1/22/14. Surviving the EMR While Maintaining Excellence in Oncology Practice. Objectives THE EMR MEANINGFUL USE AND PRODUCTIVITY MEASURES

Transcription

1 Surviving the EMR While Maintaining Excellence in Oncology Practice Wendy Andrews, BS, Practice Manager Christopher Campen, PharmD, BCPS, BCOP Sandra Kurtin, RN, MS, AOCN, ANP-C The University of Arizona Cancer Center Objectives 1. Describe the difference between Medicare and Medicaid EHR Meaningful Use along with identifying the required productivity measures 2. Describe three strategies to improve your electronic health record to benefit patient care or improve efficiency 3. Identify strategies for integrating oral oncolytic therapies and supportive care protocols into the EMR Wendy Andrews, BS Practice Manager The University of Arizona Cancer Center THE EMR MEANINGFUL USE AND PRODUCTIVITY MEASURES 1

2 Disclosure Wendy Andrews has nothing to disclose. American Recovery and Reinvestment Act of 2009 Authorizes Centers for Medicare & Medicaid Services (CMS) to give financial bonuses to eligible professionals (EPs) and hospitals that adopt, implement, upgrade, or demonstrate meaningful use of a certified electronic health record (EHR) to: Improve quality, safety, efficiency; reduce health disparities Engage patients and families Improve care coordination, population and public health Maintain privacy, security of patient health information Have you enrolled in the EHR (Meaningful Use) incentive through Medicare or Medicaid and implemented an EHR yet? A. Yes B. No C. I don t know 2

3 Medicare vs. Medicaid Medicare EHR Incentive Program Medicaid EHR Incentive Program Run by CMS Run by Your State Medicaid Agency Maximum incentive amount is $44,000 Maximum incentive amount is $63,750 Payments over 5 consecutive years Payments over 6 years, does not have to be consecutive Payment adjustments will begin in 2015 for providers who are eligible but decide not to participate No Medicaid payment adjustments Providers must demonstrate meaningful use every year to receive incentive payments. Submit clinical quality measurement data to the CMS Registration and Attestation System or electronically using the QRDA format In the first year providers can receive an incentive payment for adopting, implementing, or upgrading EHR technology. Providers must demonstrate meaningful use in the remaining years to receive incentive payments. Submit clinical quality measurement data to State Medicaid Agency Incentive Programs Year 1 Eligibility Medicare - $44, Medicaid - $63, Must demonstrate meaningful use Adopt, implement, or upgrade Certain providers, hospitals Certain providers, hospitals Definition Medicare definition of meaningful use is standard Implemented Federal government Important dates Begin participation by 2014 Last payment in 2016 States adopt own definition (based on Medicare definition) States: voluntarily Begin participation by 2016 Last payment in Eligible Professionals (EPs) Medicare physicians MD, DO Podiatrist Chiropractor Oral surgeon Dentist Optometrist Therapists PT, OT Speech, language Practitioners APN (NP, CNS, nurse anesthetist, nurse midwife) PA Clinical psychologist Clinical social worker Registered dietician Nutrition professional Audiologist 3

4 Medicare, Medicaid EHR Incentive Programs Stage 1 Stage 2 90 days in year 1 Full year year 2 Full year Full year Meet Stage 1 requirements Meet Stage 2 requirements Stage 1: Meaningful Use Core and menu set of objectives specific to eligible professionals, eligible hospitals, and critical access hospitals (CAH) Eligible Professionals 24 Meaningful Use Objectives Meeting 19 (14 required from core) objectives to qualify for incentive payment and choosing 5 out of 10 available menu objectives Eligible Hospitals and CAH 23 Meaningful Use Objectives Meeting 18 (13 required from core) objectives to qualify for incentive payment and choosing 5 out of 10 available menu objectives Examples: EP Stage 1 Core Objectives Authorized licensed health care professionals use computerized provider order entry (CPOE) for med orders Drug-drug, drug-allergy interaction checks implemented Up-to-date problem list (current and active diagnoses) Permissible prescriptions generated, transmitted electronically (erx) Smoking status recorded for patients 13 years old Patients get clinical summaries for each office visit Patients can get an electronic copy of their health information (i.e., tests results, problem list, medication lists, medication allergies) upon request 4

