Understanding the CMS Understanding the CMS EHR Incentive ProgramsEHR Incentive Programs

Adele AllisonAdele Allison

National Director of Government National Director of Government AffairsAffairs

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Understanding the CMSUnderstanding the CMSEHR Incentive ProgramEHR Incentive Program

• Overview Final Rule – Stage 1Overview Final Rule – Stage 1• Registration• Stage 2 – Forecasting • Project Management• Practice Redesign• Questions

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Summing-up HITECHSumming-up HITECHgoalsgoals

1. Push Provider adoption/use of approved (certified) EHR Technology

2. Capture DATA3. Move DATA – Interoperability4. Report DATA

• $27B in “Carrots” - incentives:– Up to $48,400 through Medicare– Up to $63,750 through Medicaid

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Stage 1 – ObjectivesStage 1 – Objectives& Measures& Measures

• Objectives are broad spanning goals/activities

• Measures are specific task(s) requirements• Meeting the measures = meeting the

Objectives for that Stage• Stage 1 MU– 15 Core Measures required by all EP’s– 10 “Menu” Measures from which EP’s choose

5– eClaims and eEligibility removed

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Stage 1 – ObjectivesStage 1 – Objectives& Measures cont.& Measures cont.

• 13 Exclusions Clause – Exclusions will reduce the number of Objectives required by EP

• Stage 2 MU– 31 Proposed measures (includes expansion

of 25 Stage 1 Measures)– Minimum additional 6 or more could be

added– Illustrates importance of implementing

Stage 1 now!5

Medicare IncentiveMedicare IncentivePayments: Fee-For-Service Payments: Fee-For-Service

• Paid out over 5-year period• Equivalent to 75% of allowables for

EP Payment Year• Capped at HITECH statutory EHR

Payment Year amounts• Reduced for late initiation• Increased 10% if practicing in a

“shortage” area

(§ 495.102)

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Potential Medicare IncentivesPotential Medicare Incentives

Calendar Year

First Calendar Year in which the EP Receives an Incentive Payment 

2011 2012 2013 20142015 and

subsequent years

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 $0

2016   $2,000 $4,000 $4,000 $0

TOTAL $44,000 $44,000 $39,000 $24,000 $0Shortage Area

Totals* $48,400 $48,400 $42,900 $26,400 $0

* Providers practicing in a federally identified shortage area are eligible for a 10% increase .7

Medicaid IncentivesMedicaid Incentives• Types of Providers - §495.100:

– Medicaid: Physicians, Dentists, Certified Nurse Midwives, Nurse Practitioners, Physician Assistants (in FQHC/RHC led by a PA)

• Year 1 - Adopt, Implement, Upgrade - §495.302:– Acquire, purchase, or secure access to certified EHR

technology;– Install/use certified EHR technology capable of MU; or– Expand functionality of certified EHR solution at the practice

with:• Staffing,• Maintenance,• Training, or• Upgrading from existing EHR to certified EHR technology.

• Year 2 – MU for 90 continuous days• Years 3 through 6 – MU for full year

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Meaningful UseMeaningful UseMedicaid DefinitionsMedicaid Definitions

• Needy Individual is a patient who - §495.302 (FQHC/RHC):– Receives Medicaid or CHIP assistance,– Receives uncompensated care by the

provider, or– Services provided at no cost or reduced

cost based on sliding scale and ability to pay.

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Meaningful UseMeaningful UseMedicaid DefinitionsMedicaid Definitions

• Hospital-based Provider Exclusion - §495.4 – (RHC):– Hospital-based EP’s DO NOT qualify for ‘Care /

‘Caid incentives– Previously was excluding “owned” RHC’s – 4.15.2010 → Revision under Jobs Bill

(Continuing Extension Act of 2010) – includes only EP’s with 90% services done inpatient and in ED’s

– Does not apply to Medicaid-EP practicing >50% in a FQHC or RHC (§495.304)

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Meaningful UseMeaningful UseMedicaid DefinitionsMedicaid Definitions• Must meet the individual state requirements

for volume threshold– 20% for Pediatricians– 30% for FQHCs and RHCs (can include “needy”)– 30% for all others

