bell bottom line of ehr.ppt0, then eps are required to report results for up to 3 alternate core...

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Pre-Conference Session:The Bottom Line of Electronic Health Record Implementation

12:30 – 2:30 pmMichael Bell, CPAWipfli LLP

California Hospital Association

Stimulus BillAmerican Recovery and Reinvestment Act of 2009

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Date or subtitle

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Michael R. Bell, CPA, PartnerWipfli Health Care Practice

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Electronic Health Record

Mandated for every American by 2014

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Provides funding for “meaningful users”

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Electronic Health Record

Must be certified – HHS to define by September 30, 2010, with help from Certification

Commission of Healthcare Information Technology (www.cchit.org)

Must provide electronic exchange –

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sharing of health informationReport clinical quality and other measures

Meaningful Use does not end with the purchase of EHR software

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Meaningful Use Overview

80% of patients must have records

in certified EHR technology to

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meet certain objectives/measures

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EPs (Eligible Providers) have to report on

20 of 25 MU (Meaningful Use) objectives

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Meaningful Use: Core Set Objectives

EPs – 15 Core Objectives

1. Computerized physician order entry (CPOE)

2. E-Prescribing (eRx)

3. Report ambulatory clinical quality measures to CMS/states

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4. Implement one clinical decision support rule

5. Provide patients with an electronic copy of their health information, upon request

6. Provide clinical summaries for patients for each office visit

7. Drug-drug and drug-allergy interaction checks

8. Record demographics

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EPs – 15 Core Objectives (continued)

9. Maintain an up-to-date problem list of current and active diagnoses

10. Maintain active medication list

11. Maintain active medication allergy list

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12. Record and chart changes in vital signs

13. Record smoking status for patients 13 years or older

14. Have capability to exchange key clinical information among providers of care and patient-authorized entities electronically

15. Protect electronic health information

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Meaningful Use: Menu Set Objectives

Eligible Professionals

• Drug-formulary checks

• Incorporate clinical lab test results as structured data

• Generate lists of patients by specific conditions

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• Send reminders to patients per patient preference for preventive/follow-up care

• Provide patient with timely electronic access to their health information

• Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate

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Eligible Professionals (continued)

• Medication reconciliation

• Summary of care record for each transition of care/referrals

• Capability to submit electronic data to immunization

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registries/systems *

• Capability to provide electronic syndromic surveillance data to public health agencies *

* At least 1 public health objective must be selected

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Eligible hospitals have to report on


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Eligible Hospitals – 14 Core Objectives

1. Computerized physician order entry (CPOE)

2. Drug-drug and drug-allergy interaction checks

3. Record demographics

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4. Implement one clinical decision support rule

5. Maintain an up-to-date problem list of current and active diagnoses

6. Maintain active medication list

7. Maintain active medication allergy list

8. Record and chart changes in vital signs

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Eligible Hospitals – 14 Core Objectives (continued)

9. Record smoking status for patients 13 years or older

10. Report hospital clinical quality measures to CMS or states

11. Provide patients with an electronic copy of their health

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information, upon request

12. Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request

13. Have capability to exchange key clinical information among providers of care and patient-authorized entities electronically

14. Protect electronic health information

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Eligible Hospitals

• Drug-formulary checks

• Record advanced directives for patients 65 years or older

• Incorporate clinical lab test results as structured data

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• Generate lists of patients by specific conditions

• Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate

• Medication reconciliation

• Summary of care record for each transition of care/referrals

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Eligible Hospitals (continued)

• Capability to submit electronic data to immunization registries/ systems *

• Capability to provide electronic submission of reportable lab results to public health agencies *

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results to public health agencies

• Capability to provide electronic syndromic surveillance data to public health agencies *

* At least 1 public health objective must be selected

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Reporting Period – 90 days for first

year; one year subsequently

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year; one year subsequently

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CQM: Eligible Professionals

• Core, Alternate Core, and Additional Clinical Quality Measures (CQMs) sets for EPs

• EPs must report on 3 required core CQMs, and 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

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0, then EPs are required to report results for up to 3 alternate core measures

• EPs also must select 3 additional CQMs from a set of 38 CQMs (other than the core/alternate core measures)

• In summary, EPs must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures

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CQM: Core Set for EPs

NQF Measure Number & PQRI Implementation Number

Clinical Quality Measure Title

NQF 0013 Hypertension: Blood Pressure Measurement

NQF 0028 Preventive Care and Screening Measure

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NQF 0028 Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention

