Meaningful Use

Jessica JacobsGeorgetown UniversityApril 14, 2011

Stage One Review

Note – I’m not an expert on Meaningful Use – please see http://www.cms.gov/EHRIncentivePrograms for more details!

(Un)fortunately, It’s more complicated than pie…

3

History Medicare v.s. Medicaid Incentives Certification Core

Objectives

Clinical Quality

MeasuresSummary

THE BACK STORY

• The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was a part of ARRA

• HITECH allocated funds to spur the adoption of electronic health records - approximately $20.8 Billion

• While they’re starting with carrots, there will be sticks

It all started with ARRA

Money Talks …

Graph Source: HIMSS Analytics Survey, September 2010, http://www.himss.org/content/files/vantagepoint/vantagepoint_201009.asp?pg=1

• ARRA gives out money, with some caveats:

1. Use of certified EHR in a meaningful manner

2. Use of certified EHR technology for electronic exchange of health information to improve quality of health care

3. Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary [of Health]

Why “Meaningful Use”?

• Works with other CMS/ONC programs

• Allows for step-wise implementation of EHRs

• Will lead to proper use of Health IT and better patient care

It’s more than just the money

The Five Pillars of Meaningful Use

Ensure Privacy and Security

Improve Population Health

Improve Safety and Quality

Engage Patients and Families

Coordinate Care

Basic Timeline

2009

•Feb: ARRA/HITECH Become Law

•Dec: NPRM on Display

2010

•Jan: NPRM Published

•March: Comment Period Closes (2000 comments received)

•July: Final Rule

•August: Certifying Bodies

2011

•Jan: States can begin to launch their programs

•~Jan: Registration

•~March: Attestation

•~May: Payments

•Nov 30th: Last day for Hospitals/CAH to register for FFY 2011

2012

•Feb 29th: Last day for EPs to register/attest for FFY 2011

2015

•Payment Adjustments (Penalties) Begin for EPs and eligible hospitals

2016

•Last year to receive Medicare Incentive Payment

2021

•Last year to receive Medicaid Incentive Payment

9

DO I QUALIFY?

History Medicare v.s. Medicaid Incentives Certification Core

Objectives

Clinical Quality

MeasuresSummary

Eligible Parties

Medicare

Eligible Professionals (EPs) • Ambulatory MD/DO• Doctor of Dental Surgery or Dental

Medicine• Doctor of Podiatric Medicine• Doctor of Optometry• Chiropractors • Medicaid Advantage (20 hours/week of

patient-care services for employees, 80% of time for partners)

Eligible Hospitals*• Acute Care Hospitals• Critical Access Hospitals (CAHs)

*Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC

Medicaid

Eligible Professionals (EPs)• Ambulatory Physicians (Pediatricians

have special eligibility & payment rules)• Nurse Practitioners (NPs)• Certified Nurse-Midwives (CNMs)• Dentists• Physician Assistants (PAs) who lead a

Federally Qualified Health Center (FQHC) or rural health clinic (RHC)

Eligible Hospitals• Acute Care Hospitals • Critical Access Hospitals • Children’s Hospitals

https://questions.cms.hhs.gov/app/answers/detail/a_id/9844/~/[ehr-incentive-program]-are-physicians-who-practice-in-hospital-basedNote: Excludes radiologists, pathologists, anesthesiologists, ER and all other hospital-based physicians

Medicaid Eligibility

Formula

Total Medicaid Encounters

in a 90-Day Period_________________________

Total Encounters in same 90-Day

Period

Entity

Minimum

Threshold

Physicians 30%

Pediatricians 20%

Dentists 30%

CNMs 30%

PAs (at FQHC) 30%

NPs 30%

Acute Care Hospitals 10%

Children's Hospitals --

Source: http://www.cms.gov/MLNProducts/downloads/EHR_Final_Rule-Medicaid.pdf

April May June July August September October November December0

5

10

15

20

25

30

35

40

45

50

5

2

8

4 4

7

1 1 1

1618

26

30

34

4142

4344

Expected States with Medicaid Programs

New State Programs Total State Programs

Num

ber

of

Sta

tes

Source: CMS, MU Program Contacts, Updated March 26, 2011, http://www.cms.gov/apps/files/statecontacts.pdf

