Len Bowes, MD, MS, Intermountain Healthcare Medical Informatics Jan 2010 *ARRA = American Recovery and Reinvestment Act
What are HITECH and ARRA? The Health Information Technology for Economic and Clinical Health Act (HITECH) is part of the American Recovery and Reinvestment Act of 2009 (ARRA) Increase adoption and use of IT Three areas of Impact Incentives, penalties, EHR Certification and use required. Privacy: Significant augmentation to HIPAA Increased research funding, NIH, other 1/26/2010 Healthcare Medical Informatics 2
HITECH and ARRA* and Intermountain $75-100M incentives Potential to impact clinical information systems, processes, and MD, RN, clinician workflow greater than many initiatives in the last 13 years. * Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the American Recovery and Reinvestment Act (ARRA) of 2009 1/26/2010 Healthcare Medical Informatics 3
HITECH Legislation to Realization ARRA-Hitech law passed Feb 09 Provided outline April 09 Dec 09 HIT* Standards and Policy Committees defined detail Iterative development of standards and policy Marc Probst and Stan Huff participating. December 09 committee recommendations to CMS 60 day comment period Early Spring 10 CMS Rules released Late Spring CMS final rules after comment period 1/26/2010 Yellow = complete White = pending Healthcare Medical Informatics 4
Incentives and Penalties Hospitals and Providers Incentives (as early as 2011, through 2015) Medicare /Medicaid incentives for hospitals could reach $75M* Intermountain Medical Group Physicians could reach $22M Penalties begin in 2015 and increase. Hospitals $2-4M/year Providers $0.8M/year Must meet the following Certification of EHRs (Ecis, HELP and HELP2) Demonstrate Meaningful Use of EHRs 1/26/2010 Healthcare Medical Informatics 5
Timing Clarification: Meaningful Use Incentives by Adoption Stage 1/26/2010 Healthcare Medical Informatics 6
Timing Clarification: Meaningful Use Incentives by Adoption Stage 1/26/2010 Healthcare Medical Informatics 7
Meaningful Use Matrix EHR Gaps at Intermountain 1. Functionality 1. Need to fill 26 of 61 2. Security/Privacy 1. Need to fill 19 of 29 3. Exchange of Electronic Clinical Data 4. Quality Measures Reporting * Meaning Use requirements in flux until Spring 2010 1/26/2010 Healthcare Medical Informatics 8
Certification Certification body: CCHIT and others CCHIT Requirements ARRA Site Certification, based on Meaningful Use definitions: Expect announcement in Spring 2010 Gaps 2011 Function (we meet 26 ARRA requirements) Security (we meet 19 ARRA requirements) Additional Gaps expected in 2013, 2015 Recertification will be required 1/26/2010 Healthcare Medical Informatics 9
Non-IT Gaps Meaningful Use: Phase 1 of 3 Intermountain Systems and processes Challenge Difficult = D E=Easy Objective Practice Hospital -Inpatient Measurement Notes Certification of CPOE (Physician Order Entry) CPOE for medications, laboratory, radiology, and provider referrals* at a minimum Enter of orders for medications, laboratory, radiology, blood bank, PT, OT, RT, rehab, dialysis, provider consults, and discharge and transfer, at a minimum Numerator: number of CPOE orders entered for all patients. Denominator: total number of orders issued. Practices must enter 80% of orders by CPOE. Hospitals must enter 10%. EHR(Help, HELP2 or ECIS) inpatient process Provider must enter orders directly from a computer and stored in a digital, structured, computable format. Orders do not have to be transmitted electronically to the recipient, however. Note that progress notes are not required. Note the requirement to count all orders issued as the denominator - counting papers orders may prove a challenge and/or time consuming. D D D M=Moder ate Outpatient Process C=Complete Comment HELP2 POE qualifies for inpatient, but will likely need to be replaced for Stg II, III. Help2 Ambulatory CPOE needs to be built. 1/26/2010 Healthcare Medical Informatics 10