NQF 0421PQRI 128

Adult Weight Screening and Follow-up

CQM: Alternate Core Set for EPs

NQF Measure Number & PQRI Implementation Number

Clinical Quality Measure Title

NQF 0024 Weight Assessment and Counseling for Children and Adolescents

NQF 0041 Preventive Care and Screening: Influenza

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NQF 0041 PQRI 110

Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older

NQF 0038 Childhood Immunization Status

CQM: Additional Set for EPs

1. Diabetes: Hemoglobin A1c Poor Control

2. Diabetes: Low Density Lipoprotein (LDL) Management and Control

3. Diabetes: Blood Pressure Management

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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

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CQM: Additional Set for EPs (continued)

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)

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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

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14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

15. Asthma Pharmacologic Therapy

16. Asthma Assessment

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17. Appropriate Testing for Children with Pharyngitis

18. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

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20. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

21. Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications,

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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

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26. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation

27. Ischemic Vascular Disease (IVD): Blood Pressure Management

28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

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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

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33. Cervical Cancer Screening

34. Chlamydia Screening for Women

35. Use of Appropriate Medications for Asthma

36. Low Back Pain: Use of Imaging Studies

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37. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control

38. Diabetes: Hemoglobin A1c Control (<8.0%)

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CQM: Eligible Hospitals and CAHs

1. Emergency Department Throughput – admitted patients –Median time from ED arrival to ED departure for admitted patients

2. Emergency Department Throughput – admitted patients –Admission decision time to ED departure for admitted patients

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3. Ischemic stroke – Discharge on anti-thrombotics

4. Ischemic stroke – Anticoagulation for A-fib/flutter

5. Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset

6. Ischemic or hemorrhagic stroke – Antithrombotic therapy by day two

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CQM: Eligible Hospitals and CAHs (continued)

7. Ischemic stroke – Discharge on statins

8. Ischemic or hemorrhagic stroke – Stroke education

9. Ischemic or hemorrhagic stroke – Rehabilitiation assessment

10. VTE prophylaxis within 24 hours of arrival

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11. Intensive Care Unit VTE prophylaxis

12. Anticoagulation overlap therapy

13. Platelet monitoring on unfractionated heparin

14. VTE discharge instructions

15. Incidence of potentially preventable VTE

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CAH Funding

Step 1 – Determine Medicare and Medicare Advantage inpatient acute care days

Step 2 – Determine total inpatient acute care daysStep 3 – Determine charity care revenue as percent of

total revenue

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Medicare reimbursement percentage = Medicare and Medicare Advantage inpatient acute care days / [total inpatient acute care days * (1- charity care percentage)] plus 20%

(may not exceed 100%)

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CAH Funding

Step 1 – Medicare and Medicare Advantage inpatient acute care days = 750

Step 2 – Total inpatient acute care days = 1,000Step 3 – Charity care revenue = $50,000

Total revenue = $1,000,000

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$ , ,

Medicare reimbursement percentage = 750 /[1,000 * (1-(50,000/1,000,000))] plus 20%

98.95%

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CAH Funding – Cost reporting periods beginning on or after October 1, 2010

Medicare reimbursement percent applied against:

Capital cost of qualified EHR purchased in cost reporting years beginning on or after October 1, 2010 –plus–

Undepreciated qualifying EHR cost carried over from prior

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p q y g pcost reporting periods

May request interim payment from CMS at start of cost report period beginning on or after October 1, 2010

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CAH Funding – Subsequent cost reporting periods beginning on or after October 1, 2011, and before September 30, 2014

Medicare reimbursement percent applied against

Capital cost of qualified EHR purchased during these time periods

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CAH Funding – Hospital cost reporting period beginning on or after October 1, 2014

Medicare reimbursement percent applied against:

Capital cost of qualified EHR purchased during period only if EHR purchase began in hospital

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period only if EHR purchase began in hospital cost report periods beginning on or after October 1, 2011, or later (four year maximum)

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CAH Funding – Hospital cost report period beginning on or after October 1, 2010

Medicare reimbursement percent 98.95%

Undepreciated qualifying EHR cost carried cost of $500,000 less $100,000 depreciation

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taken equals $400,000Capital cost of qualified EHR purchased during

period - $500,000

$890,550

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CAH Funding – Hospital cost report periods beginning on or after October 1, 2011, and before September 30, 2014

Medicare reimbursement percent - 98.95% (may change from year to year)

Capital cost of qualified EHR purchased during

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these periods - $100,000

$98,950 each year

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CAH Funding – All Years

Capital cost is defined as depreciable cost

Medicare regulations use AHA guidelines to assist with the definition of depreciable cost

