EHRs and Meaningful Use: Benefits and Challenges for EPs

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1 EHRs and Meaningful Use: Benefits and Challenges for EPs Presented by: Donna Garwood, RN, BSN, CPHQ KFMC HITREC Educator April 8, 2011 KAOM Overland Park, KS

2 Acronyms REC ONC HITRC MU RHIO HIE ARRA HITECH ehac PPCP CAH RH EP Regional Extension Center Office of National the Coordinator Health Information Technology Research Center Meaningful Use Regional Health Information Organization Health Information Exchange American Recovery and Reinvestment Act Health Information Technology for Economic and Clinical Health Act e-health Advisory Council Priority Primary Care Provider Critical Access Hospital Rural Hospital Eligible Professional

3 ARRA and HITECH The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, Title XIII of Division A and Title IV of Division B, together are cited as the Health Information Technology for Economic and Clinical Health Act (HITECH Act). HITECH includes provisions to promote meaningful use of health information technology to improve the quality and value of American health care. Established the Office of the National Coordinator for Health Information Technology (ONC) within the Department of Health and Human Services. ONC is principally responsible for coordinating the effort to implement a nationwide health information technology infrastructure that allows for the use and exchange of electronic health information in electronic format.

4 The HITECH Act s Framework Paper records HITECH Act EHRs & HIE Blumenthal D. Launching HITECH. N Engl J Med posted online Dec

5 HIT Presentations at KAOM KAOM Speakers Kansas Health Information Network (KHIN) Informatics Corporation of America (ICA) CMS KFMC Health Information Technology Regional Extension Center 5

6 The big picture HEALTH INFORMATION EXCHANGE IN KANSAS KHIN

7 Three Separate Programs Physician Quality Reporting System (formerly PQRI) 1% incentive for satisfactory reporting in 2011 Payment adjustments begin in 2015 erx Incentive Program 1% incentive for successful electronic prescribers in 2011 Payment adjustments begin in 2012 EHR Incentive Program Incentives dependent on registration category Medicare and Medicaid Programs Payment adjustments begin 2015

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10 Breast Cancer Screening Rate Jen Brull, MD (shared with permission Dec 2010) 100% 97% 94% 99% 82% 86% 80% 60% 65% 76% Improvement is attributed to having accurate, reliable data available at point of care and involvement of a care team, nurse and doctor to address gaps. Initial large gain is due to proactive campaign by nursing staff which involved ordering mammogram and notifying patient if overdue. This method required patient to actively decline 40% 20% 0% Base Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 This baseline data reflects a 2 year period beginning 1/1/07 thru 12/31/08 and then updated quarterly.

11 100% Colo-Rectal Cancer Screening Rate Jen Brull, MD (shared with permission Dec 2010) 80% 68% 74% 81% 60% 54% 40% 20% 43% 43% 44% Improvement is attributed to having accurate, reliable data available at point of care and involvement of a care team, nurse and doctor to address gaps. Starting Quarter 3, nurse suggested intervention to place stool hemoccult kit in patient room to trigger physician discussion with patients not current. During Quarter 5, the referral process for colonoscopy was streamlined to allow the provider to complete the referral kit at the point of care which eliminated an existing barrier. 0% Base Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 This baseline data reflects a 2 year period beginning 1/1/07 thru 12/31/08 and then updated quarterly.

12 Goals for Value-Based Purchasing Financial Viability where the financial viability of the traditional Medicare fee-forservice program is protected for beneficiaries and taxpayers. Payment Incentives where Medicare payments are linked to the value (quality and efficiency) of care provided. Joint Accountability where physicians and providers have joint clinical and financial accountability for healthcare in their communities. Effectiveness where care is evidence-based and outcomes-driven to better manage diseases and prevent complications from them. Ensuring Access where a restructured Medicare fee-for-service payment system provides equal access to high quality, affordable care. Safety and Transparency where a value based payment system gives beneficiaries information on the quality, cost, and safety of their healthcare. Smooth Transitions where payment systems support well coordinated care across different providers and settings. Electronic Health Records where value driven healthcare supports the use of information technology to give providers the ability to deliver high quality, efficient, well coordinated care.

13 ARRA In entive$

14 Medicaid Payments Started As of 4/6/11 - $64 million in Medicaid incentive payments have paid to Eligible Professionals and Hospitals by 4 states Oklahoma, Kentucky, Louisiana, and Iowa Additional payments are in process in the states above as well as in Alaska, Michigan, Mississippi, North Carolina, South Carolina, Tennessee and Texas Medicare providers will be able to attest to meaningful use in mid- to late April, and issuance of Medicare payments is scheduled to begin in May.

