hcit and the stimulus the american recovery & reinvestment act of 2009 corporate public affairs...

HCIT and the StimulusThe American Recovery & Reinvestment Act of 2009

Corporate Public AffairsMBA Intern CandidatesFebruary 28, 2008

Tammy EdenVP of SalesMcKesson Physician Practice SolutionsApril 8, 2010

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4444 McKesson’s EHR SolutionsMcKesson’s EHR Solutions

1111 Stimulus Plan OverviewStimulus Plan Overview

3333 Eligible Provider ProgramsEligible Provider Programs

2222 HITECH Act SpecificsHITECH Act Specifics

HCIT and the StimulusAgenda

5555 Next Steps and DiscussionNext Steps and Discussion

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January 25, 2009H.R. 1 introduced in the House Appropriations Committee

January 28, 2009House votes 244 – 188 for the bill estimated at $819 B

February 10, 2009Senate votes 61 – 37 for their bill estimated at $837 B

February 11, 2009Conference Committee reaches compromise with a bill estimated at $787 B

February 13, 2009House passes 246 – 183Senate passes 60 – 38

February 17, 2009President Obama signs The American Recovery & Reinvestment Act of 2009

The American Recovery & Reinvestment Act of 2009 (H.R. 1)─ One of the largest single pieces of legislation in U.S. history

─ Signed 23 days after official introduction (28 days after inauguration)

Stimulus Plan OverviewWhere are we and how did we get here?

Scale = 1 day

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$787 billion in total net impact on the federal deficit

$154 billion in total net spending for healthcare

$19 billion for health information technology

Stimulus Plan OverviewWhat is in the stimulus plan for healthcare?

Source: Congressional Budget Office Summary of Estimated Cost of the Conference Agreement for H.R. , The American Recovery and Reinvestment Act of 2009; figures are rounded

“HITECH”Act

Medicaid$90B Health

Insurance$25B

Incentives$19B

ONCHIT$2BNIH

$10BHHS$10B

• Increased match to State Medicaid

• COBRA extension

• Research grants

• Various initiatives

• Adoption incentives

• Infrastructure and budget

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Certification

─ Qualified EHR

─ Meets specifications

─ HIT Standards, NIST, etc.

HITECH Act SpecificsIncentives require both certified systems and “meaningful use”

“Meaningful Use”

─ Electronic Prescriptions

─ Interoperability

─ Quality reporting

“The eligible [provider] demonstrates…that during such period the [provider] is using

certified EHR technology in a meaningful manner”

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Vision for Meaningful UseHealth IT and Transformed Health Care

Enable significant and measurable improvements in population health through a transformed health care delivery system.

Key goals*:─ Improve quality, safety, & efficiency

─ Engage patients & their families

─ Improve care coordination

─ Improve population and public health; reduce disparities

─ Ensure privacy and security protections

Source: HIT Policy Committee, Meaningful Use Workgroup Presentation June 23, 2009

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Estimated EHR Adoption with StimulusEstimated EHR Adoption with Stimulus

20%

40%

60%

80%

2009 2010 2011 2012 2013 2014

Source: Congressional Budget Office; Thomas Weisel Partners; Raymond James; MTS analysis

“Carrot” and “stick”

Incentives begin in 2011

Penalties begin in 2015

Physician Adoption

70% of physicians by 2014

90% of physicians by 2019

PhysicianHospital

HITECH Act ImpactIncentives and penalties expected to drive adoption of EHRs

Incentives(~$36B)

Penalties(~$17B)

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October 1, 2010

Medicare / Medicaidincentive program forhospitals begins

January 1, 2011

Medicare / Medicaid incentive program for

physicians begins

July 31, 2009

Formal recommendation to ONC on Meaningful Use from HIT Policy

April 3, 2009

HIT Policy Committee appointed

July 21, 2009

Preliminary approach to Certification fromHIT Standards

June 16,2009Preliminary draft on “Meaningful Usefrom HIT Policy

May 8, 2009

HIT Standards Committeeappointed

December 30, 2009Initial rule publication on Meaningful Use (NPRM)