• Defined in the State’s SMHP - Methods available:– By Encounter– By Panel– By Group– Other

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Formula 1 :  Medicaid Encounter Approach  

(Total Medicaid encounters in a representative continuous 90-day period in the preceding calendar year)___________________________________________      X 100 = %

(Total Patient Encounters in the same 90-day period)

Formula 2 :  Managed Care / Medical Home Approach

(Total Medicaid patients assigned to the provider in a representative continuous 90-day period in the    preceding calendar year with at least 1 encounter in the year preceding the start of the 90-day period) 

+ (Unduplicated Medicaid encounters in that same 90-day period)________________________________________________________________________     X 100 =  %

(Total patients assigned to the provider in the same 90-days with at least 1 encounter in the year precedingthe start of the 9-day period) + (All unduplicated encounters in that same 90-day period)

Meaningful UseMeaningful UseMedicaid DefinitionsMedicaid Definitions

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Potential Medicaid IncentivesPotential Medicaid Incentives

Calendar YearFirst Calendar Year in which the EP Receives an Incentive Payment

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 $0 $8,500 $8,500 $8,500 $8,500 $8,500

2018 $0 $0 $8,500 $8,500 $8,500 $8,500

2019 $0 $0 $0 $8,500 $8,500 $8,500

2020 $0 $0 $0 $0 $8,500 $8,500

2021 $0 $0 $0 $0 $0 $8,500

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

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Stage 1 – MedicaidStage 1 – MedicaidIncentive ProgramIncentive Program

• States can move 1-4 “Menu” measures to “Core” measures (up to 4 Menu can be moved for hospitals)

– Generate Lists of patients – can specify condition

– Reporting to Immunization Registry – can specify testing requirements

– Reporting Lab Results – can specify testing requirements

– Syndromic Surveillance – can specify testing requirements

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Stage 1 – MedicaidStage 1 – MedicaidIncentive Program cont.Incentive Program cont.

• Additional point of variance by state:– Additional State Registration

Requirements–Method(s) for patient volume calculations– Program launch date

• States launch so far: AK, AL, IA, KY, LA, OK, MI, MS, MO, NC, SC, TN, and TX

• State launching May 2011: CA• All Others: www.cms.gov/apps/files/medicaid-

HIT-sites/

– Requirements to prove A/I/U15

Understanding the CMSUnderstanding the CMSEHR Incentive ProgramEHR Incentive Program

• Overview Final Rule – Stage 1• RegistrationRegistration• Stage 2 – Forecasting • Project Management• Practice Redesign• Questions

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Medicare EHRMedicare EHRIncentive EnrollmentIncentive Enrollment

• EP registers with CMS at http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp

– Login – EP’s User ID and Password for National Plan and Provider Enumeration System (NPPES)• NPPES is same as Provider Enrollment, Chain &

Ownership System (PECOS) – used to verify ‘Care enrollment – for PECOs enrollment go to http://www.cms.gov/MedicareProviderSupEnroll/

• November, 2013 is the “trigger” date• To enroll in NPPES, go to

http://www.cms.gov/NationalProvIdentStand/06a_DataDissemination.asp

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Medicare EHRMedicare EHRIncentive Enrollment cont.Incentive Enrollment cont.– Need: NPI (Type 2 if assigning), TIN, and address

from IRS Form CP-575– Select “Start Registration” on the registration tab

under Action– Answer the questions with a red * including the

incentive program selected, type of EP, and whether they have a certified EHR

– Follow instructions – upon completion, system will display check marks for completed information

– Select “Begin Submission,” review/validate information, agree to terms and “submit”

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Medicare EHRMedicare EHRIncentive Enrollment cont.Incentive Enrollment cont.

