EMR Use in the Age of Healthcare Reform. C. Martin Harris, M.D. Chief Information Officer, Cleveland Clinic Executive Director, ecleveland Clinic

Transcription

1 EMR Use in the Age of Healthcare Reform C. Martin Harris, M.D. Chief Information Officer, Cleveland Clinic Executive Director, ecleveland Clinic

2 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

3 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

4 Key Dates of Meaningful Use January, 2009 President signs the American Recovery & Reinvestment Act January, 2010 Official Notice of Proposed Rulemaking in Federal Register (over 2,000 responses from the public received by CMS) July 13, 2010 CMS releases pre-publication Final Rule Anticipated on July 28, 2010 Official publication of the Final Rule in Federal Register Anticipated on September 25, 2010 Final Rule becomes effective (60 days after publication)

5 Purpose of Meaningful Use 1. Improve quality, safety, efficiency, and reduce health disparities 2. Engage Patients and Families 3. Improve Care Coordination 4. Ensure adequate privacy and security protections for Personal Health Info 5. Improve Population and Public Health

6 ARRA s Text on Meaningful Use An EP and an eligible hospital shall be considered a meaningful EHR user for an EHR reporting period for a payment year if they meet the following three requirements: Utilize certified EHR technology in a meaningful manner; Utilize certified EHR technology that is connected in a manner that provides for the electronic exchange of health information to improve the quality of healthcare such as promoting care coordination; and, Submit information on clinical quality measures and other measures in a form & manner specified by Secretary of HHS

7 Critical Decision Points for CMS Where practically possible and legally permissable, CMS aligned the EHR Incentive Program across 3 programs: Medicare Fee-for-Service Medicare Advantage Medicaid Medicare payments released by CMS Medicaid payments released by States

8 Scope of Provider Impact CMS estimates 624,000 US hospitals and EPs will be impacted CBO estimates, on average: EPs: $54K to purchase/implement certified EHR technology and $10K annually to maintain it Hospitals: $5M (range of $1M-$100M) to purchase/implement, and $1M for maintenance

9 Data on Eligible Professionals CMS estimates 477,500 eligible non-hospitalbased Medicare EPs in 2011 Of these, approximately 95,500 are also eligible for Medicaid in 2011 CMS assumes these EPs will choose Medicaid because it s larger (note: no double-dipping allowed) CMS estimates 44,100 Medicaid-only EPs

10 Data on Eligible Hospitals CMS estimates 5,011 eligible hospitals: 3,620 acute-care hospitals 1,302 critical access hospitals 78 children s hospitals 11 cancer hospitals

11 Data on Medicare Advantage CMS estimates 12 MA organizations 28,000 EPs 29 hospitals

12 Payment and Benefits Impact CMS s low scenario estimates total impact of $9.7B CMS s high scenario estimates $27.4B Estimates include payments to EPs / hospitals, cost savings, and improved health outcomes

13 Financial Impact of Non-Participation CMS notes the Program is voluntary CMS notes EPs could collectively lose up to $135M for non-participation

14 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

15 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

16 Definitions Meaningful Users Eligible for Medicare EHR Incentive: MD, DO, DDS, DMD, DPM, OD, DC Eligible Medicaid EHR Incentive: MD, DO, DDS, DMD, DPM, CNMW, NP, certain PAs Ineligible: If greater than 90% of a professional s Medicare / Medicaid services are provided in inpatient hospitals or emergency rooms (POS codes 21 & 23)

17 Definitions Eligible Hospitals Eligible for both Medicare and Medicaid Incentive Programs: Acute Care Hospitals Critical Access Hospitals Eligible only for Medicaid Incentive: Children s Hospitals Cancer Hospitals

18 Qualified EHR Defined An individual s e-record that: Includes patient demographics and clinical health information, and Has the capacity to: Provide CDS Support physician order entry Capture & query quality information Exchange e-health information with, and integrate such information from other sources

19 Program Effective Dates January 1, 2011 for Eligible Professionals (calendar years) October 1, 2010 for Eligible Hospitals and Critical Access Hospitals (federal fiscal years)