15 Who are Eligible Professionals Eligibility determined in law Hospital-based EPs are not eligible for incentives Definition: 90% or more of their covered professional services in either an inpatient (POS 21) or emergency room (POS 23) of a hospital Definition of hospital-based determined in law Incentives are based on the individual, not the practice

16 Who are Eligible Professionals Medicare Eligible Professionals include: Doctors of medicine or osteopathy Doctors of dental surgery or dental medicine Doctors of podiatric medicine Doctors of optometry Chiropractors Specialties are eligible if meet one of above criteria EPs may not be hospital-based

17 Payment Year ARRA Medicare Payment Incentives for EPs Medicare Incentives/Penalties for Eligible Professionals EHR Adoption Year $ 18,000 $ - $ - $ - $ $ 12,000 $ 18,000 $ - $ - $ $ 8,000 $ 12,000 $ 15,000 $ - $ $ 4,000 $ 8,000 $ 12,000 $ 12,000 $ $ 2,000 $ 4,000 $ 8,000 $ 8,000-1% 2016 $ - $ 2,000 $ 4,000 $ 4,000-2% 2017 $ - $ - $ - $ - -3% 2018 $ - $ - $ - $ - -4% 2019 $ - $ - $ - $ - -5% Total $ 44,000 $ 44,000 $ 39,000 $ 24,000 Note: The above table represents the maximum potential incentive unless the EP also qualifies for the HPSA bonus of 10%.

18 Who are Eligible Professionals Medicaid Eligible Professionals include: Physicians Nurse practitioners Certified nurse-midwives Dentists Physician assistants working in a Federally Qualified health Center (FQHC) or Rural Health Clinic (RHC) that is so led by a physicians assistant EPs may not be hospital based

19 Who are Eligible Professionals Medicaid Eligible Professionals must also meet one of the three patient volume thresholds: Have a minimum of 30% Medicaid patient volume Pediatricians ONLY: Have a minimum of 20% Medicaid patient volume Working in an FQHC or RHC ONLY: Have a minimum of 30% patient volume attributed to needed individuals CHIP, sliding scale, free care only count towards thresholds if working in RHC or FQHC

20 ARRA Medicaid Payment Incentives for EPs Note: Payment years do not have to be consecutive to receive all incentive payments available through 2021.

21 RECs Where We Fit In

22 Regional HIT Extension Program $640 Million dollars to fund ~62 RECs Goal is to help 100,000 providers $6400 per provider Awarded in two cycles At least one REC in each region during first round of funding Final count 62 REC s covering 98% of US

23 KS REC Objectives Provide hands on expertise to assist providers in leveraging HIT and moving towards MU. Help at least 1,200 PPCPs move towards MU Onsite tailored assistance from experienced staff MU resource Q&A available on website CAH/RH support 95 facilities qualify Partnership with KHERF/KHA Education and tools to help these facilities move towards MU Assistance to Non-PPCPs also available Onsite tailored assistance is also available to non-subsidized providers

24 Priority Primary Care Providers For purposes of the REC cooperative agreements, a primarycare provider is any MD or DO, any ARNP, Nurse mid-wife, or PA with prescriptive privileges in the locality where s/he actively practices in one of the following specialties: family, internal, pediatric, obstetrics and gynecology, or geriatric. Priority primary care providers function in the following settings: Individual and small group practices (ten or fewer professionals with prescriptive privileges) primarily focused on primary care; Public and Critical Access Hospitals Community Health Centers and Rural Health Clinics; and Other settings that predominantly serve uninsured, underinsured, and medically underserved populations

25 Kansas REC Participating Practices 579 Kansas Physicians/Practitioners Receiving Assistance 516 Priority Primary Care Providers (PPCPs) and 63 Specialists Atwood (1) Saint Francis (1) Phillipsburg (1) Belleville (1) Hanover (1) Sabetha (1) Goodland (1) Colby (1) Oakley (1) Hoxie (1) Ransom (1) Dighton (1) Scott City (1) Garden City (2) Quinter (2) Jetmore (1) Hays (1) Plainville (4) Kinsley (1) Hutchinson (1) Clay Center (1) Hoisington (1) Lindsborg (1) McPherson (1) Ellinwood (1) Great Bend (1) Moundridge (1) Marion (1) Larned (1) Hesston (1) Greensburg (1) Osborne (1) Salina (1) Newton (1) Junction City (3) Augusta (1) Wichita (12) Manhattan (4) Eureka (1) Leavenworth (1) Lansing (1) Kansas City (2) Topeka (2) Lawrence (5) Fredonia (3) Iola (1) Chanute (1) Atchison (1) Spring Hill (1) Ottawa (1) Meade (1) Medicine Lodge (1) Wellington (1) Winfield (1) Neodesha (2) Pittsburg (2) Arkansas City (1) Rural Health Clinic Community Health Center Private Practice (1-10) Specialty Practice As of 4/5/2011