The Road Toward “Meaningful Use”Estimated timeline for key events to finalize regulations

Scale = 1 month

June 2010 (Late Spring/Early Summer estimate)

Final Rule on Meaningful Use and Temporary Certification

December 30, 2009

HHS publication of interim final on Certification criteria (IFR)

February 17, 2009

President Obamasigns ARRA

March 2, 2010

Initial rule publication on Establishment of Certification Programs (NPRM)

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The Road Toward “Meaningful Use”CMS & ONC Publications

CMS Notice of Proposed Rule Making for Meaningful Use (NPRM)─ Defines the provisions for incentive payments to eligible professionals and hospitals

participating in Medicare and Medicaid programs that adopt and meaningfully use certified EHRs.

• Deadline for Public Comments... March 15, 2010• Final Rule Released................... Late Spring, takes effective 60 days later

ONC Interim Final Rule (IFR) with Comment on Standards and Certification Criteria─ Proposes initial set of standards, implementation specifications, and certification criteria to

“enhance the interoperability, functionality, utility, and security of health IT and to support its meaningful use.”

• Deadline for Public Comments... March 15, 2010• Final Rule Released................... Late Spring

ONC Rule on Certification Process (NPRM)─ Proposes the establishment of two certification programs for the purposes of testing and

certifying health IT, one temporary and one permanent• Deadline for Public Comments Temporary Program…Mid-April w/final rule Late Spring• Deadline for Public Comments Permanent Program…Mid-May w/final rule Fall 2010

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Eligible Provider Program Providers must choose a program

General─ Must be office-based physicians─ Eligible professional must prove meaningful use of a certified EHR

Medicare Incentive─ Pays 75% of the all Part B claims submitted up to an annual maximum─ Potential incentives up to $44,000 over a 5-year period beginning 2011─ Administered through CMS

Medicaid Incentive─ Pays 85% of the “Net Average Allowable Cost” up to an annual maximum─ Requires 30% Medicaid patient volume or 20% for pediatricians─ Administered through the State

No Double Dipping─ Providers may receive incentive payments from only one program, even if they qualify for both

Election Change─ Permitted to change election once during the life of the EHR incentive programs prior to 2014─ EP would continue in the next program at whichever payment year he or she would have attained had the EP not

chosen to switch─ Payout can not exceed $63,750

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Eligible Provider Program Medicare Provision

Eligible Professional is a physician as defined in the Social Security Act section 1861: ─ a doctor of medicine or osteopathy

─ a doctor of dental surgery or of dental medicine

─ a doctor of podiatric medicine

─ a doctor of optometry

─ a chiropractor

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Eligible Provider Program Medicaid Provision

The Medicaid HIT Incentive program expands the definition of “eligible professionals” to include: ─ certified nurse mid-wife

─ nurse practitioner

─ physician assistant practicing in an FQHC or RHC that is so led by a physician assistant

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Eligible Provider Program Hospital-based Provider

Hospital-based EPs are not eligible Defined as: Provide “substantially all” of their services as

hospital based practitioners furnishing at least 90% of services in an inpatient or outpatient hospital setting

Determination made using place of services (POS) codes on claims

─ 21 (inpatient hospital)

─ 22 (outpatient hospital)

─ 23 (emergency room, hospital)

Services provided in a provider-based outpatient department would count toward the 90 percent threshold

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Eligible Provider ProgramMedicare incentive program uses a part B claims method

Medicare Incentive Potential($ Thousands)

$15$12

$8

$4$2

$3

$24

$16

$10.7

$2.7

$5.3

$0

$5

$10

$15

$20

$25

$30

Year 1 Year 2 Year 3 Year 4 Year 5

Up to $44k per physician

Potential Payout Bonus Part B Claims Req’d

Pays 75% of “allowed charges” based on claims submitted to Medicare up to max

─ “allowed charges” the lesser of the actual charge or the Medicare physician fee schedule amount

