meaningful use & cqm: c urrent and future guidance sanjaya kumar, md, m.sc., mph chief medical...
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MEANINGFUL USE & CQM:CURRENT AND FUTURE
GUIDANCE
Sanjaya Kumar, MD, M.Sc., MPH
Chief Medical Officer, Xstor Medical Systems
MHA Conference
August 2, 2011
CURRENT STATE OF AFFAIRS:
Currently the US system is:Expensive: We spend more on healthcare
than any other nation (> 20% of GDP) Ineffective: Low quality and inadequate
outcomes on standards comparable to other countries
Fraught with high rates of medical errorsNot universally availableStructured in a manner unsupportable with
impending workforce shortages
THE AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA) & HIT
$36 billion investment by the Federal Government in Health IT. $2 billion in grant funds for HIE and for
technical assistance to providers. $34 billion paid out directly to
providers who prove “meaningful use” of a “certified” EHR system.HospitalsHealthcare practitioners
WHERE IS MU TODAY…?
Starting in 2011, providers (EPs) and hospitals (including CAHs) can receive incentive payments from Medicare and Medicaid if they achieve “Meaningful Use” of a certified electronic health record.
On July 13, 2010, the Centers for Medicare & Medicaid Services released the final rule defining the requirements for meaningful use in 2011 and 2012. The rules contain more flexibility than those originally
proposed, but the basic elements are unchanged Health organizations need to quickly assess their gaps
in meaningful use and make sure their systems will be certified
See Update Document from CSC (2010)
2011/2012: STAGE 1 In this Stage the focus is on data capture
In most cases this is necessitating adding modules to existing clinical information systems
For Stage 1 Incentive payments hospitals must meet:14 mandatory and 5 of 10 other requirements to demonstrate
meaningful use The requirements for Stage 2 include demonstration
that the EHR has been integrated into transformed processes and are used in health information exchange.
For Stage 3, the emphasis shifts to achieving improved outcomes with new care processes enabled by the EHR
FEDERAL CHAIN OF COMMANDHealth and Human Services Secretary
Reviews ONC endorsements and approves adoptionCollaborates with CMS in the rule making process
Office of the National Coordinator (ONC)
•$2 billion•Regional Extension Centers•Electronic health record (EHR) Loan Fund•Health Information Exchange
Centers for Medicare and Medicaid Services (CMS)
•$34 billion •Medicare/Medicaid EHR incentives for meaningful use
FLOW OF FUNDS
Office of the National Coordinator (ONC) Regional Extension Centers
Local Extension Centers Service Providers
EHR Loan Fund - On hold Health Information Exchange
Local health information organizations
Centers for Medicare and Medicaid Services (CMS) Medicare Incentives
Eligible providers who choose the Medicare MU $$ Medicaid Incentives
State Medicaid Offices (Eligible Professionals)
WHY THE EMPHASIS ON HIT?
HIT and EHRs have the POTENTIAL to: Reduce costs Improve the quality of care by delineating areas for
improvement Save lives Improve access Redesign the work of providers to focus on critical
activities
Health IT has the potential to save the federal government more than $12 billion over 10 years, improve the quality of care, and make our health-care system efficient”(Dr. David Blumenthal, the National Coordinator of Health IT)
ADDRESSING NATIONAL HEALTH POLICY GOALS
Meaningful Use Addresses Five National Health Policy Goals:
Improve quality, safety, efficiency, and reduce health disparities
Engage patients and families
Improve care coordination
Improve population and public health
Ensure adequate privacy and security protections for personal health information
MORE WORK FOR THE GUYS IN THE BACK ROOM
The HIT phase ushered in by ARRA and MU is highly complex, which is illustrated by the plethora of acronyms emerging!