5 Example of Specific Measurement: Record Demographics What this measure requires What that means for you Are you excluded from doing this? More than 80% of all unique patients seen by the EP have demographics recorded as structured data For more than 80% of your patients you have to record the following in the certified EHR: Preferred language Gender Race Ethnicity Date of Birth There are no exclusions: Everyone must meet this objective Examples: EPs Stage 1 Menu Objectives Implement drug formulary checks Generate lists of patients by specific conditions for QI, disparity reduction, research, or outreach Send patient reminders per patient preference for preventive /follow-up care Use certified EHR technology to identify patient-specific education resources and provide to patients as appropriate EP who transitions or refers their patient to another care setting or provider provide summary care record Eligible Hospitals: Stage 1 Core Objectives Any authorized licensed health care professional uses CPOE to enter medication orders Maintain active medication list Maintain active medication allergy list Record demographic data (e.g., preferred language, gender, race, ethnicity, DOB, date/preliminary cause of death in hospital) Report ambulatory clinical quality measures to CMS or the state, as appropriate Provide patients with electronic copy of discharge instructions, on request Protect electronic health information by implementing appropriate technical capabilities 5

6 Eligible Hospitals: Stage 1 Menu Objectives Implement drug formulary checks Record advanced directives for patients 65 years old Lab-test results incorporated as structured data into EHR Use certified EHR technology to identify patient-specific education resources and provide those resources to patient as appropriate Hospital can submit electronic data to immunization registries or systems according to applicable law and practice Can submit electronic data on reportable lab results (as required by law) to public health agencies Can submit electronic syndromic surveillance data to public health agencies as legislated Stage 1 vs. Stage 2 (2014 Updates) Stage 1- Eligible Professionals Stage 2 - Eligible Professionals 13 Core Objectives 17 Core Objectives 5 of 10 Menu Objectives 3 of 6 Menu Objectives 18 Total Objectives 20 Total Objectives Select and implement an EHR system prior to Must meet 2014 Standards if implementing in Must electronically report on Clinical Quality Measures (CQM) using 2014 standards. No longer a core objective. EHR required to meet CMS and Office of the National Coordinator for Health Information Technology (ONC) 2014 Standards and Certification Criteria Must electronically report on Clinical Quality Measures (CQM) using 2014 standards. No longer a core objective. Examples: Stage 1 vs. Stage 2 Stage 1 Objective Stage 1 Measure Stage 2 Objective Stage 2 Measure Use CPOE for medication orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines More than 30% of unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local, and professional guidelines More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP during the EHR reporting period are recorded using CPOE Implement drug-drug and drug-allergy interaction checks The EP has enabled this functionality for the entire EHR reporting period No longer a separate objective for Stage 2 This measure is incorporated into the Stage 2 Clinical Decision Support measure 6

7 2014 CQM Reporting Requirements Beginning in 2014, eligible professionals must select and report on 9 of a possible list of 64 approved CQMs for the EHR Incentive Programs. There is also a new requirement in 2014 that the quality measures selected must cover at least 3 of the 6 available National Quality Strategy (NQS) domains, which represent the Department of Health and Human Services NQS priorities for health care quality improvement. Patient and Family Engagement Population and Public Health Patient Safety Efficient Use of Health Care Resources Care Coordination Clinical Processes/Effectiveness A complete list of the 2014 CQMs for the EHR Incentive Programs and their associated National Quality Strategy domains on the Clinical Quality Measure webpage at EHRIncentivePrograms/ClinicalQualityMeasures.html 2014 Optional Reporting Periods For 2014 Only Because all providers must upgrade or adopt newly certified EHRs in 2014, all providers regardless of their stage of meaningful use are only required to demonstrate meaningful use for a 3-month (or 90-day) EHR reporting period in Medicare eligible professionals beyond their first year of meaningful use must select a 3-month reporting period fixed to the quarter of the calendar year for eligible professionals. Providers must attest to these reporting periods no later than February 28, 2015, at 12 am ET. Medicare eligible professionals in their first year of meaningful use may select any 90-day reporting period. Medicaid eligible professionals can select any 90-day reporting period that falls within the 2014 calendar year. Given that 2014 allows you to only have to report on a 90-day period, do you feel that the practice you are in will be able to implement the EHR meaningful use incentive criteria this calendar year? A. Yes B. No C. Already implemented 7