$3,000 bonus to qualify by 2012

Up to $44k per physician over 5 years

10% bonus if 50%+ of Medicare covered professional services furnished in a geographic Health Physician Shortage Area (HPSA)

Must qualify by 2012 to receive max─ Reduced incentives for 2013 – 2015

No payments to providers after 2016

Penalties begin in 2015─ 2015 – 1% cut in Medicare payment─ 2016 – 2% cut─ 2017 and beyond – 3% to 5% cut

pending overall market adoption rate

Medicare Advantage (MA) providers qualify for the Medicare incentives using MA claims instead of part B claims

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Maximum Incentive PaymentsMaximum Incentive Payments

Eligible Provider Program Medicare Reimbursement Schedule

Now-2011

2012 2013 2014

2011 $18k - - -

2012 $12k $18k - -

2013 $8k $12k $15k -

2014 $4k $8k $12k $12k

2015 $2k $4k $8k $8k

2016 - $2k $4k $4k

Total $44K $44K $39K $24K

Shortage

Area $48.4K $48.4K $42.9K $26.4K

Source: MTS Primary Research Survey

Adoption Year

Paym

ent

Year

Part B Part B Annual Annual

ChargesCharges

Maximum Maximum Payment Payment

$24,000 $18,000

$16,000 $12,000

$10,667 $8,000

$5,334 $4,000

$2,667 $2,000

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Eligible Provider ProgramMedicaid incentive program uses a cost based method

Requires 30% Medicaid patient volume─ 20% for pediatricians, but receive

only 66% of net allowable costs─ 30 percent of all patient encounters

attributable to Medicaid (or “needy individuals” in an FQHC or RHC) over any continuous 90-day period within the most recent calendar year prior to reporting

Pays 85% of the “net allowable costs”─ Payments are not direct reimbursement for

the purchase and acquisition of the EHR─ Intended to serve as incentives for EPs to

adopt and meaningfully use certified EHR technology

─ Net average allowable cost determined based on a study conducted by HHS

Requires “meaningful use” by Year 2, Year 1 can be for adoption only

Meaningful Users in Year 1 would also be eligible for the full payment

Must qualify by 2016 to receive max with no payments after 2021

Medicaid Incentive Potential($ Thousands)

$21.3

$8.5 $8.5 $8.5 $8.5 $8.5

$25

$10 $10 $10 $10 $10

$0

$5

$10

$15

$20

$25

$30

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

Up to $63,750 per physician

Potential Payout Net Allowable Costs

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Maximum Incentive PaymentsMaximum Incentive Payments

Eligible Provider Program Medicaid Reimbursement Schedule


Adoption Year

Paym

ent

Year

Allowable CostsAllowable Costs Max Pmt Max Pmt

For 30% For 30% providerprovider

(85% of (85% of allowable allowable cost)cost)

Max Pmt Max Pmt

For For Pediatrician Pediatrician (20% to 29%) (20% to 29%) Allowable Allowable Cost*2/3*85%)Cost*2/3*85%)

$25,000 (year 1 only) $21,250 $14,167

$10,000 $8,500 $5,667

30% Provider2011 – 2016

20% Pediatrician2011 – 2016

Year 1 $21,250 $14,167

Year 2 $8,500 $5,667

Year 3 $8,500 $5,667

Year 4 $8,500 $5,667

Year 5 $8,500 $5,666

Year 6(up to 2021)

$8,500 $5,666

TOTAL $63,750 $42,500

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Eligible Provider ProgramMeaningful Use “Reporting Period”

For the First Year Incentive Qualification─ 90 day reporting period to prove meaningful use through required

measures

─ First opportunity to start reporting is January 1, 2011 For example, EP has until Oct 1, 2011 to begin meaningful use of their certified HER technology & receive incentive for payment year 2011 (EP must begin by Oct 1, 2012 to receive maximum incentive payments)