When discussing meaningful use of EHRs, in order to not go crazy, humor helps: HITECH: An Interoperetta in Three Acts
http://www.youtube.com/watch?v=Gv1s8fM3mMk
SUMMARY OF FINAL STAGE 1 MEANINGFUL USE CRITERIA & REQUIREMENTS:
NOTE: REQUIREMENTS FOR HOSPITALS USE MEASURES BASED ON PERCENTAGE (INPATIENT AND EMERGENCY DEPARTMENT, EXCEPT AS NOTED)
STAGE 1 REQUIREMENTS FUNCTIONAL REQUIREMENTS
Computerized Physician Order Entry (Mandatory) >30 percent of patients with medication orders
have at least one order entered via CPOE Medication Reconciliation (Optional)
Performed at >50 percent of admissions and transition from one care setting to another
Physician Documentation For >80 percent of all patients (Mandatory):
Maintain an up-to-date diagnosis/problem list of current and active diagnoses (ICD-9-CM or SNOMED CT)
Maintain active medication list Maintain active medication allergy list
All recorded as structured data (Optional)
STAGE 1 REQUIREMENTS FUNCTIONAL REQUIREMENTS Other Documentation
Record demographics for >50 percent of admitted patients (Mandatory) Preferred language, gender Ethnicity, race, date of birth Date of death and preliminary cause, if applicable
Record vital signs for >50 percent of admitted patients ≥ 2 years of age (Mandatory) Height, weight, BP Display BMI Display growth chart, including BMI (pt 2-20 years)
For >50 percent of patients record smoking status (pt > 13 years) (Mandatory)
Incorporate clinical laboratory test results into EHR as structured data for >40 percent of all clinical lab tests ordered with positive/negative or numeric results (Optional)
For >50 percent of hospital patients over age 65, record whether the patient has an advanced directive (Optional)
STAGE 1 REQUIREMENTS FUNCTIONAL REQUIREMENTS
Performance ImprovementDrug-drug and drug-allergy checks enabled
(Mandatory)Drug formulary checks enabled (Optional) Implement at least one clinical decision
support rule relevant to high clinical priority (Mandatory)
Generate at least one list of patients by specific conditions to use for quality improvement, reduction of disparities, outreach, etc. (Optional)
STAGE 1 REQUIREMENTS FUNCTIONAL REQUIREMENTS
Performance Measurement/Reporting (Mandatory)Report hospital quality measures to CMS or
the states (if only qualifying for Medicaid) for 15 measures use of certified EHR technology for data capture, calculation and reporting For 2011: attest to accuracy and completeness of
aggregate numerator, denominator and exclusions For 2012: submit electronically
STAGE 1 REQUIREMENTS HEALTH INFORMATION EXCHANGE
Health Information Exchange: PatientsProvide >50 percent of patients who request
it with an electronic copy of their health information (diagnostic test results, problem list, medication and allergy lists) within 3 business days (Mandatory)
Provide >50 percent of patients requesting discharge instructions with an electronic copy of their discharge instructions at the time of discharge (Mandatory)
Use EHR to identify appropriate education materials and provide to 10 percent of patients (Optional)
STAGE 1 REQUIREMENTS HEALTH INFORMATION EXCHANGE
Health Information Exchange: External ProvidersPerform at least one test of the capability to
exchange key clinical information (e.g., discharge summary, procedures, problem list, medication list, allergies, test results) among providers belonging to different legal entities using different EHR systems (Mandatory)
Provide summary care record for >50 percent of patients for transitions in care and referrals (does not have to be electronic) (Optional)
STAGE 1 REQUIREMENTS HEALTH INFORMATION EXCHANGE Health Information Exchange: Public Health
Authorities (Mandatory) Perform at least one test of the capability to submit
electronic data to immunization registries where required and accepted
Perform at least one test of the capability to provide electronic submission of reportable lab results (as required by state or local law) to public health agencies where it can be received
Perform at least one test of the capability to provide electronic surveillance data to public health agencies where it can be received
STAGE 1 REQUIREMENTS PRIVACY & SECURITY
Perform a security risk analysis before every qualifying year and implement needed changes (Mandatory)
EMR ADOPTION…SLOW PROGRESS…
EHR Implementation in U.S. Hospitals Comprehensive, used on all units 1.5% CPOE for medications 17% Physician notes 12% Problem list 27% Clinical guidelines (post-AMI care) 17%
SUMMARY OF CLINICAL QUALITY MEASUREMENT COMPONENTS FOR MU
SEE CMS FOR CURRENT DETAILS: HTTP://WWW.CMS.GOV/QUALITYMEASURES/03_ELECTRONICSPECIFICATIONS.ASP
ELECTRONIC SPECIFICATIONS FOR CLINICAL QUALITY MEASURES
To report clinical quality measures (CQMs) from an electronic health record (EHR), electronic specifications must be developed that include the data elements, logic and definitions for that measure in a format that can be captured or stored in the EHR so that the data can be sent or shared electronically with other entities in a structured, standardized format, and in an unaltered form.
CQM ELECTRONIC SPECIFICATION COMPONENTS Measure Overview/Description - This contains the measure
title, description, number, measurement period, measure steward, and other relevant information to the measure.
Measure Logic - This contains the population criteria and measure logic for the numerator, denominator and exclusion categories. The measure logic contains the algorithm used to calculate performance.
Measure Code Lists - This contains all of the codes pertaining to the measure.
QDS Elements - This lists and describes each Quality Data Set (QDS) data element associated with the measure. The QDS is a model of information that contains the standard
element, the quality data element, and the data flow attributes. The QDS model also describes information in a manner that
allows EHR and other clinical electronic system vendors to unambiguously interpret the data and clearly locate the data required.