– Confirmation / Regis. ID tracking numbergiven• KEEP TRACK OF THIS NUMBER

– Attestation started April 18th, go to:• https://ehrincenives.cms.gov/hitech/

login.action

– Attestation EP Meaningful Use Calculator• http://www.cms.gov/apps/ehr/

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Medicaid EHR Incentive Medicaid EHR Incentive Enrollment, GenerallyEnrollment, Generally• EP must register with CMS• Medicaid Programs are run by the

state• States launched so far: AK, AL, IA, KY, LA, OK,

MI, MS, MO, NC, SC, TN, and TX• States launching in May: PA, CA and OH• States launching in June/July: AZ, CT, KS, ND,

NM, RI, WA (possible: AR, DE, IL, MT)• Websites:

www.cms.gov/apps/files/medicaid-HIT-sites/

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Medicaid EHR Incentive Medicaid EHR Incentive Enrollment cont.Enrollment cont.

• Required to provide documentation supporting adoption, implementation or upgrade

• Common forms of documentation: Vendor Receipt, Contract, Service / Performance Agreements, Screenshot of Sign-on, Upgrade Agreement, Vendor Letter, Work-plan, Cost Report, Invoices

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Medicaid EHR Incentive Medicaid EHR Incentive Enrollment cont.Enrollment cont.

• Common Data Points needed for registration:– Provider Name– Provider NPI or Organizational NPI (if applicable)

– Provider Address (should reflect the location of the technology)

– CMS Certification ID (SuccessEHS’s is 30000001SWGTEAS)

– ONC Certification number (SuccessEHS’s is CC-1112-909422-1)

– EP’s Medicaid Provider Number22

Understanding the CMSUnderstanding the CMSEHR Incentive ProgramEHR Incentive Program

• Overview Final Rule – Stage 1• Registration• Stage 2 – Forecasting Stage 2 – Forecasting • Project Management• Practice Redesign• Questions

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Since Stage 1 Final RuleSince Stage 1 Final Rule

• HITPC – 11 Workgroups –Recommendations on:– 9.1.2010 – Privacy & Security Policies & Practices– 9.7.2010 – Efficient, transparent enrollment in HHS

programs (required under PPACA)– 11.29.2010 – Privacy & Security on Provider

authentication– 12.16.2010 – NHIN governance for HIE within and

across states– 1.12.2011 – Comment requested on Stage 2

Criteria– 1.14.2011 – Entity-Level Provider Directories for HIE– 2.8.2011 – Accurately matching patients to health

information standards– 4.13.2011 – Suggested pathways for HIE; HIE and

public trust; Federal data services 24

Since Stage 1 Final RuleSince Stage 1 Final Rule

• HITSC – 5 Workgroups, 2010:– 8.30.2010 – Eligibility checking through web

service programs– 9.21.2010 – Working to develop a common core

focused on HIE called the National Information Exchange Model (NIEM) Health

– 10.27.2010 – Work on managing intellectual property issues for MU related to vocabularies (e.g. SNOMED CT, RxNORM) and associated costs

– 11.30.2010 – HIE testimony heard from Verizon, VisionShare, Covisint, Axolotl, Surescripts and Intel

– 12.17.2010 – Discussed the importance of lab interface cost reduction through a universal compendium of LOINC codes

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Since Stage 1 Final RuleSince Stage 1 Final Rule

• HITSC – 5 Workgroups, 2011:– 1.12.2011 – Problem noted of 56 HIEs, which will

create 56 different directories, formats, security standards that may not allow inter-state transmission.

Concise interoperability specs needed now.– 2.16.2011 – CQMs focused. 1,100 comments

received on Stages 2 & 3 CQMs. ONC wants cross-cutting measures that can take advantage of longitudinal EHR.

– 3.29.2011 – NPRM on Certification Standards Stage 2 target publish date Q4 2011. 26

Forecast: Stages 2 & 3Forecast: Stages 2 & 3

Stage 1 Proposed – Stage 2 Proposed – Stage 3CPOE for Rx Orders – 30% COPE for Rx and lab/radiology – 60% CPOE for Rx and lab/radiology – 80% Drug-Drug, and Drug-Allergy Interactions

Evidence-based interactions:Drug-Drug, and Drug-Allergy Interactions

Evidence-based interactions: Drug-Drug, Drug-Allergy, Drug-Age, Drug-Dose, Drug-lab, and Drug-condition 

ePrescribing – 40% ePrescribing transmission of 50%  ePrescribing transmission of 80% Demographics – 50% Demographics on 80% of patients and ability 

to produce stratified quality reports.Demographics on 90% of patients and ability to produce stratified quality reports.