─ Attestation methodology proposed for 2011

─ Electronic reporting starting in 2012

Subsequent years reporting period─ Entire 12 months (calendar year for EP) in the respective year

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Meaningful Use Regulatory Definition

The Act provides that an eligible provider (EP) shall be considered a meaningful EHR user for an EHR reporting period for a payment year if they meet the following three requirements:

1. use of certified EHR technology in a meaningful manner (e.g. e-Prescribing);

2. that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and

3. that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

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Meaningful Use Update HITECH Program Stages

Stage 1 defined in Notice of Proposed Rule Making Criteria of meaningful use will be updated through future rulemaking

─ Stage 2 criteria proposed by the end of 2011

─ Stage 3 criteria proposed by the end of 2013.

Stage Goal

Stage 1 (formerly 2011) Electronic Capture of Patient Data

Stage 2 (formerly 2013) Improved Clinical Processes

Stage 3 (formerly 2015) Quality Measurement & Improvement

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Meaningful Use Update Respective Criteria per Payment Year

First Payment Year

Payment Year

2011 2012 2013 2014 2015+

2011 Stage 1 Stage 1 Stage 2 Stage 2 Stage 3

2012 Stage 1 Stage 1 Stage 2 Stage 3

2013 Stage 1 Stage 2 Stage 3

2014 Stage 1 Stage 3

2015+ Stage 3

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Meaningful Use CriteriaObjectives and Measures

Grouped into two categories─ Health IT functionality measures

• Rely solely on capabilities included as part of Certified EHR Technology

─ Clinical quality measures

• Use certified EHR technology to submit information “on such clinical quality measures and such other measures” as the CMS shall select

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Meaningful Use Health IT Functionality Measures

25 Health IT functionality measures matched to the objectives for Meaningful Use

IT functionality measures are fully defined in the NPRM and must be reported in the first payment year via attestation

The format and mechanism for attestation are not yet defined

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Meaningful Use Update Health IT Functionality Measures 1 – 9

ObjectiveObjective MeasureMeasure

1 Use CPOE CPOE is used for at least 80 percent of all orders

2 Implement drug-drug, drug-allergy, drug- formulary checks

The EP has enabled this functionality

3 Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®

At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.

4 Generate and transmit permissible prescriptions electronically (eRx).

At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

5 Maintain active medication list. At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.

6 Maintain active medication allergy list. At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.

7 Record demographics. At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

8 Record and chart changes in vital signs.

For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

9 Record smoking status for patients 13 years old or older

At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded

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10 Incorporate clinical lab-test results into EHR as structured data.

At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

11 Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.

Generate at least one report listing patients of the EP with a specific condition.

12 Report ambulatory quality measures to CMS or the States.

For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures discussed in section II.A.3. of this proposed rule.

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

Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over

14 Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules.

Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.

15 Check insurance eligibility electronically from public and private payers.

Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP

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17 Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request

At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

18 Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)

At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information

19 Provide clinical summaries to patients for each office visit

Clinical summaries provided to patients for at least 80 percent of all office visits.

20 Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.

Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

21 Perform medication reconciliation at relevant encounters and each transition of care.

Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

22 Provide summary care record for each transition of care and referral.

Provide summary of care record for at least 80 percent of transitions of care and referrals.

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23 Capability to submit electronic data to immunization registries and actual submission where required and accepted.

Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries.

24 Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.

Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).

25 Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.

Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.

www.mckesson.com/doctors

Stimulus 101

Meaningful Use

http://www.mckesson.com/doctors

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Meaningful Use UpdateClinical Quality Measures

Clinical quality measures are specific to setting and specialty

─ 3 core measures to be reported by all EPs

• tobacco use, blood pressure, and drugs to be avoided in the elderly

─ 15 sets of specialty measures, with each EP expected to report one of these sets

Specifications for the measures have not been published with a target to do so in April 2010

CMS has asked for comments on whether quality measure reporting should be deferred until 2012

Medicaid EPs will report Clinical Quality Measures to the State

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EHR Certification Update Certification Criteria

Requirements for EHR certification will be more stringent than the requirements for demonstrating meaningful use

At this time, there is no recognized certification process available for vendors and there is no certification body formally recognized by HHS

In the past CCHIT was the certification agency for EHRs but at this point there has been no ruling on who will be the final certifying entity

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Certification UpdateCertified EHR Technology

Two Types of Certification of EHR Technology

1. Complete EHR

• EHR must certify all requirements to certify as Complete EHR

2. Certified EHR Module

• “..any service, component, or combination thereof that can meet the requirements of at least one certification criterion adopted by the Secretary.”