8 Resources Topic Resource Description Certified EHR Technology CPHL Certified EHR List Webpage maintained by ONC that provides a comprehensive listing of complete EHRs and EHR modules Clinical Quality Measures 2014 Stage 2 Stage 1 vs. Stage CQM page Guidance/Legislation/ EHRIncentivePrograms/ 2014_ClinicalQualityMeasures.html Stage 2 Homepage Guidance/Legislation/ EHRIncentivePrograms/Stage_2.html Stage 1 vs. Stage 2 table comparison Guidance/Legislation/ EHRIncentivePrograms/Downloads/ Stage1vsStage2CompTablesforEP.pdf Webpage of the EHR website for information on the 2014 CQMs Stage 2 webpage of the EHR website, providing basic Stage 2 information and resources A PDF document that gives EPs a sideby-side look at Stage 1 vs. Stage 2 Christopher Campen, PharmD, BCPS BCOP The University of Arizona Cancer Center SURVIVING THE EMR TAILORING THE ELECTRONIC MEDICAL RECORD TO ONCOLOGY PRACTICE Disclosure Christopher Campen is lead protocol builder for EMR implementation at the University of Arizona Health Network. He has no financial ties to disclose. 8

9 How Many Clicks Does It Take to Get to the Middle of an EHR? Gomella, L. G. (2011). Can J Urol, 18, 5860; What Were They Thinking. (n.d) /03/22/What-Were-They-Thinking.aspx. Surviving the EMR The EHR will ultimately serve the health care needs of the future if we can all survive the challenges of the implementation process. Gomella, L. G. (2011). Can J Urol, 18, What is an example of a poor strategy for the implementation or maintenance of an EMR? A. Standardizing protocols B. Minimal testing C. Multidisciplinary involvement D. Leadership involvement 9

10 Background Project: Entire system with fully integrated EMR q 2 primary hospital campuses q 7,000 employees Three outpatient oncology treatment centers, two inpatient oncology units Oncology EMR multidisciplinary implementation team q Physician, nursing, pharmacy Definitions EMR EHR CPOE EMR systems Fully integrated q Oncology module? Chemotherapy Supportive care Labs, imaging results? Stand-alone q Integrated with other EMRs? Who Will Treat My Lung Cancer? (2012, October 23). booklet/who-will-treat-my-lung-cancer. 10

11 Optimizing Your Practice Treatment and supportive care plans Workflow Error reduction Treatment and Supportive Care Plans Follow national guidelines Accept change Simplify q Less is more Standardize q More is better Simplification Simplification q Fewer protocols means less maintenance later and faster turnaround for new protocols Use of standardized order groups q Allows for quick modification when standard of care does change ü Drug shortages 11

12 Cannot accept tradition Standardization q Tradition must be sent through systematic method of critical review q Requires leadership q Set attainable and realistic goals q Discuss current problems pre-emr implementation Blake, E. Standardization Areas of standardization q Labs q Treatment parameters q Hydration q Supportive care q Hypersensitivity management q Port and line management orders Which of the following is NOT an example to follow for chemotherapy plan build or maintenance? A. Following national guidelines B. Provider-specific plans C. Standardized plan build 12

13 Plan Build and Review Three physician project leaders q Standardized build template Weekly meetings q Reviewed by disease site/team Workflow Empower yourself in the process q Start from scratch q View the entire cancer center as a single entity q Change will occur ü Who drives change? q Test, test, and test again Workflow System design q Quick reports dependent upon area of focus q Provider q Nurse q Pharmacist 13