CQM REPORTING REQUIREMENTS BY ELIGIBLE PROFESSIONALS (EP) Eligible professionals must report from a total of
44 clinical quality measures which includes, 3 Core, 3 Alternate Core, and 38 additional CQMs. Core CQMs - 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 alternate core measures.
EPs also must also select 3 additional CQMs from a set of 38 CQMs (excluding the core/alternate core measures). For these measures it is acceptable to have a '0'
denominator provided the EP does not have an applicable population.
REQUIRED CQM REPORTING BY EPS:
EPs must report on:6 total measures: 3 required core
measures (substituting alternate core measures where necessary) and 3 additional measures.
Note: A maximum of 9 measures would be reported if the EP needed to attest to the 3 required core, the three alternate core, and the 3 additional measures.
CQM REPORTING REQUIREMENTS BY ELIGIBLE HOSPITALS & CAHS
Hospitals & CAHs wanting to join the MU incentive program need to report on 15 CQMs
Measures focusing on:Quality deficits in evidence based careHigh variation among practitionersInappropriate utilization of servicesHigh costs to system
HOSPITAL CQM SUMMARY SPECIFICATIONSMeasure Number Brief Description
STK-1 Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission
STK-2 Ischemic stroke patients prescribed antithrombolytic therapy at hospital discharge
STK-3 Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge
STK-4 Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well
STK-5 Ischemic stroke patients administered antithrombolytic therapy by the end of hospital day 2
STK-6 Ischemic stroke patients with LDL >= 100 mg/dL, or LDL not measured, or, who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.
STK-8 Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke
STK-10 Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services
HOSPITAL CQM SUMMARY SPECIFICATIONS
Measure Number Brief Description VTE-1 […patients] who received VTE prophylaxis or have documentation why
no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission
VTE-2 […patients] who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial
admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer)
VTE-3 […patients] diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and
warfarin therapy. For patients who received less than five days of overlap therapy, they must be discharged on both medications. Overlap therapy must be administered for at least five days with an international normalized ratio (INR) ≥ 2 prior to discontinuation of the parenteral anticoagulation therapy or the patient must be discharged on both medications
VTE-4 […patients] diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using
defined parameters such as a nomogram or protocol VTE-5 […patients] diagnosed with confirmed VTE that are discharged to home, to
home with home health or home hospice on warfarin with written discharge instructions that address all four criteria: compliance issues,
dietary advice, follow-up monitoring and information about the potential for adverse drug reactions/interactions
VTE-6 […patients] diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date
HOSPITAL CQM SUMMARY SPECIFICATIONS
Measure Number Brief Description ED-1 Median time from emergency
department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department
ED2 Median time from admit decision time to time of departure from
the emergency department for emergency department patients admitted to inpatient status
ARRA & MEDICARE
Medicare Incentive Payments for Hospitals Hospitals can receive up to $8 million over four
years if they are using health IT starting in 2011 Paid only a pro-rated amount of the total based
on Medicare share and transition factor Critical Access Hospitals are eligible for
incentives that cover actual costs based on Medicare share plus 20% Covers an average of 86% of allowed costs
Medicare payments reduced for non-users beginning in 2015
REPORTING PERIOD
The reporting period for the EHR Incentive program using a certified EHR is any continuous 90 day period during the first payment year.
Note: Although the measure specifications assume a full calendar year you should only calculate the denominator and numerator from the first day of the 90 day reporting period to the last day of the 90 day reporting period.
GETTING IT DONE…
Do not wait for further information to get started – it is what needs to be done.
Send a clear message from the executive suite — both in words and through personal involvement — that this is the right thing to do for patients and a must for the hospital's future.
Achieving meaningful use is a huge clinical and operational change project. Put clinical and operational executives in the lead and make them accountable for success.
Work toward meaningful use as a highly coordinated effort rather than as a series of separate projects.
GETTING IT DONE…
Devil is in the details — process nuances, data and EHR functions. Commit sufficient time and resources to ensure they are addressed in a way that is workable for every patient care unit and support clinician workflow.
Business as usual in tackling process improvement — a prolonged consensus building process — takes too much time: Learn from the experience of others and make key strategic
decisions upfront to guide the process and empower knowledgeable, credible representatives of departments and clinicians to decide on the operational and tactical details.
Workarounds abound and "our unit is different" is often a long-held belief. Be prepared to take a hard line on standardized practices
that are in line with industry best practices.
GETTING IT DONE…
There is no time for multiple iterations and rework.
Include front-line users and even patients in order to increase adoption of modules that require re-engineered work flow – change management a key to success
Get it right the first time No time for work arounds
QUESTIONS
Contact Information:[email protected]
Authored Books:Demand Better! – Released April 2011Fatal Care – Released 2009
www.fatalcare.com