Meaningful Use: Phase 1 of 3 Intermountain Systems and processes Objective Practice Hospital -Inpatient Measurement Notes CPOE (Physician Order Entry) Drug Prescribing Alerts CPOE for medications, laboratory, radiology, and provider referrals* at a minimum a. Real-time alerts for drugdrug interactions and drug allergy contraindications. 1/26/2010 Enter of orders for medications, laboratory, radiology, blood bank, PT, OT, RT, rehab, dialysis, provider consults, and discharge and transfer, at a minimum a. Real-time alerts for drugdrug interactions and drug allergy contraindications. Numerator: number of CPOE orders entered for all patients. Denominator: total number of orders issued. Practices must enter 80% of orders by CPOE. Hospitals must enter 10%. Functionality is enabled. Provider must enter orders directly from a computer and stored in a digital, structured, computable format. Orders do not have to be transmitted electronically to the recipient, however. Note that progress notes are not required. Note the requirement to count all orders issued as the denominator - counting papers orders may prove a challenge and/or time consuming. Estimate Cost in $K (Time, Resource, Deliverables) IT estimate Cost Practice Process IP Process Total $K Comment C=Complete IT Process EP Process Hospitals Deliverable is new ambulatory POE e.g. tab on Eprescrib, use HELP2 POE for inpatient, but will likely need to be time in month #FTEs time in month # FTEs time in month # FTEs 3,600 180 2,700 6,480 replaced for Stg II, III. 18 20 12 2.5 18 25 If must alert to MD in HELP then Big change for software and process in inpatient Healthcare Medical Informatics 11
Meaningful Use Gaps at Intermountain Process Gaps Phase 1 EHR not Certified CPOE used for % 80 all OP orders, 10% of IP Medication Reconcilliation 80% transition encounters 5 Clinical Decision Support rules 80% pts must have med, allergy, problem list maintained Quality measures must be reported to CMS >60% of which we do not yet report on Patients must receive reminders, clinic summaries Most clinical data, will need to be in EHR Transition of care summaries, discharge, referral Drug allergy, drug-formulary checking must activated Electronic exchange (HIE< probs, meds, allergies, result) Patient access to Personal Health Record Receive and submit public health info 1. Phase II: See MU Matrix 100% CPOE IP, OP, etc. 2. Phase III: See MU Matrix 1/26/2010 Healthcare Medical Informatics 12 * Meaning Use requirements in flux until Spring 2010
Implications to Intermountain Incentives Certify Clinical Systems Project to certify HELP and HELP2 Identify gaps/requirements Certify; Process, Team, periodic Demonstrate Meaningful Use Actually Use EHR! Huge change for some MDs and clinicians Implementation challenge Exchange Data Report Quality Metrics 1/26/2010 Healthcare Medical Informatics 13
Implications to Intermountain HIPAA We need continued collaboration between IS and Privacy and Security Teams at Intermountain to track changes mandated by ARRA. Account of Disclosure provisions Restrictions on sharing information Access to Certain PHI in Electronic Format Penalties and Enforcement Application of HIPAA Security and Privacy Provisions to Business Associates Breach notification 1/26/2010 Healthcare Medical Informatics 14
Implications to Intermountain: Research Intermountain can take part in the following available nationally: $11 Billion for the National Institutes of Health (NIH) appropriated for Increased funding opportunities for research $2.5 Billion appropriated nationally for Health Resources and Services Administration $1.2 Billion in Grants available nationally to Help Hospitals and Doctors Use Electronic Health Records $ 1 Billion appropriated nationally for Prevention and Wellness Contact: Lucy Savitz, Peter Haug, Homer Warner Center for Informatics Research 1/26/2010 Healthcare Medical Informatics 15
Implications exec* Shorter reporting period in first year allows providers longer window to demonstrate meaningful use Absent HIEs, exchange requirements still significant in Stage 1 Achieving meaningful use requires high performance levels on most non-clinical quality measures Significant time and resource commitment required to demonstrate meaningful use measures IT Non-it, Process, MD, Rn, Reporting, Privacy Hospitals failing to achieve meaningful use before 2013 face steep climb to avoid penalties Lack of clarity on Stage 2 meaningful use requirements will impede IT investment planning Hospitals can expect reporting requirements to expand significantly in 2013 *Meaningful Use of EHRs The Proposed Definition and Its Implications for Health Care Providers ADVISORY BOARD ANALYSIS FROM PROTIMA ADVANI, PRACTICE MANAGER IT INSIGHTS PROGRAM 1/26/2010 Healthcare Medical Informatics 16
Thanks Katie Gorris, Suzie Draper, Joe Hales: Privacy Kathy Konishi, Mark Vawdrey, and Dave Jacobs: Medicare and Medicaid Sid Thornton: Research 1/26/2010 Healthcare Medical Informatics 17
Next Steps Formation of Steering Committee Leadership Clinical IT Regulatory Privacy Feasibility Comments to CMS Priority planning, 5 yr roadmap 1/26/2010 Healthcare Medical Informatics 18