14 Error Reduction Clinical decision advisories Standardization Reporting Develop metrics for success Summary Multidisciplinary team Leadership involvement Set achievable goals Test, test, and re-test Don't be satisfied with stories, how things have gone with others. Unfold your own myth. Rumi, Essential Rumi Sandra Kurtin, RN, MS, AOCN, ANP-C Nurse Practitioner, Clinical Assistant Professor of Medicine The University of Arizona Cancer Center MEANINGFUL CARE INTEGRATING ORAL ONCOLYTICS AND SUPPORTIVE CARE INTO THE EMR 14

15 Disclosure Sandra Kurtin has nothing to disclose. Meaningful Care in the Era of the EMR and Meaningful Use Identified Gaps in the EHR Oral anti-cancer agents q Not fully integrated into the oncology treatment plan q Requires a comprehensive approach tailored to the oncology patient Evidence-based supportive care protocols for oncology practice q Tailored to the patient q Includes written patient and caregiver instructions 15

16 Provider-Patient Consultation Treatment is determined Patient Starts Medication How to adjust the follow-up schedule according to start date Reinforcement of self-management strategies Early identification of AEs Cancer Diagnosis Requiring Oral Oncolytics Oral Therapy Prescribed How is oral therapy prescribed? Who meets with the patient to discuss therapy and potential side effects? How is the therapy integrated into the EMR? Financial Determination (co-payment and out-of-pocket) Pursue potential assistance programs Prior authorization required? System for follow-up? Potential delays in starting treatment When is it most common for patients to discontinue their oral cancer therapy? A. Within the first week of treatment B. Within the first year of treatment C. Once they are in remission D. Within the first 2 months of treatment Projected Growth of Oral Therapies and the Challenges This Presents Projected cancer incidence: 45% by 2030 q 1.6 million in 2010 q 2.3 million in 2030 ~ 35% 40% of cancer drugs in the pipeline are oral Majority of oral therapies are discontinued in the first 2 months of treatment Patient self-management is prerequisite Reimbursement to health care systems presents additional challenges Streeter et al. (2011). Am J Manag Care, 17(5 Spec No.), SP38-SP44. 16

17 Oral Cancer Treatments Dispensed Primarily by Retail and Specialty Pharmacies 45% by retail pharmacy channels 31% through specialty pharmacies 16% by mail order 7% by physician offices Khandelwal et al. (2012). J Natl Compr Canc Netw, 10, Drugs don t work in patients who don t take them. C. Everett Koop, MD To be adherent, the patient must: 1. Fill the prescription 2. Consume it in a manner consistent with the prescription 3. Continue to take it unless directed otherwise by the HCP 4. Keep follow-up appointments Non-adherence is: 1. A multifaceted process 2. Linked to both intentional and unintentional factors 3. Not linked to any one type of disease 4. There is no typical patient profile for adherence Patient Osterberg, L., et al. (2005). N Engl J Med, 353, ; Moore, S. (2007) Cancer Nurs, 30, Health Care System Provider Common Barriers to Adherence Unintentional Outside of patient s control Easiest to identify and address, e.g., out-of-pocket costs q Primary medication q Co-medications Includes patient reported factors q Had side effects q Difficult to administer Complex routine Delivery system (bubble packs, capsules) Number of medications Eliasson, L., et al. (2010). Leukemia Res, 35, Intentional Active decision to stop therapy due to beliefs q Difficult to identify these beliefs and change q Adherence experts identify this as the primary reason for nonadherence Patients are unconvinced of need for therapy or effectiveness of therapy q Never needed it, asymptomatic q Competing health priorities q Patients have fear of side effect or safety issues Perceived affordability of medication by patient 17

