hemorrhagic stroke Stroke education 9. Ischemic or hemorrhagic stroke Rehabilitation assessment 10. VTE prophylaxis within 24 hours of arrival 11. Intensive Care Unit VTE prophylaxis 12. Anticoagulation overlap therapy 13. Platelet monitoring on unfractionated heparin 14. VTE discharge instructions 15. Incidence of potentially preventable VTE

30 Participation in HITECH and other Medicare Incentive Programs for EPs Other Medicare Incentive Program Medicare Physician Quality Reporting Initiative (PQRI) Medicare Electronic Health Record Demonstration (EHR Demo) Medicare Care Management Performance Demonstration (MCMP) Electronic Prescribing (erx) Incentive Program Eligible for HITECH EHR Incentive Program? Yes, if the EP is eligible. Yes, if the EP is eligible. Yes, if the practice is eligible. The MCMP demo will end before EHR incentive payments are available. If the EP chooses to practice in the Medicare EHR Incentive Program, they cannot participate in the Medicare erx Incentive Program simultaneously in the same program year. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare erx Incentive Program simultaneously.

31 EHR Incentive Program Timeline Registration for the EHR Incentive Programs will begin in January 2011 For Medicare providers, attestation for the EHR Incentive Programs will begin in April 2011 EHR incentive payments will begin a month following the start of attestations For Medicaid providers, States may launch their programs in January 2011 and thereafter November 30, 2011 Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011 (Medicare providers) February 29, 2012 Last day for EPs to register and attest to receive an incentive payment for CY 2011 (Medicare providers) 2015 Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology** 2016 Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program** 2021 Last year to receive Medicaid EHR incentive payment** **Statutory

32 Questions Regarding the Regulation CMS website CMS subject matter experts will be working with ONC and the states to do webinars and other information sessions to help answer questions CMS will develop FAQs to respond to various questions and provide toolkits and other materials to assist providers CMS will issue additional guidance on how to register and attest to meaningful use Requirements in the regulation can only be modified through further rulemaking

33 So, what are we to do next? Internal approach to Readiness Assessment

34 Leadership

35 Top CEO Issues The American College of Healthcare Executives annual survey asked CEOs to identify their top three issues Issue Percentage responding Financial challenges 76% Healthcare reform implications* 53 Care for the uninsured 37 Patient safety and quality 32 Governmental mandates 30 Physician-hospital relations 25 Patient satisfaction 15 Personnel shortages 13 Capacity 7 Technology 7 Governance* 2 Disaster preparedness 1 Issues about not-for-profit status 1 Source: American College of Healthcare Executives *New issues added for 2009

36 Project Management Methodology

37 Challenges Political Champions Supportive environment Organizational Governance Shared goals and objectives Operating rules Financial Access to capital Sustainable model Technical Integration with legacy systems Security and privacy Data management

38 Self-Assessment Who should we be aligned with to move our vision, mission and values forward? Where can we best contribute to the improvement efforts, quality, care and safety? What are the timelines and milestones to which our organization must strive to achieve meaningful use? How will our organization differentiate in the market place?

39 Clinical IT Adoption Process Planning Design Implementation Training Go-Live Support / Improvement

40 Clinical IT Adoption Have your organizational goals and expected results for the clinical IT project been identified in the planning stage? Speed Bump: A project that has not involved both the executive leadership and clinicians in setting a vision is initially set up as just another IT project Is your organization designing the system from the clinician perspective? Speed Bump: It is well documented that attempts to implement a system by excluding clinicians in the design phase can lead to resentment, lack of confidence in the organization and counter-productive behaviors that will challenge the success of the project

41 Clinical IT Adoption (cont.) Have you incorporated a formalized project charter into your implementation process, identifying challenges and overcoming obstacles? Speed Bump: Without a formalized process it is difficult for clinicians to recognize that the clinical implementation project represents a true commitment to success What is your training approach; do you have different models for different roles in your organization? Speed Bump: Physicians have rigorous time restraints; therefore the lack of adequate staff and planning for oneon-one physician training will decrease willingness for physicians to adopt the system

42 Clinical IT Adoption (cont.) Have you built in adequate time and resources for your Go-Live and Support phase with the clinicians day-to-day routine in mind? Speed Bump: Clinician buy-in will dramatically drop at this juncture if the process does not adequately sustain clinician use with day-to-day support and incorporate feedback to further improve the system, producing greater benefits for the clinician, the organization and the patients

43 Next Steps in the Journey Towards Meaningful Use

44 Linear View of MU Assessment

45 Assessment Matrix Technology Platforms and Applications Review Capital Budget Planning and Prioritization IT Staffing Plan Review Physician Alignment Summary On-Site Interview Notes Other Operational Considerations Privacy and Security Overview HIE

46 Other Considerations Calculate ARRA Incentives Define IT Projects in Relation to MU grid Complete GAP Analysis Prioritize Capital and Operational Investment

47 Important Areas of Focus Vendor Sustainability and Focus Patient Throughput and Clinical Integration Quality Reporting Capital Spending and Incentive Reimbursements

48 Questions & Answers Interactive Session

49 Thank You! Kevin R. Burchill, Esq., FACHE

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