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THE MONEY

History Medicare v.s. Medicaid Incentives Certification Core

Objectives

Clinical Quality

MeasuresSummary

–Medicare: $44k/physician• Bonuses for EPs in Health Provider Shortage

Areas (HPSAs)

–Medicaid: up to $63,750k/physician– Incentives will be paid 2011- 2016, then

penalties will begin

• Switching between programs: – Allowed, but only once

Ambulatory Incentive Structure

Year MUer

2011 2012 2013 2014

2011 $18,000 - - -

2012 $12,000 $18,000 - -

2013 $8,000 $12,000 $15,000 -

2014 $4,000 $8,000 $12,000 $12,000

2015 $2,000 $4,000 $8,000 $8,000

2016 - $2,000 $4,000 $4,000

TOTAL $44,000 $44,000 $39,000 $24,000

Medicare EPs

Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

Year MUer

2011 2012 2013 2014

2011 $1,800 - - -

2012 $1,200 $1,800 - -

2013 $800 $1,200 $1,500 -

2014 $400 $800 $1,200 $12,000

2015 $200 $400 $800 $8,000

2016 - $200 $400 $4,000

TOTAL $4,400 $4,400 $3,900 $2,400

Medicare HPSA EP Bonuses

Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

Year MUer

2011 2012 2013 2014 2015 2016

2011 $21,250

- - - - -

2012 $8,500 $21,250 - - - -

2013 $8,500 $8,500 $21,250 - - -

2014 $8,500 $8,500 $8,500 $21,250 - -

2015 $8,500 $8,500 $8,500 $8,500 $21,250 -

2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250

2017 - $8,500 $8,500 $8,500 $8,500 $8,500

2018 - - $8,500 $8,500 $8,500 $8,500

2019 - - - $8,500 $8,500 $8,500

2020 - - - - $8,500 $8,500

2021 - - - - - $8,500

TOTAL $63,750

$63,750 $63,750 $63,750 $63,750 $63,750

Medicaid EPs

Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

Hospital Incentive Structure• The Money:

• Two Million Dollar Base + Variable Based on Discharges (Medicare/Medicaid Share)

• Hospitals meeting Medicare MU requirements may be eligible for Medicaid payments

• The Timeline: • Medicare: no payments after 2016, Sticks start in 2015• Medicaid: can’t initiate payments after 2016

• The Caveats: – All Medicare Hospitals qualify as Medicaid Hospitals– Hospitals eligible for Medicare dollars may be eligible for

Medicaid dollars

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19

ARE YOU LEGAL?

History Medicare v.s. Medicaid Incentives Certification Core

Objectives

Clinical Quality

MeasuresSummary

Certification

• Temporary Certification Program will expire December 31, 2011, Permanent program starts January 1, 2012. ‘

• National Institute of Standards and Technology (NIST) will help accredit testing bodies through its National Voluntary Laboratory Accreditation Program (NVLAP)

• Handled by external bodies

• Currently there are five certifying agencies: – CCHIT – Chicago, IL. (8/30/10)– Drummond Group – Austin, TX.

(8/30/10)– InfoGard – San Luis Obispo, CA.

(9/17/10)– ICSA - Mechanicsburg, PA. (12/10/10)– Surescripts, LLC – Arlington, VA.

(12/23/10)

Vendors Planning to Achieve Certification

Graph Source: HIMSS Analytics Survey, September 2010, http://www.himss.org/content/files/vantagepoint/vantagepoint_201009.asp?pg=1

Certification: Current Stats• There are 575 Current Certifications

– 393 Ambulatory– 182 Acute

• This is up from 136 Certifications last December

Acute

Ambulatory

30%

70%

70%

30%

Type of Certification

Complete EHR Modular EHR

57%

43%

Product Type

Complete EHR Modular EHR

CCHIT50%

Drummond Group Inc.34%

ICSA Labs1%

In-foG-ard14%

SLI Global1%

Certifying Body

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THE HEART OF IT

History Medicare v.s. Medicaid Incentives Certification Core

Objectives

Clinical Quality

MeasuresSummary

• You Gotta Have: – Ambulatory Providers = 15– Hospitals = 14– All Hospital Criteria Overlap with