18 Adherence Communication HCPs assume patients are adherent q In one study, 89% of surveyed physicians believed >75% adhered to their medical recommendations q Second study: 74% of MDs perceived their patients to be highly adherent Patients do not communicate openly with their providers q Among 1,100 adult patients: 68% said they would never communicate to their provider that they did not want a drug 83% said they would never communicate to their provider that they did not plan on buying the drug Davis, M. S. (1966). J Med Edu, 41, ; Goldberg, A., et al. (1998). Soc Sci Med, 47, ; Lapane, K. L., et al. (2007). Am J Manag Care, 13, Drug Cost: A Primary Factor in Adherence Analysis of > 10,000 pharmacy claims for oral anti-cancer drugs between 2007 and 2009 q 10% of patients abandoned their anticancer medicine q 25% of patients had some delay in initiating another oncolytic q 31% did not fill their initial prescription for oral anticancer medication (OR, 4.46; p <.001) 25% of patients if the co-payment amount was > $500 6% of patients with cost-sharing of $100 failed to fill their initial prescription Streeter et al. (2011). Am J Manag Care, 17(5 Spec No.), SP38-SP44. Persistence Rates for Oral Chronic Cancer Medications Lower in Real-World Settings Compared With Clinical Trials Treatment Regimen Arimidex, Tamoxifen Alone or in Combination Trial Breast International Group 1-98 persistence with letrozole IRIS trial: Imatinib in CML Avalere Health, Part D Specialty Tier Analysis, May On Clinical Trial Persistence Rates 71.7% at 3 yr 65% at 3.5 yr In Real-World Claims Analysis 84% at 4 yr 77% at 1 yr 23% of patients with > 30-day treatment gap 91% 12 mo: 56% 24 mo: 41% (gaps of > 30 days excluded) from 100% to 77% between months 4 and 14 of treatment 18

19 Effective Communication of Treatment Plan Patients must be able to understand how to take their medications in order to adhere However, simple instructions do not guarantee improved understanding or that people will want to follow them Complexity is not the key issue, but how well the treatment fits in with the individual patient s routine Drug-drug interactions Food-drug interactions Daily activities: Enjoyment or employment Perceived benefit Individual health beliefs Reinforcement of learning is critical to successful self-management SPrOChETS Safety Program for Oral Chemotherapy Education Training and Support Goal: To provide a comprehensive multidisciplinary safety and support program for the administration of oral cancer therapies Includes: q Formal process to educate providers, support staff, nurses, pharmacists, patients and caregivers about individual oral oncolytic agents q System tools for financial assistance and reimbursement q Medicare requirements for e-prescribing q Requirements to integrate into the EHR Political Action Guide for Oral Parity Legislation Process for Implementation of SPrOChETS The University of Arizona Cancer Center Similar approach to patient support, financial authorization, and follow-up as for injectable drugs q Informed consent (provider/prescriber) q Individualized chemotherapy education Oral oncolytic only: RN Clinical Coordinator Combined therapy: Infusion Nurses and Clinical Coordinators q Rx entered in EMR for oral chemotherapy triggers process Clinical coordinators (RN) are specialty based, serve as navigators for patients on oral medications q Involvement of nurse coordinators and infusion nurses in development of the standing order sets; invested in the program, develop expertise 19

20 SPrOChETS Implementation: The University of Arizona Cancer Center Tools to Facilitate Process Standing order sets: Baseline, f/u evaluation Safety recommendations q Links: REMS and financial assistance programs q Common dosing regimens, administration q Drug-food, drug-drug interactions 1 Quick Tips : Teaching tools for patients, caregivers Billing process for f/u visits, counseling Scheduled f/u, evaluation criteria 1 Process for Implementation of SPrOChETS The University of Arizona Cancer Center Projected Outcomes Improved adherence q Tracked by Rx fills/refills, patient self-report Reduction of treatment emergent adverse events q ED visits, hospitalizations, grade > 3 AEs q Reduced treatment discontinuation due to treatmentemergent AEs What Is Oral Parity? A. An algorithm to determine the oral equivalent of an IV compound. B. Current legislation to classify oral anti-cancer therapies the same as IV therapies for insurance purposes. C. Current legislation to classify oral anti-cancer therapies under the pharmacy benefit D. I don t know 20