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

27 Basic Overview of MU Final Rule Stage 1 (2011 and 2012) To meet certain objectives/measures, 80% of patients must have records in the certified EHR technology EPs have to report on 20 of 25 MU objectives (15 core and 5 menu set) EHR Reporting Period 90 days for first year; one year subsequently Medicaid for the 1 st participation year there is no EHR reporting period. MU can be met through A/I/U Reporting by attestation required in 2011, electronic reporting to CMS required in 2012

28 MU Final Rule Measures Core Set Objective 1. Use computerized order entry for medication orders 2. Implement drug-drug and drug-allergy checks 3. Generate and transmit permissible prescriptions electronically (EPs only) 4. Record patient demographics-gender, race, ethnicity, date of birth, preferred language. Hospitals add mortality date & cause of death 5. Maintain an up-to-date problem list of current and active diagnoses 6. Maintain active medication list Measure 1. More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE 2. Functionality is enabled for these checks for the entire reporting period 3. More than 40% are transmitted electronically using certified EHR technology 4. More than 50% of patients demographic data recorded as structured data 5. More than 80% of patients have at least one entry recorded as structured data 6. More than 80% of patients have at least one entry recorded as structured data

29 MU Final Rule Measures Core Set Objective 7. Maintain active medication allergy list 8. Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth charts for <20yo) 9. Record smoking status for patients 13 years old or older 10. Implement one clinical decision support rule and ability to track compliance with the rule 11. Report Clinical Quality Measures (CQMs) to CMS or the States Measure 7. More than 80% of patients have at least one entry recorded as structured data 8. More than 50% of patients 2 years of age or older have height, weight and blood pressure recorded as structured data 9. More than 50% of patients 13 years of age or older have smoking status recorded as structured data 10. One clinical decision support rule implemented : provide aggregate numerator and denominator through attestation; 2012: electronically submit measures

30 MU Final Rule Measures Core Set Objective 12. Provide patients with an electronic copy of their health information upon request-diagnostic test results, problem list, medication lists, medication allergies. Hospitals add discharge summary and procedures 13. Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request (hospital only) Measure 12. More than 50% of requesting patients receive electronic copy within 3 business days 13. More than 50% of all patients who are discharged who request an electronic copy of their discharge instructions are provided it 14. Provide clinical summaries to patients for each office visit (EPs only) 14. Clinical summaries are provided to patients for more than 50% of all office visits within 3 business days

31 MU Final Rule Measures Core Set Objective 15. To exchange key clinical information electronically among providers and patient authorized entities Measure 15. Perform at least one test of EHR s capacity to electronically exchange information key clinical information 16. Protect electronic health information (privacy & security) 16. Conduct or review a security risk analysis; implement security updates as necessary; correct identified security deficiencies

32 MU Final Rule Measures Menu Set Objective 1. Implement drug-formulary checks 2. Incorporate clinical lab-test results into certified EHR as structured data 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach 4. Send reminders to patients per patient preference for preventive/ follow-up care (EPs only) Measure 1. Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period 2. More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data 3. Generate at least one listing of patients with a specific condition 4. More than 20% of patients 65 years old or 5 years old are sent appropriate reminders

33 MU Final Rule Measures Menu Set Objective 5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) (EPs only) Measure 5. More than 10% of patients are provided electronic access to information within 4 days of its being updated in the HER 6. Use certified EHR to identify patientspecific education resources and provide to patient if appropriate 6. More than 10% of patients are provided patient-specific education resources 7. Perform medication reconciliation as relevant (between care settings) 8. Provide summary care record for transitions in care or referrals 9. Record advance directives for patients 65 years old or older (Hospitals only) 7. Medication reconciliation is performed for more than 50% of transitions of care 8. Summary of care record is provided for more than 50% of patient transitions or referrals 9. More than 50% of patients will have an indication of advance directive status recorded

34 MU Final Rule Measures Menu Set Objective 10. Capability to submit electronic data to immunization registries and actual submission* 11. Capability to provide electronic syndromic surveillance data to public health agencies and actual submission* 12. Capability to submit electronic data on reportable lab results to public health agencies and actual submission* (Hospitals only) * At least one public health objective must be selected. Measure 10. Perform at least one test of data submission and follow-up submission (where registries can accept electronic data) 11. Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) 12. Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

35 CQMs Eligible Professionals Core CQM (must report on all 3*) Hypertension: Blood Pressure Management (NQF 0013). Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded. Preventive Care and Screening Measure Pair: Tobacco Use Assessment and Tobacco Use Intervention (NQF 0028). Percentage of patients aged 18 years or older who have been seen for at least 2 office visits, who were queried about tobacco use one or more times within 24 months. And percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention. Adult Weight Screening and Follow-Up (NQF 0421). Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a followup plan is documented. * If the denominator of 1 or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures.

