EHR Meaningful Use Incentives for School-Based Health Clinics

EHR Meaningful Use Incentives for School-Based Health Clinics Denise Holmes Institute for Health Care Studies Michigan State University September 27, 2011

Background The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the American Recovery and Reinvestment Act of 2009 (ARRA, a.k.a. the stimulus act. ) HITECH provides grants, financial incentives, standards, and mandates to promote health IT. The act devotes the largest sum of money ($32 billion) to electronic health record (EHR) incentives for hospitals and professionals, payable through Medicare and Medicaid. To collect incentives, eligible hospitals and professionals must: 1.) Meet patient volume requirements for Medicare and/or Medicaid; 2.) Use Certified EHR Technology and 3.) Meet meaningful use of the EHR criteria.

Incentive Payments Hospitals (including critical access) hospitals may participate in both programs. Eligible professionals must choose either Medicare or Medicaid, although they are allowed a one-time switch. They must not be hospital-based (provide more than 90% of services in an in-patient setting). Eligible professionals under Medicare can collect up to $44,000 over 5 years (plus 10% in designated shortage areas) Eligible professionals under Medicaid can collect up to $63,750 over 6 years A flow chart prepared by CMS and comparison of incentive payments follows.

Medicaid EHR Incentives Since school-based health centers are most likely to qualify under the Medicaid Eligible Professional category, we ll concentrate on this option. Clinicians who qualify include: 1. Physicians 2. Dentists 3. Certified Nurse Mid-wives 4. Nurse Practitioners 5. Physician Assistants (PA) practicing in a PA-led FQHC or Rural Health Clinic

Medicaid Patient Volume Most eligible professionals must have a Medicaid patient volume of at least 30% to qualify. Exceptions: Pediatricians may have as low as a 20% Medicaid patient volume, but if they have between 20 and 30 percent Medicaid patient volume they will receive two-thirds of the maximum amount. The total incentive for pediatricians in this situation is $14,167 in the first year and $5,667 in subsequent years. This adds up to a maximum Medicaid EHR incentive payment of $42,500 over a six-year period. Non-hospital based providers that practice predominantly in FQHC or RHC may count all needy individuals toward the volume requirements.

Pediatrician Definition CMS does not define pediatrician for this program. Pediatricians have special eligibility and payment flexibilities offered under the program and it is up to States to define pediatrician, consistent with other areas of their Medicaid programs. * *CMS, Frequently Asked Question #61 at: https://www.cms.gov/ehrincentiveprograms/downloads/faqsremediateda ndrevised.pdf

Needy Individuals Definition Needy Individuals are those that: 1. received medical assistance from Medicaid or the Children Health Insurance Program (CHIP), 2. were furnished uncompensated care by the provider 3. were furnished services at either no cost or reduced cost based on a sliding scale determined by the individual s ability to pay

Medicaid Patient Volume In determining your Medicaid patient volume, keep in mind: The volume measurement applies to the eligible professional, not the organization. An eligible professional who works at multiple locations, but does not have certified EHR technology available at all of them would: 1.) Have to have 50% of their total patient encounters at locations where certified EHR technology is available, and 2.) Would base all meaningful use measures only on encounters that occurred at locations where certified EHR technology is available.

Patient Volume Calculation The two options offered in the final EHR Incentive rule* include: 1) a ratio where the numerator is the total number of Medicaid patient encounters (or needy individuals) treated in any 90-day period in the previous calendar year and the denominator is all patient encounters over the same period; or 2) a similar ratio where the state may take into account Medicaid patients on a primary care patient panel (see next slide) Contact your state Medicaid Agency to see how they are implementing the rule. * See fact sheet at http://www.cms.gov/apps/media/press/factsheet.asp?counter=3793&intnumperpage =10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=& keywordtype=all&chknewstype=6&intpage=&showall=&pyear=&year=&desc=&cbo Order=date

Medicaid Patient Volume From EHR Incentive Program Final Rule: Medicaid Provisions Presented by Jessica Kahn and Michelle Mills Centers for Medicare & Medicaid Services Center for Medicaid, CHIP, and Survey & Certification, available at : https://www.cms.gov/mlnproducts/downloads/ehr_final_rule-medicaid.pdf

Certified" EHR Technology EHR products must be certified for meaningful use. See http://www.cms.gov/ehrincentiveprograms/25_certification.asp for the database of products. (If you already have an EHR product, please pay attention to the version of the product and not just the name). You will need to know your CMS EHR Certification ID when registering for the EHR Incentives It can be found at: http://onc-chpl.force.com/ehrcert

Certified" EHR Technology EHRs may either be complete (able to meet all meaningful use functions in one product) or modular (specific software applications that together can meet the meaningful use requirements. Example of Modular EHR: Clinic uses separate e-prescribing, patient registry, patient portal, and practice management software that together can meet the meaningful use criteria.