Ambulatory• the only addition to the ambulatory provider

list is e-Prescribing

–Most measures must be reported as structured data

The Core Objectives

Core Objectives – Gotta Do ‘em All

Maintain/Record

• Maintain an up-to-date problem list of current and active diagnoses (50%)

• Maintain active medication list (80%)

• Maintain active medication allergy list (80%)

• Record and chart changes in vital signs (50%)

• Record smoking status for patients 13 years or older (50%)

• Record demographics (50%)

Do/Implement

• Computerized physician order entry (CPOE) (30%)

• E-Prescribing (Ambulatory Only, 40%)

• Drug-drug and drug-allergy interaction checks (enabled whole period)

• Clinical decision support (1 rule)

• Protect electronic health information (whole period)

Provide/Report

• Report clinical quality measures to CMS or States (2011 Attestation, 2012 Electronically)

• Provide Patients with an electronic copy of their health information, upon request (50% within 3 days)

• Provide clinical summaries for patients for each office visit/at each discharge (50% within 3 days)

• Capability to exchange key clinical information among providers of care and patient-authorized entities electronically (perform at least one test)

Source: http://healthpolicyandreform.nejm.org/?attachment_id=3742

Menu Sets – Pick Five Maintain/Record

• Incorporate clinical lab test results (50%)

• Record advanced directives for patients 65 years or older (Acute Only, 50%)

Do/Implement• Drug-formulary checks (whole

period)• Medication reconciliation

(50%)

Provide/Report

• Generate lists of patients by specific conditions (at least 1 list)

• Summary of care record for each transition of care/referrals (50%)

• Capability to provide electronic syndromic surveillance data to public health agencies (1 test)

• Capability to submit electronic data to immunization registries/systems (1 test)

• Provide patient-specific education resources and provide to patient (10%)

• Send reminders to patients per patient preference for preventive/follow up care (Ambulatory Only, 20%, in the 65< & <5 age groups)

• Provide patients with timely electronic access to their health information (Ambulatory Only, 10% within 4 days)

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CLINICAL QUALITY MEASURES (CQM)

History Medicare v.s. Medicaid Incentives Certification Core

Objectives

Clinical Quality

MeasuresSummary

• Many selected from the Physician Quality Reporting Initiative (PQRI) and Pay-for-Performance Initiatives (P4P)*– CMS intends to create an added incentive for EPs to adopt EHRs by leveraging the PQRI

measures and eventually integrate both programs.– CMS envisions a single reporting infrastructure for electronic submission in the future,

eliminating redundant or duplicative reporting.

• The HITECH Act required that in selecting clinical quality measures CMS give preference to those endorsed by the National Quality Forum.* – NQF is a nonprofit organization that ensures clinical quality measures are developed

and maintained through a consistent and collaborative process.– All clinical quality measures selected in the final rule are endorsed by NQF.

• Number of Measures – EPs – 3 core, 3 pick

• If your practice doesn’t have the 3 core to report on (pediatricians don’t have adult weight screenings), then you pick an “alternate” measure to report

– Hospitals – 15, all required

*Source: http://journal.ahima.org/2010/09/15/clinical-quality-measures-for-providers-3/

Clinical Reporting Measures

EP CQM •CORE SET: •Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention (NQF 0028)

•Hypertension: Blood Pressure Measurement (NQF 0013)

•Adult Weight Screening and Follow-up (NQF 0421, PQRI 128)

•ALTERNATE SET: •Preventive Care and Screening: Influenza Immunization for Patients > 50 Years old (NQF 0041, PQRI 110)

•Childhood Immunization Status (NQF 0038)

•Weight Assessment and Counseling for Children and Adolescents (NQF 0024)