Report CQM electronically Continued and expanded CQM reporting. Continued and expanded CQM reporting.Maintain Problem List – 80% Continue Stage 1 80% problems lists are up-to-dateMaintain Active Rx List – 80% Continue Stage 1 80% Active Rx lists are up-to-dateMaintain active medication allergy List – 80%

Continue Stage 1 80% Rx allergy lists are up-to-date

Record vital signs – 50% 80% of unique patients have vital signs recorded

80% of unique patients have vital signs recorded

Record Smoking Status – 50% 80% of unique patients have smoking status recorded

90% of unique patients have smoking status recorded

Implement 1 CDS Rule Use CDS to improve performance on high-priority conditions and establish CDS attributes for purposes of certification.

Use CDS to improve performance on high-priority conditions and establish CDS attributes for purposes of certification.

Menu Measure – Implement Drug-Formulary Checks

Drug-Formulary Checks becomes a Core Measure

80% of Rx orders are checked against relevant formularies

Hospital Menu Measure – Record advance directives – 50%

Becomes core measure.  Advance directives for 50% of patients age 65+

Advance directives for 90% of patients age 65+

Menu Measure – Incorporate Lab Results – 40%

Lab Results becomes a Core Measure, but only where results are available.

90% of lab results are electronically ordered through EHR and reconciled with results, where results and structured orders are available. 27

Forecast: Stages 2 & 3Forecast: Stages 2 & 3

Stage 1 Proposed – Stage 2 Proposed – Stage 3Menu Measure – Generate patient lists for specific conditions

Measure becomes Core requirement. Generate lists for multiple patient-specific parameters

Use patient lists to manage patients for high-priority health conditions

Menu Measure – Reminders to patients age 65+ and/or age 5 and under

Measure becomes a Core requirement. 20% of active patients with preference for electronic reminders receive preventive or follow-up reminders

Non-existent in Stage 1 At least 1 electronic note for 30% of patient visits. At least 1 electronic note for 90% of patient visits.

Menu Measure – Provide electronic copy of health information upon request

Continue Stage 1 90% of patients have timely access 

EHR-enabled patient-specific educational resources – 10%

Continue Stage 1 20% offered patient-specific educational resources online in common primary languages.

Provide clinical summaries for each office visit – 50%

Patient can view and download relevant information about a clinical encounter within 24 hours of visit.  

Follow-up tests not “ready,” included in future summaries within 4 days 

Data is available human-readable and structured forms

Same as Stage 2

Timely electronic access provided to the patient – 10%

Patient can view/download relevant information in the longitudinal record within 4 days of information being available to the practice

Patient can filter/organize information by date, encounter, etc.

Data is available in human-readable and structured formats

Same as Stage 2

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Forecast: Stages 2 & 3Forecast: Stages 2 & 3

Stage 1 Proposed – Stage 2 Proposed – Stage 3Timely electronic access and clinical summaries for each office visit.

20% of patients use a web-based portal to access information at least once.

Exclusions:  Patients with no Internet access.

30% of patients use a web-based portal to access information at least once.

Exclusions:  Patients with no Internet access.

Non-existent in Stage 1 Online secure patient messaging in use. Same as Stage 2Non-existent in Stage 1 Patient preferences for communication medium 

recorded – 20%Patient preferences for communication medium recorded – 80%

TBD Exchange data between EHRs and PHRs using standards-based HIE.

TBD Patients have ability to report experience of care measures online

TBD Ability to upload and incorporate patient-generated data 

Perform 1 test of HIE Connect to at least 3 external providers in “primary referral network” (but outside delivery system that uses same EHR), or 

Establish ongoing bidirectional connection to at least 1 HIE.

Connect to at least 30% of external providers in “primary referral network,” or

Establish ongoing bidirectional connection to at least 1 HIE.