References 1) Interim Final Rule http://www.federalregister.gov/ofrupload/ofrdata/2009-31216_pi.pdf 2) Notice of proposed Rule-making http://www.federalregister.gov/ofrupload/ofrdata/2009-31217_pi.pdf *Meaningful Use of EHRs The Proposed Definition and Its Implications for Health Care Providers ADVISORY BOARD ANALYSIS FROM PROTIMA ADVANI, PRACTICE MANAGER IT INSIGHTS PROGRAM H.R. 1, S.1, American Recovery and Reinvestment Act of 2009, Health Information Technology for Economic and Clinical Health Act (the HITECH Act), 13001, et seq. (Feb. 17, 2009) Echols H, et al. HITECH Act: Analysis of Policy Implications, Requirements of Health IT Stimulus Provisions, Health Plan and Provider, BNA, Inc. Bureau of National Affairs, Inc. http://www.bna.com. Privacy Brief on HITECH, Internal Intermountain Document. Katie Gorris, March, 2009, Updated July 2009. Medicare and Medicaid Internal analyses by Dave Jacobs and Mark Vawdrey, Internal Intermountain Document. Impact of audit repository requirements to Intermountain IS applicatons, prepared by Nathan Moon and Carl Allen, Internal Intermountain Document, 2008. July 17 09, HIT Standards Committee final recommendations for definition of Meaningful Use. http://healthit.hhs.gov/portal/server.pt/gateway/ptargs_0_11113_872719_0_0_18/meaningful %20Use%20Matrix.pdf 1/26/2010 Healthcare Medical Informatics 19
Questions Len Bowes, MD 1/26/2010 Healthcare Medical Informatics 20
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Gaps at Intermountain Function Grid Need to fill 26 Requirements in 11 Count of FirstOfCriteria CCHIT_ARRA_H1_H2 Both_IP_EP Component not C Grand Total IP M: CMS QUALITY REPORTING 3 3 W: EXCHANGE CLINICAL INFORMATION 2 2 T: PATIENT ELECTRONIC ACCESS TO HEALTH INFORMATION 1 1 O: CLINICAL DECISION RULE 1 1 IP Total 7 7 OP M: CMS QUALITY REPORTING 2 2 W: EXCHANGE CLINICAL INFORMATION 1 1 O: CLINICAL DECISION RULE 1 1 D: ELECTRONIC PRESCRIBING 1 1 N: PATIENT REMINDERS 1 1 OP Total 6 6 OP and IP W: EXCHANGE CLINICAL INFORMATION 2 2 M: CMS QUALITY REPORTING 2 2 X: MEDICATION RECONCILIATION 2 2 A: COMPUTER PHYSICIAN ORDER ENTRY 2 2 R: ELECTRONIC CLAIMS SUBMISSION 1 1 AA: ELECTRONIC SYNDROMIC SURVEILLANCE 1 1 C: PROBLEM LIST 1 1 B: DRUG DECISION SUPPORT 1 1 Q: INSURANCE ELIGIBILITY 1 1 G: DEMOGRAPHICS 1 1 1/26/2010 Healthcare Medical Informatics 22
Intermountain Gaps Security; 19 Requirements 11 AR.FND 01.05 Provide the capability to encrypt and decrypt electronic protected health information. AR.FND 01.06 Provide the capability to encrypt data at rest using AES. AR.FND 02.02 Provide the capability to use the ATNA profile to communicate audit messages between Secure Nodes and to establish Audit Repository nodes to collect audit information. AR.FND 03.01 Person or entity authentication: Provide the capability to verify that a person or entity seeking access to electronic protected health information is the one claimed. AR.FND 03.02 Provide the capability to authenticate users and entities within an organization using Kerberos. AR.FND 03.03 1/26/2010 Implement the EUA Profile (which uses Kerberos) to provide a single sign-on capability within enterprises. Healthcare Medical Informatics 23
Intermountain Gaps: Clinical Data Exchange; Expectations for 2011-2015 Meaningful Use objectives requiring health exchange 2011 Lab results delivery Prescribing Claims and eligibility checking Quality & immunization reporting, if available Increases volume of transactions that are most commonly happening today Lab to provider Provider to pharmacy 2013 2015 Registry reporting and reporting to public health Electronic ordering Health summaries for continuity of care Receive public health alerts Home monitoring Populate PHRs Access comprehensive data from all available sources Experience of care reporting Medical device interoperability Substantially steps up exchange Provider to lab Pharmacy to provider Office to hospital & vice versa Office to office Hospital/office to public health & vice versa Hospital to patient Office to patient & vice versa Hospital/office to reporting entities Starts to envision routine availability of relatively rich exchange transactions Anyone to anyone Patient to reporting entities 1/26/2010 Healthcare Medical Informatics 24
Key Characteristics of the Proposed Meaningful Use Definition Definition comprised of three stages Discrete measures to demonstrate achievement of objectives Stage 1 requirements similar to those proposed by HIT Policy Committee CPOE adoption remains a crucial criterion Reporting through attestation in 2011 1/26/2010 Healthcare Medical Informatics 25
Eligible providers 1/26/2010 Healthcare Medical Informatics 26