•Pneumonia Vaccination Status for Older Adults

Prevention

•Hemoglobin A1c Poor Control

•Low Density Lipoprotein (LDL) Management and Control

•Blood Pressure Management

•Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

•Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

•Eye Exam•Urine Screening•Foot Exam•Hemoglobin A1c Control (<8.0%)

Diabetics

• Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

• Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)

• Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD

• Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

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

• Ischemic Vascular Disease (IVD): Blood Pressure Management

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

• Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol

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

Cardiology

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

•Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

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

Oncology

•Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)

•Prenatal Care: Anti-D Immune Globulin

•Prenatal Care: Controlling High Blood Pressure

•Cervical Cancer Screening•Chlamydia Screening for Women

OBGYN

•Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies

• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement

•Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment

Psychology

•Asthma Pharmacologic Therapy

•Asthma Assessment•Use of Appropriate Medications for Asthma

•Appropriate Testing for Children with Pharyngitis

Respiratory

•Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

•Low Back Pain: Use of Imaging Studies

Other

EP CQM

Hospital CQM Requirements

• Ischemic stroke – Discharge on anti-thrombotics

• Ischemic stroke – Anticoagulation for A-fib/flutter

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

• Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2

• Ischemic stroke – Discharge on statins• Ischemic or hemorrhagic stroke – Stroke education

• Ischemic or hemorrhagic stroke – Rehabilitation assessment

Stroke

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

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

Throughput

• VTE prophylaxis within 24 hours of arrival• Intensive Care Unit VTE prophylaxis• Anticoagulation overlap therapy• Platelet monitoring on unfractionated heparin• VTE discharge instructions• Incidence of potentially preventable VTE

Surgery

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SO WHAT WAS THE POINT?

History Medicare v.s. Medicaid Incentives Certification Core

Measures

Clinical Reporting Measures

Summary

OverviewMedicare Medicaid

Implementers Federal Level (CMS) States (Voluntary)

Initiate By 2014 2016

Carrots 2011-2016 2011-2021

Sticks 2015 (1%), 2016 and on (2%)

None Federally Mandated

By year one… Demonstrate MU 90 days A/I/U (Adopt, Implement, Upgrade)

Maximum EP Incentive

$44,000 (HPSA Bonus) $63,750

Rule Variance None State Specific

Eligible Providers physicians, subsection (d) hospitals and CAHs

5 types of EPs, acute care hospitals, CAHs, and children’s hospitals

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EPs80% of Patient Records

Certified EHR15 Core + 5

Menu Objectives

3 Core + 3 Alternative

CQM

Meaningful Use

Hospitals80% of Patient Records

Certified EHR14 Core + 5

Menu Objectives

15CQM

Meaningful Use

Overview - Requirements

Overview - Pursuit and Achievement

Providers Planning to Pursue

Providers who will Achieve

Graph Source: HIMSS Analytics Survey, September 2010, http://www.himss.org/content/files/vantagepoint/vantagepoint_201009.asp?pg=1

Overview

Overall Satisfaction Decreases Costs Increase Revenue Increase Productivity

72%

40% 42% 39%

14%

34% 36%30%

14%23% 22%

31%

Current Sentiments on Adoption

Satisfied Neutral Unsatisfied

Source: MGMA Study, April 6, 2011, http://www.mgma.com/press/default.aspx?id=1248514, n= 4588, representing practices/organizations with 120,000 physicians, online survey

13.6% will achieve MU

13.9% could achieve if systems asdfasdfasdf are fully utilized.

27.5% will achieve

• This was only the first stage– Stages Two: expected 2011, menu set becomes core, new

parameters, more HIE, device guidelines – Stage Three: expected 2013, likely more patient access

• Using Electronic Health Records Meaningfully will (hopefully) lead to: – better clinical outcomes for patients – Less waste– Less fraud and abuse– Better ROI– Reduce health disparities and improve public health – Engage patients and family

The Point…

Why we need Meaningful Use

Health Information Exchange

EHR #1

eRX

CDS

RCM

PHR

mHealth

Community Health Record

EHR #2

eRX

CDS

RCM

PHR

PHR

Lab

Labs

Lab

Any Questions?

jess.a.jacobs@gmail.com