Adopt, Implement, or Upgrade Under the Medicaid program (unlike the Medicare program), eligible professionals do not need to meet Meaningful Use requirements in the first year. Instead, they may show evidence of adopting, implementing, or acquiring EHRs. 1. Adopt: acquired and installed e.g., evidence of acquisition, installation etc. 2. Implement: commenced utilization e.g., staff training, data entry of patient demographic information into EHR, data use agreements 3. Upgrade: new version or expanded functionality e.g., upgrade to a new certified version or additional functionality required for meaningful use

Five Broad Healthcare Goals for 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 information 5. Improve population and public health

Meaningful Use Three Stage Approach Stage 3 Stage 1 Stage 2 Data capture & sharing Advance clinical processes Improved outcomes

Meaningful Use Current rules apply to Stage 1. Rules for Stages 2 and 3 have not been announced, but they will likely build on stage 1 rules. Stage 2 has been delayed until 2013. States have the option of seeking CMS approval for additional public health-related 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 eligible professional would be excluded from having to meet that measure. CMS has posted a meaningful use attestation worksheet on its web site at: http://www.cms.gov/ehrincentiveprograms/downloads/ep_atte station_worksheet.pdf

Core Set: All 15 Measures Required Objective (Measure, usually percentage of unique patients) 1. Demographics (50%) 2. Vitals: BP and BMI (50%) 3. Problem list: ICD-9-CM or SNOMED (80%) 4. Active medication list (80%) 5. Medication allergies (80%) 6. Smoking status (50%) 7. Patient clinical visit summary (50% in 3 days) 8. Hospital discharge instructions (50 %) 9. Patient with electronic copy (50 % in 3 days) E-prescribing(40%) CPOE(30% including a med) Drug-drug and drug-allergy interactions (functionality enabled) Exchange clinical information (perform test) Clinical decision support (one rule) Security risk analysis 10. Report clinical quality measures (see next slide)

Core Set: Clinical Quality Measures # 10: Report clinical quality measures Providers are required to report on 3 core clinical quality measures and 3 clinical quality measures from an additional set of 38 optional measures. For more information and links to the measures, see https://www.cms.gov/qualitymeasures/03_electronicspecification s.asp

Menu Set: Choose 5 Measures The 10 menu requirements (from which five must be chosen for implementation) 1. Implement drug formulary checks 2. Incorporate clinical lab test results 3. Generate patient lists by condition 4. Identify patient-specific education resources 5. Perform medication reconciliation between care settings 6. Generate summary of care for transferred patients 7. Submit immunization data to registries 8. Submit epidemiology data to public health 9. Send care reminders to patients 10. Provide patient with timely access to electronic health information Selected menu measures must include one of the two public health measures (#7 or #8).

Registration & Payment Providers must register with the National Level Repository (NLR) at the federal level to start their registration process: https://www.cms.gov/ehrincentiveprograms/20_registrationan dattestation.asp Once registered at the federal level, providers will be invited to complete their registration at the state level. Medicaid payment and verification procedures will vary by state. If your eligible professionals do not bill Medicaid for services but are otherwise eligible for incentive payments, you will need to contact the official in charge of Medicaid EHR incentives for guidance. Eligible professionals have options concerning where they direct their incentive payments. Make sure they use the Federal Employer Identification Number (FEIN) for your clinic.

More information For more information on the program in general, go to: http://www.cms.gov/ehrincentiveprograms/ A list of state Medicaid EHR programs and contacts can be found at: http://www.cms.gov/apps/files/statecontacts.pdf Learn about certification and certified EHRs, as well as other ONC programs designed to support providers as they make the transition: http://healthit.hhs.gov The HITECH Act also funded a network of regional extension centers to aid small providers on the path to meaningful EHR use. A list of such centers can be found at: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov l isting_of_regional_extension_centers/3519

Denise Holmes Director, Institute for Health Care Studies College of Human Medicine Michigan State University Denise.Holmes@hc.msu.edu (517) 432-9807 www.ihcs.msu.edu