Menu Measure – Medication reconciliation during transitions in care – 50%

Medication reconciliation at 80% of care transitions by receiving provider 

Medication reconciliation at 90% of care transitions by receiving provider 

Menu Measure – Provide summary of care record during transitions in care- 50%

Measure becomes Core. Summary of care record provided electronically for 80% of transitions and referrals

Non-existent in Stage 1 List of care team members (including PCP) available for 10% of patients in EHR

List of care team members (including PCP) available for 50% of patients in EHR

Non-existent in Stage 1 Record a longitudinal care plan for 20% of patients with high-priority conditions

Record a longitudinal care plan for 50% of patients with high-priority conditions 29

Forecast: Stages 2 & 3Forecast: Stages 2 & 3

Stage 1 Proposed – Stage 2 Proposed – Stage 3Menu Measure – Submit immunization data

Mandatory test.  Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law.

Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law.

During well child/adult visits, providers review IIS via the EHR.

Menu Measure – Submit reportable lab data

Lab reporting menu option.  Ensure lab results and conditions are submitted to public health agencies either directly or through performing labs 

Mandatory Test.  Lab reporting menu.  Ensure lab results and conditions are submitted to public health agencies either directly or through performing labs 

Menu Measure – Submit syndromic surveillance data

Measure becomes a core requirement. Mandatory test; Submit if accepted.

TBD “Public Health Button”:  Mandatory test and submit if accepted.  Submit notifiable conditions using a reportable public-health submission button.  

EHR can receive and present public health alerts or follow-up requests.

TBD Patient-generated data submitted to public health agencies

Conduct security review analysis and correct deficiencies.

TBD TBD30

Understanding the CMSUnderstanding the CMSEHR Incentive ProgramEHR Incentive Program

• Overview Final Rule – Stage 1• Registration• Stage 2 – Forecasting • Project ManagementProject Management• Practice Redesign• Questions

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Assessment –Assessment –“You Are Here”“You Are Here”

• Clinic Culture Prep– Think about Users and Roles– Create a Vision Statement– Identify Leadership (Formal / Informal)– Communicate Plans

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Assessment –Assessment –“You Are Here”“You Are Here”

• Workflow Self-Assessment – Identify sources of:– Assessment Worksheet– Inefficiency / Delay / Duplication– Risk / Liability / Non-Compliance (e.g. HIPAA)– Quality concerns– High costs

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Leadership:Leadership:AdministrationAdministration• Remember – this is a Provider Program

• Remember – the Providers are part of a Clinic / Group Practice

• Plan for Administration Ease– Consistency in measures– Evaluate Technology and Workflows

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Provider AssessmentProvider Assessment

• Identify potential barriers before reengineering– Low comfort level with technology (Provider /

Support Staff)– Gaps in Hardware – Impact on productivity– What additional problems can be solved?

• Workflows MUST BE CONSISTENT for data capture and reporting

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Understanding the CMSUnderstanding the CMSEHR Incentive ProgramEHR Incentive Program

• Overview Final Rule – Stage 1• Registration• Stage 2 – Forecasting • Project Management• Practice RedesignPractice Redesign• Questions

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Practice RedesignPractice Redesign

• Compliant and certified for MU EHR Software• Senior Leadership and Staff – Awareness and

Understanding

• Identified Champions – Formal and Informal

• Key Partner Collaboration– Lab Interfaces – (ORM/ORU) Results to Patient Chart– Immunization Interface – (VXU) Single entry / upload to

Registry– HIE Interface

• HIPAA Security Analysis• Implementing New Technologies

− Patient Portal− IT Needs 37

Practice RedesignPractice Redesign• Data Collection Considerations • Must be consistent• Like CDS - Identifying the “5 Rights” in

Workflow• Right Information• Right Person Collecting• Right Format• Right Channel (e.g. EHR, Portal, PM)• Right Time in Workflow

• Data Needed: Vitals, Smoking Status, Rx Reconciliation, Refills, Health Disparities

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Practice RedesignPractice Redesign• Set-up / Configuration – e.g. CEM for patient

reminders, alerts

• Training• MU Dashboard, Reporting, Ongoing Quality

Improvement

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To learn more about the CMS EHR Incentive Programs, visit: http://www.successehs.com/item/hitech-meaningful-use-certified-systems/erx-and-meaningful-use-incentive-programs.htm.

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