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Certification UpdateCertification Process/Bodies

Certification process NPRM issued on March 2nd Was placed in the Federal Register (FR) on March 10th - Proposes two different process – temporary and permanent

─ Temporary Process• Accreditation of bodies will be governed by ONC• ONC will take application of bodies applying for accreditation prior to the rule being

final• Expected timeframe for first bodies being accredited is May-June 2010• Comment period will be 30 days after publication placed in the FR• No recertification of temporary certification bodies expected; temporary processes

will only apply to Stage 1 meaningful use certification─ Permanent Process

• Accreditation of bodies expected to be completed through private entities with guidance from National Institute of Standards and Technology (NIST)

• Expected timeframe for first bodies under permanent program to accredited January 2012

• Comment period will be 60 days after publication in FR

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McKesson’s EHR for Independent PracticesPractice Partner, Medisoft Clinical, Lytec MD

Certification Track Record─ Practice Partner 9.3, Medisoft v15

and Lytec 2009 are CCHIT Certified® products for CCHIT Ambulatory EHR 2008 and Child Health

Surescripts Solution Provider─ Certified for all three message

types – Benefit, History and Routing

Backed by an Industry Leader─ McKesson Corporation, currently

ranked 15th on the FORTUNE 500, is the longest-operating company in healthcare

Industry Certifications & RecognitionIndustry Certifications & Recognition

http://www.cerner.com/public/uploadedimages/About_Cerner/Awards/TEPRlogo2.jpg

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Traditional Barriers to EMR AdoptionCost and Disruption

Barriers for EMR Adoption(# of Respondents w/o EMR)

Barriers for EMR Adoption(# of Respondents w/o EMR)

6

10

11

16

19

21

23

25

33

65

0 10 20 30 40 50 60 70

Liability Concerns

No Appropriate System

No Market Leader

Data Security / Loss

Puchased / Purchasing

MD / Staff Resistance

Physical ChartPreference

Support

Disruption

System Cost

n = 107 Respondents


Cost has been the top barrier for physicians adopting an EMR

Disruption second highest barrier to adoption

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Addressing the Cost BarrierOFFEHR Special Promotion

Applies to Practice Partner, Medisoft Clinical and Lytec MD

$1000 Cash Rebate for the first provider, $500 each additional provider

For more information go to www.offehr.com

http://www.offehr.com/

3804/18/23 38

A dynamic processing technology that enables physicians to utilize their preferred charting style to capture information in a single note. With one touch, data is instantly synchronized across the complete chart. Searchable patient

data is then automatically generated so providers can quickly access meaningful clinical care reporting.

A dynamic processing technology that enables physicians to utilize their preferred charting style to capture information in a single note. With one touch, data is instantly synchronized across the complete chart. Searchable patient

data is then automatically generated so providers can quickly access meaningful clinical care reporting.

Addressing the Disruption Barrier Bright Note TechnologyTM Inside

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What is the provider application process for the incentives?

What are the specifications for CMS quality reporting measures? (due in April)

What is the vendor certification process?

Who are the certifying bodies?

Will Practice Management systems need to be certified?

Next Steps and DiscussionSeveral key questions remain to be answered

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Next Steps and DiscussionQ & A

hcit and the stimulus the american recovery & reinvestment act of 2009 corporate public affairs...

Documents

b slide

b incentives

b penalties

b health insurance

stimulus source

b onchit

budget slide

stimulus agenda