Some costs are obviously capital cost: hardware and software

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software

Some costs may or may not be capital cost: installation cost and training cost. We have heard that CMS would like to exclude that cost from the definition

Some costs are not capital cost: annual maintenance fees and staffing cost associated with operating a system

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CAH Funding – All Years

Noncapital costs are run through the Medicare cost report and paid based on normal cost-based reimbursement, which may be fairly small if the CAH has services that are not cost-based reimbursed like

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a nursing home

For CAHs there may be a variance of 30% between the percentage of EHR capital cost reimbursed using the inpatient formula and the normal reimbursement determined on the cost report

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PPS Hospital Funding

Medicare reimbursement percentage = CAH Medicare reimbursement percentage without 20% add-on

Maximum base amount $2 000 000

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Maximum base amount $2,000,000

Not based on cost!

Additional $200 added to maximum base amount for each discharge between 1,150 and 23,000

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PPS Hospital Funding Qualified for the periods from October 1, 2010 to September 30, 2013

Year 1 – Maximum base amount * Medicare reimbursement percentage * 100%


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PPS Hospital Funding Qualified on or after October 1, 2013



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PPS Hospital Funding Qualified on or after October 1, 2014



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p g %



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Practitioner Funding

Practitioner is:

Physician

Dentist

Nurse midwife

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Nurse midwife

Nurse practitioner

Physician’s assistant (PA owned RHC or working within FQHC)

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Practitioner Funding – Medicare

75% add-on to Medicare fee scale for calendar year 2011 to 2014 up to annual maximum

10% added to annual maximum if in geographic HPSA

Hospital services excluded

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Aggregate maximum for all years based on when first implemented:

2011 and 2012 - $44,000

2013 - $39,000

2014 - $24,000

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Practitioner Funding – Medicare

Aggregate maximum based on the following:

Year 1 is calendar year 2011 and 2012 - $18,000

Year 1 after calendar year 2012 - $15,000

Year 2 - $12 000

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Year 2 - $12,000

Year 3 - $8,000

Year 4 - $4,000

Year 5 - $2,000

Year 6 - $0

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Other Provider-Based Funding

The law states reimbursement for provider-based services is

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pincluded with main provider’s

funding

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Practitioner with 90% of services related to inpatient, outpatient, and

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emergency room is deemed to be provider-based and will not be eligible for additional payments

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This would suggest that the EHR capital cost associated with CAH provider-based

departments such as RHC, NH, HHA,

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hospice, and clinics would be included in CAH EHR capital cost.

However!!!

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PPS hospitals have complained that it is unfair that all provider-based funding is included in their fixed inpatient payments

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included in their fixed inpatient payments

CAHs have not complained at all because they are reimbursed based on cost

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There are some unsubstantiated rumorsProvider-based practitioners may be allowed to be

reimbursed as if they were not provider-based

CMS may try to limit CAH EHR capital cost i b t t th t f i ti t h it l d t t

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reimbursement to the cost of inpatient hospital and try to exclude the cost associated with outpatient services. The basis may be that PPS hospitals are only paid for their inpatient-related HER, so why should CAHs be paid for both inpatient and outpatient cost? (This type of behavior is not inconsistent with some of the misinterpretations coming out of CMS recently.)

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Other Providers – Left Out

HHS instructed to issue study of need for stimulus funding for

home health hospice nursing

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home health, hospice, nursing homes, and other providers

excluded from the initial law by June 30, 2010

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Freestanding RHC/FQHC Funding

May obtain funding from Medicaid if Medicaid + Medicaid managed care + charity care + sliding fee

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care charity care sliding fee scale > 30%

May not request Medicare funding

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Maximum Medicaid reimbursement per federal law is:

$25 000 i 1

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$25,000 in year 1

$10,000 in years 2 through 5

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We do not find any provisions in the Stimulus Bill that provides for

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pMedicare RHC and FQHC funding

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Practitioner Medicaid Funding

Pediatricians may qualify for Medicaid funding if 20% of patient volumes are Medicaid or Medicaid managed care

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May not request Medicare funding

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The Stick

For cost report years beginning on or after October 1, 2014, and other providers after December 31, 2014 – penalties if not in compliance

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Reductions in Medicare reimbursement for all types of providers

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The Stick

Hardship exceptions for up to five years will be available

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years will be available

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EHR Incentive Program Timeline

• January 2011 – Registration for the EHR Incentive Program begins

• January 2011 – For Medicaid providers, states may launch their programs if they so choose