21 HR1801. The bill will require oral anticancer treatments to be covered at the same rate as IV treatments. Many insurance plans treat patient-administered chemotherapy, like oral pills, differently than other forms of chemotherapy, creating a financial barrier to treatment for many cancer patients. Key Elements, Standing Order Sets for Oral Agents: Supportive Care Protocols Individualized by regimen Micromedex for basic drug information (automatic updates) Evidence-based supportive care and symptom management protocols Patient and caregiver self-management strategies Linking Oncology Treatment Plans to Supportive Care Protocols Order Set Number Regimen Frequency Link to Reference Drug Information (Micromedex) and Supportive Care Protocols Abraxane every 3 weeks Medium pubmed/ Abraxane every 2 weeks Medium pubmed/ Abraxane weekly High pubmed/ Micromedex links: Abraxane Myelosuppression: Anemia, thrombocytopenia, neutropenia Alopecia Neuropathy Constipation Reportable signs and symptoms AC every week (weekly) High pubmed/ AC every 2 weeks (dose High dense) pubmed/ AC every 3 weeks High pubmed/ Micromedex links: Adriamycin; cyclophosphamide Myelosuppression: Anemia, thrombocytopenia, neutropenia Nausea and vomiting Phlebitis Alopecia Constipation Diarrhea Mucositis Cystitis Reportable signs and symptoms 21

22 Linking Oncology Treatment Plans to Supportive Care Protocols Order Set Number Regimen Link to reference Drug Information (Micromedex) and Supportive Care Protocols DOXOrubicin Liposomal Q14D DOXOrubicin Liposomal Q21D DOXOrubicin Liposomal Q28D DOXOrubicin Liposomal/ Cyclophosphamide Q21D DOXOrubicin Liposomal/ Trastuzumab Q21D Myelosuppression: Anemia, thrombocytopenia, neutropenia Nausea and vomiting Phlebitis Alopecia Constipation Diarrhea Mucositis Acral erythema Cystitis (when given with Cytoxan) Fatigue Cardiomyopathy (focus on reportable signs and symptoms) Reportable signs and symptoms Capecitabine Diagnosis: Stage III adenocarcinoma of the colon (finance ü for approved indication) Chemotherapy q Informed consent for patient (automated forms?) q Rx entered in EHR (e-prescribe or print) Capecitabine (Xeloda) 500 mg tablet Take 4 tablets by mouth in the morning and 3 tablets by mouth in the evening Take on days 1-14 and no drug days Nurse coordinator notified of Rx: Support process activated Capecitabine Support Process Rx triggers support process q Authorization and Financial Assistance Evaluation Genentech q Individualized patient teaching Bag-It Individualized teaching: Quick tips Palmar-plantar erythrodysesthesia (PPE) Diarrhea Nausea Sun sensitivity/skin flare Staying well Reportable signs and symptoms 22

23 Capecitabine: Automated Rx for Pre-treatment Medications and Testing Pre-treatment medications (automated Rx) q Prochlorperazine (Compazine) 10 mg tablet Take 1 tablet (10 mg total) by mouth every 6 hours as needed (nausea/ vomiting). Normal, Disp-30 tablet, R-5 every 6 hours PRN q Loperamide (Imodium) 2 mg capsule Take 2 capsules by mouth followed by 1 capsule after each loose stool up to a maximum of 8 capsules a day. Normal, Disp-30 capsule, R-0 starting S Laboratory parameters for treatment q Nursing communication CBC with diff and CMP prior to treatment q Treatment conditions Hold if ANC < 1500, platelets < 100,000, Hgb < 9 g/dl, or serum creatinine > 1.4 mg/dl and notify provider Any grade 3 AEs 23

24 Reduction in severity of adverse events, ED visits, hospitalizations, discontinuation of therapy Improved patient satisfaction Physician-patient consultation Informed consent Prescription cntered in the EHR SPrOChETS Individualized patient/ caregiver education provided by RN Activates prior authorization and financial assistance process Implementation of treatmentspecific standard of care for follow-up including toxicity checks and reinforcement of learning Patient notifies RN when Rx filled RN follow-up call within 1 week of new Rx 24