20 Reporting Requirements Medicare providers Year 1: must report utilization of certified EHR technology on 90 consecutive days Subsequent Years: must report utilization for 12 full months Medicaid providers Year 1: no requirement to report implementation or upgrade Year 2: must report utilization for 90 consecutive days Subsequent Years: must report utilization for 12 full months Medicaid providers are not required to report on consecutive years until 2017 / FY17

21 Meaningful Use Criteria 15 core measures must be met by EPs; 14 for eligible hospitals and CAHs For 2011/FY11, EPs and eligible hospitals / CAHs choose 5 from a second menu set of 10 criteria Denominators mostly equal unique patient visits, not office visits Final Rule s criteria threshold was lowered

22 eprescribing Requirements EPs: requires 30% of orders be entered electronically by prescribers Down from 80% in the NPRM 60% = potential Stage 2 requirement

23 Hospital-Based Order Entry Requirements Eligible Hospitals & CAHs: requires 30% Up from 10% in the NPRM 60% = potential Stage 2 requirement

24 Two-Part Quality Measures for EPs 3 required core measures Hypertension & Blood Pressure Mgt Tobacco Use Assessment and Cessation Intervention Adult Weight Screening and Follow-Up If no denominator for core measures, EPs report on replacement measures from list 3 ala carte measures from a list of 38

25 Measures for Eligible Hospitals and CAHs 15 required core measures Must report numerators, denominators, and exclusions Even if 1 or more values are 0 There is no minimum threshold value for any numerator, denominator, or exclusion

26 Providing Patients ecopies Upon request, all MU providers have 72 hours to provide an ecopy on more than 50% requests This includes EPs, an EH s inpatient and emergency departments, and CAHs Upon request, all MU providers must provide ecopies of diagnostic tests, problem lists, med lists, and med allergies In addition, upon request an EH s inpatient and emergency department, and a CAH must also provide ecopies of discharge summaries and procedures; EPs must include clinical summaries

27 Stages Two and Three Criteria to be updated bi-annually Stage 2 expected at end of 2011 Stage 3 expected by end of 2013 What to expect in Stage 2 Increased e-prescribing & CPOE use Incorporating structured lab results E-transmission of patient care summaries All optional Stage 1 criteria will be required All thresholds and exclusions to be re-evaluated Criteria may be more broadly applied to outpatient hospitals settings (not just the ED)

28 Attestation and ereporting Clinical quality measures electronically reported beginning in 2012 / FY12 All other MU criteria may be demonstrated through attestation Attestation must be thru a secure mechanism Claims-based reporting or Online portal

29 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

30 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

31 Hospital Incentive Payments Single CCN remains as billing criteria no allowance made for multi-hospital systems using a single CCN Total hospital discharge calculation and total hospital days calculation necessary for the payment process will be amended before the federal FY11 payment year via Medicare s updated cost report

32 Timing of Hospital Payments Timing of payments, especially during the first payment year, may be affected by factors such as the timeline for implementing the requisite systems to calculate and disburse the payments

33 Incentive Payments for CAHs Payments via a single CMS contractor CAH must attest it is a meaningful user and submit its documentation to its FI/MAC to support costs incurred for the certified EHR system Upon review by the FI/MAC, CMS will direct release of a single payment Payments begin in May, 2011

34 Medicare Payments for EPs Medicare Program allows for up to 5 years of payments: The second year must be consecutive to the first; the third year must follow the second, and so on If an EP achieves MU in a year, but fails to do so in a subsequent year, that year still counts towards the total of 5 possible years Anticipates one lump payment within days of submission of successful attestation