April 2011 Attestation for the Medicare EHR Incentive

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• April 2011 – Attestation for the Medicare EHR Incentive Program begins

• May 2011 – EHR incentive payments begin

• November 30, 2011 – last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011

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EHR Incentive Program Timeline (continued)

• February 20, 2012 – Last day for EPs to register and attest to receive an incentive payment for CY 2011

• 2015 – Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology

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EHR technology

• 2016 – Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program

• 2021 – Last year to receive Medicaid EHR incentive payment

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Physician Supervision Requirements

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Requirements

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Physician Supervision Requirements – 1-1-11

History FY 2000 – CMS issued physician supervision regulations, which

were ignored and not enforced

FY 2008 – CMS reissued physician supervision regulations, which were ignored and not enforced

FY 2009 CMS i d h i i i i l ti hi h

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FY 2009 – CMS reissued physician supervision regulations, which were ignored and not enforced

FY 2010 – CMS announced that they really mean it this time and reissued physician supervision regulations, which were ignored and not enforced

CMS believes these regulations are the clarification of regulations that have existed since FY 2000

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CMS has indicated that it will not instruct RACs to look for prior violations

However CMS has stopped short of indicating


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However, CMS has stopped short of indicating that it will prohibit RACs from retroactively enforcing the regulations

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Direct Supervision Proposed – 01-01-11

Define Supervision:

General Supervision – furnished under direction and control of physician without physical presence required

Direct Supervision – Physician physically present on campus (location under ownership and operated as

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campus (location under ownership and operated as part of the hospital) and immediately available to furnish assistance and direction throughout procedure

Personal Supervision – Physician physically present in the room throughout procedure

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Expanded the definition of direct supervision

1. Physician (MD or DO)

2. Physician assistant *

3. Nurse practitioner *


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4. Clinical nurse specialist *

5. Certified nurse midwife *

* if permitted by state law, their scope of practice, and hospital-granted privileges

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CMS has emphasized the need for “strict requirements” for physician supervision of the following and provides “no flexibility” and prohibits the use of mid-level practitioners from the definition:

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1. Pulmonary rehabilitation (PR)2. Cardiac rehabilitation (CR)3. Intensive cardiac rehabilitation (ICR)

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Outpatient Diagnostic Services:

Follow MPFS requirement for each test

Required for hospitals

Not required for CAHs

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Direct Supervision Requirements – 1-1-11

Location:

On-campus (within 250 yards from main hospital building) – general supervision is required with a few exceptions

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Off-campus – personal supervision is required

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Type of outpatient service:

Diagnostic

Therapeutic

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CAH requirements for therapeutic services On-campus:

Observation – direct supervision during the initiation of the service followed by general supervision. Initiation of service is from the beginning of a service to the period

h th ti t i t bl ( d fi d b EMTALA) d

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when the patient is stable (as defined by EMTALA) and the practitioner believes the remainder of the service can be provided under general supervision

Infusion therapy – same as observation

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CAH requirements for therapeutic services On-campus (continued):

Blood transfusion – direct supervision

Chemotherapy – direct supervision

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Chemotherapy – direct supervision

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CAH requirements for therapeutic services Off-campus:

Observation – personal supervision

Infusion therapy – personal supervision

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Blood transfusion – personal supervision

Chemotherapy – personal supervision

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CAH use of emergency room practitioners for physician supervision:

CMS believes emergency room physician and non-physician practitioner can directly supervise outpatient

i l th titi t th th

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services so long as the practitioner meets the other requirements of direct supervision. The individual needs to be immediately available, so that if needed, the individual could reasonably be expected to be interrupted to furnish assistance and direction in the delivery of therapeutic services provided elsewhere in the hospital

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CAH use of emergency room practitioners for physician supervision (continued):

CMS believes most emergency room practitioners can appropriately supervise many services with the scope of th i k l d kill d li d h it l

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their knowledge, skills, and licensure, and hospital-granted privileges, including observation services

CMS has indicated that each hospital would need to assess the level of activity in their emergency room and determine whether a practitioner could be interrupted to furnish assistance and direction in the treatment of outpatients

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Outpatient Therapeutic Services:

CMS indicated that CAH CoPs related to on-call practitioners and 30-minute response time is a minimum Medicare participation requirement and not a payment requirement

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CMS indicated that CAH longstanding and prevailing practices do not matter

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www.wipfli.com

Thank you

Michael Bell, CPAPartner in ChargeWipfli LLP(509) [email protected]

bell bottom line of ehr.ppt0, then eps are required to report results for up to 3 alternate core...

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