36 CQMs Eligible Professionals Alternate Core CQM Preventative Care and Screening: Influenza Immunization for Patients 50 Years Old (NQF 0041) Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February) Weight Assessment and Counseling for Children and Adolescents (NQF 0024) Percentage of patients 2-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. Childhood Immunization Status (NQF 0038) Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or more rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.

37 CQMs Additional set for Eligible Professionals (select 3 of 38) 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

38 CQMs Additional set for Eligible Professionals (select 3 of 38) 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

39 CQMs Additional set for Eligible Professionals (select 3 of 38) 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 State IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer patients

40 CQMs Additional set for Eligible Professionals (select 3 of 38) 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

41 CQMs Additional set for Eligible Professionals (select 3 of 38) 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

42 CQMs Additional set for Eligible Professionals (select 3 of 38) 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%)

43 CQMs Eligible Professionals Summary EPs must report on 6 total measures 3 required core measures (substituting alternate core measures where necessary) 3 additional measures CQMs align with Physician Quality Reporting Initiative (PQRI) Alignment between 4 HITECH CQM and the CHIPRA initial core set that providers report to States More Information

44 Meaningful Use Beyond Stage 1 Stage 2 would expand upon the Stage 1 criteria in the areas of disease management, clinical decision support, medication management, support for patient access to their health information, transitions in care, quality measurement and research, and bi-directional communication with public health agencies. CMS may consider applying the criteria more broadly to both the inpatient and outpatient hospital settings. Consistent with other provisions of Medicare and Medicaid, Stage 3 would focus on achieving improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data, and improving population health outcomes.

45 If Only Current State Future State

46 REC Services Education and Outreach Participate in National Learning Consortium Vendor Selection and Group Purchasing Plans EHR Implementation and Project Management Workflow Redesign Functional Interoperability and Health Information Exchange Privacy and Security Practices Progress Towards Meaningful Use

47 APS, KFMC and REC Participants Thanks to a strategic partnership between APS and KFMC, providers who sign up with the KFMC HITREC to implement their EHR automatically gain membership in APS. This means your facility will have access to powerful group purchasing capabilities that were previously available primarily to Kansas and Missouri hospitals. In addition to saving money on your EHR hardware and software, your membership allows you to take advantage of many contract areas such as Technology, Office, Clinical, etc.

48 EHR Vendor Partners Tier I Cerner eclinicalworks e-mds McKesson Pulse SuccessEHS Tier II NextGen Sage

49 Willingess to comply with APS standard contract terms / conditions Hosted (SaaS) EHR & PM 30 Acceptance MOST FAVORABLE CONTRACTS 25 VENDOR A VENDOR B VENDOR E VENDOR F 20 VENDOR C VENDOR D VENDOR G 15 VENDOR H 10 VENDOR J VENDOR I 5 Rejection LEAST FAVORABLE CONTRACTS 0 $200,000 $180,000 $160,000 VENDOR K $140,000 $120,000 $100, Yr Cost of Ownership Higher Cost Vendors Lower Cost Vendors Price includes hosted software cost + interfaces over 10 years for 1 provider, 1 mid-level practitioner, and 1 RN for Electronic Medical Record and Practice Mgmt. software $80,000

50 I am delighted to be working with KFMC, the Kansas Regional Extension Center! Dr. Jen Brull of Prairie Star Family Practice said. I anticipate their team will assist me greatly in achieving Meaningful Use, and I look forward to their help. Dr. Brull is a family medicine physician in solo practice in Plainville, Kansas. This is her ninth year of private practice in a rural community. Special interests include electronic health records, maternal/child care, and preventive medicine.

51 Kansas Foundation for Medical Care, Inc Your Regional Extension Center Expertise invaluable experience working with Kansas providers on implementation of HIT Availability KFMC staff are located in your area of the state in order to answer your questions, provide hands-on education, and performon-site analysis Costs are lower. We are a not-for-profit, and federal subsidies support our technical assistance to Priority Primary Care Providers for adopting and optimizing HIT Partners We have many partners throughout the state of Kansas to help ensure that the REC is aware and properly aligned with statewide activities

52 What You Can Do Now Contact your Regional Extension Center Phone: Follow our Website at Sign up for updates on our Blog (link on KFMC website) Our field staff are scheduling visits today! This material was prepared by Kansas Foundation for Medical Care, Inc. as part of our work as the Kansas Regional Extension Center, under grant #90RC0003/01 from the Office of the National Coordinator, Department of Health & Human Services. RC_2011_58