35 Medicaid Payments for EPs Medicaid Program is a 6-year program: Incentive payments may, generally, be nonconsecutive

36 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

37 Agenda General Overview Requirements Payments Process to Achieve Meaningful Use

38 Process to Achieve Meaningful Use Objectives Operating Model Use CPOE for all order types including medications [OP, IP] Implement drug-drug, drug-allergy, drug-formulary checks [OP, IP] Maintain an up-to-date problem list [OP, IP] Generate and transmit permissible prescriptions electronically (erx) [OP] Maintain active medication list [OP, IP] Maintain active medication allergy list [OP, IP] Record primary language, insurance type, gender, race, ethnicity [OP, IP] Record vital signs including height, weight, blood pressure [OP, IP] Incorporate lab-test results into EHR [OP, IP] Generate lists of patients by specific condition to use for quality improvement, reduction of disparities, and outreach [OP] Send reminders to patients per patient preference for preventive / follow up care [OP, IP]

39 1. Independent Physician s Office 4. Cleveland Clinic Inpatient Meaningful Use Operating Model 2. Independent commercial pharmacy, labs, and patient at home 3. Cleveland Clinic Ambulatory sites

40 Physician: Scheduled Patient Arrives 01:00 PM B :23 PM EST PATIENT Closed Comp 6 MONTHS FOLLOW 01:20 PM R. 20 1:23 PM EST PATIENT Closed Comp HOSP FOLLOW UP 01:40 PM A. 20 1:09 PM EST PATIENT Closed Sch FOLLOW UP 02:00 PM N. 20 1:11 PM EST PATIENT Closed Arr 4 MONTH FOLLOW UP 02:20 PM L. 20 1:50 PM EST PATIENT Closed Comp 4 MONTH FOLLOW UP 02:40 PM P. 20 1:50 PM EST PATIENT Closed Comp 6 MONTH FOLLOW UP 03:00 PM W. 20 2:28 PM NEW/ESTAB Closed Arr PHYSICAL 03:20 PM B. 20 3:54 PM EST PATIENT Closed Sch 4 MONTH FOLLOW UP 03:40 PM C. 20 3:29 PM EST PATIENT Closed Sch 4 WEEK FOLLOW UP 04:00 PM S. 20 3:40 PM EST PATIENT Closed Comp ONE MONTH FOLLOW UP 04:20 PM A. 20 4:17 PM NEW/ESTAB Closed Arr HOSP FOLLOW UP 04:40 PM M. 20 4:28 PM EST PATIENT Closed Comp SIX MONTHS FOLLOW UP, MD, MD, MD, MD, MD

41 MA/LPN/RN After rooming the patient, the office staff confirms pharmacy benefits

42 MA/LPN/RN Recently ordered/refilled medications reviewed during medication reconciliation process

43 Physician: Best Practice alert reminder to assess screening tests based on Health Maintenance List

44 Physician: Reviews Summary showing Problem List and Medication List

45 Physician: Confirms Penicillin Allergy

46 Physician: Completes History and Physical and Writes a Note

47 Physician: Orders a Laboratory Test Hospital and Commercial Laboratories

48 Physician: Reviews Test Result Final

49 Physician: Medication Information Presented Upon Ordering as a Part of e-prescribing. If the Medication is Non-formulary, the System Automatically Presents Alternative

50 Physician: After completing the visit documentation, follow-up can be scheduled and a summary of the visit can be routed to other providers, if indicated Specialist

51 Physician: At the end of the visit, an After Visit Summary is printed and presented to the patient

52 Process to Achieve Meaningful Use Objectives Use CPOE for all order types including medications [OP, IP] Implement drug-drug, drug-allergy, drug-formulary checks [OP, IP] Maintain an up-to-date problem list [OP, IP] Generate and transmit permissible prescriptions electronically (erx) [OP] Maintain active medication list [OP, IP] Maintain active medication allergy list [OP, IP] Record primary language, insurance type, gender, race, ethnicity [OP, IP] Record vital signs including height, weight, blood pressure [OP, IP] Incorporate lab-test results into EHR [OP, IP] Generate lists of patients by specific condition to use for quality improvement, reduction of disparities, and outreach [OP] Send reminders to patients per patient preference for preventive / follow up care [OP, IP] Operating Model The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities. Meaningful Use: A Definition Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee June 16, 2009