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Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System
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Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System

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The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health …

The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health management. Most physician practices will need supplemental information technology that automates the basic tasks of identifying, contacting, and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.

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  1. PHYTEL | WHITEPAPERPopulation HealthMeaningful Use and the Path to PopulationHealth and Quality in a TransformingHealthcare System
  2. ContentsThe ChallengeThe U.S. healthcare system is on the verge of a majortransformation that has the potential to achieve severalnational prioritiesIncentive Structuregovernment IncentivesThree-Stage ProcessMeaningful Use in Stage 1A Graphical TimelineMajor Barriers to Meaningful UseAdjunctive TechnologiesAchieving Meaningful UseConclusionAppendix
  3. The Challenge: The U.S. healthcare system is on the verge of a majortransformation that has the potential to achieve several national priorities.At the highest level, these priorities focus on expanding access to care, improving the quality of care, and reducingcost growth to a sustainable level. More specifically, the agenda set forth in the federal reform legislation and theHITECH provisions of the 2009 American Recovery and Reinvestment Act (ARRA) has these goals:•  Improve quality, safety, efficiency and reduce health disparities•  Engage patients and their families in their health care•  Improve care coordination•  Improve population health•  Ensure privacy and confidentiality for personal health informationIn a previous paper, we discussed the importance and the role of population health management (PHM) in healthcare transformation.1 While PHMis still largely confined to some large healthcare organizations and governmental systems, several elements of the Affordable Care Act (ACA)that affect Medicare are driving the healthcare system in this direction. Among them are pilots of or incentives for care coordination, value-basedpurchasing, accountable care organizations, and payment bundling.2 In addition, the “meaningful use” requirements of the HITECH Act aredesigned to steer healthcare toward PHM.The HITECH Act stipulates that physicians must show “meaningful use” of certified EHRs or EHR technology to qualify for government incentives.3While the legislation instructs the Department of Health and Human Services (HHS) to fill in the details, it does specify that electronic prescribing,health information exchange, and quality data reporting—all key to quality improvement--must be among the requirements.4 The Notice ofProposed Rulemaking (NPRM) on the meaningful use regulations, issued in December 2009, went several steps further in laying out a frameworkfor population health management (PHM).5 The final regulations, which HHS released in July 2010, retain most of that framework, although theymake some PHM-related requirements optional or postpone them to a later stage of meaningful use.6 So, while the HITECH Act is primarilydesigned to accelerate EHR adoption, the meaningful use rules turn the government incentives into a vehicle for launching transformationalinitiatives.1. Richard Hodach, “The Promise of Population Health Management,” White Paper, July 2010, accessed at xxxx2 David Cutler, “How Health Care Reform Must Bend The Cost Curve,” Health Affairs, June 2010, 1131-1135.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 3
  4. Incentive Structure: To be eligible for government incentives, physiciansmust not practice primarily in a hospital setting, although they may beemployed by hospitals or healthcare systems.Both Medicare and Medicaid will provide do not have EHRs or do not use themsubsidies, but an eligible professional (EP) meaningfully by 2015 will lose 1 percent ofcan receive incentives from only one of Medicare reimbursement that year. Theythese programs in a given year. To receive will give up 2 percent in 2016, and theirMedicaid incentives, physicians must derive reimbursement will drop 3 percent in 201730% or more of their income from Medicaid and each subsequent year.8(20 percent for pediatricians). Other providers Medicaid incentives are structured a bitmay also be eligible for Medicaid subsidies, differently. According to the Centers forincluding dentists, certified nurse-midwives, Medicare and Medicaid Services (CMS),nurse practitioners, and physician assistants “Eligible professionals may receive up towho are practicing in Federally Qualified 85 percent of the net average allowableHealth Centers (FQHCs) or Rural Health costs for certified EHR technology, includingClinics (RHCs) led by a physician assistant.7 support and training (determined on theAn eligible professional who can show basis of studies that the Secretary willmeaningful use of a “qualified” EHR—one undertake), up to a maximum level, andthat has been certified by an HHS-approved incentive payments are available for no morecertifying body--may obtain incentives of up than a 6-year period.”9to $44,000 from Medicare or nearly $64,000from Medicaid. The Medicare incentiveswill be paid over a five-year period, startingin 2011. A physician who applies for aMedicare incentive in 2011 or 2012 can get 1%$18,000 the first year, followed by annualpayments of $12,000, $8,000, $4,000, and$2,000. Those who apply in 2013 and 2014will receive less, and anyone who applies lower Medicare reimbursementafter that will get nothing. Physicians who that are not meaningfully using an EHR by 2015.3. Centers for Medicare and Medicaid Services (CMS), “Medicare and Medicaid Health Information Technology: Title IV of the American Recovery and Reinvestment Act,” Fact Sheet, June16, 2009, accessed at https://www.cms.gov/apps/media/press/factsheet.asp?Counter=3466&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date.4. Ibid.5. HHS (Department of Health and Human Services)/CMS, “Medicare and Medicaid Programs; Electronic Health Record Program; Proposed Rule,” aka “Notice of Proposed Rulemaking,”Federal Register, 42 CFR Parts 412, 413, 422 and 495.6. HHS (Department of Health and Human Services)/CMS, “Medicare and Medicaid Programs; Electronic Health Record Program; Final Rule, Federal Register, 42 CFR Parts 412, 413, 422,and 495.7. HHS/CMS, NPRM, 1930.8. Ken Terry, “The EHR Stimulus: A Complete Primer,” Physicians Practice, July/August 20099. CMS Fact Sheet, op. cit.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 4
  5. Three-Stage ProcessThe process of showing meaningful use will be divided into three stages, each more difficult than the last. The Stage 1 criteria, the subject of thispaper, focus on electronically capturing health information in a coded format; using that data to track key clinical conditions; communicating thatinformation for purposes of care coordination; implementing clinical decision support tools; and reporting clinical quality measures and publichealth information.In Stage 2, the requirements for EPs and hospitals will be expanded “to encourage the use of health IT for continuous qualityimprovement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission oforders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results.”The Stage 3 criteria will “focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priorityconditions, patient access to self management tools, access to comprehensive patient data, and improving population health [emphasis added].”10The details of Stage 2 and 3 will be defined at a later stage, after policy makers have had some experience with Stage 1.Meaningful Use in Stage 1On Dec. 30, 2009, HHS published a Notice of Proposed Rulemaking (NPRM) that presented the draftregulations governing meaningful use.11 That document was accompanied by an Interim Final Rule that coveredthe standards for EHR certification and interoperability.12 On July 13, 2010, HHS issued final rules with regard toboth meaningful use and EHR certification.13Physician and hospital associations pushed back strongly against the draft regulations, saying that thetimeline was too short and that the requirements were too rigid and too difficult to meet.14 The Medical GroupManagement Association said that, taken as a whole, the criteria were “onerous” and would result in reducedphysician productivity.15The final rule on meaningful use showed that HHS had listened carefully to the complaints and had respondedto most of them. In place of the 23 criteria that eligible providers had to meet and the 25 required of hospitalsin the NPRM, the final rule stipulated 15 “core” requirements for eligible providers and 14 for hospitals.Providers may choose any five of 10 additional criteria on an optional menu and have until the end of 2012 tomeet them. (One of the optional criteria has to be a public health measure--either immunizations or syndromicsurveillance.)16The measures for both the core and optional requirements have been substantially revised. In some corecategories, such as patient demographics, vital signs, and smoking status recorded in the EHR, the requiredpercentage of the population has been reduced from 80 percent to 50 percent. Physicians need send only40 percent of their prescriptions online to pharmacies, compared to 80 percent in the original draft. Therequirement that practices import 50 percent of lab results into their EHRs as searchable data has been10. HHS/CMS, NPRM, 1852.11. HHS/CMS, NPRM, op. cit.12. Department of Health and Human Services, “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic HealthRecord Technology; Interim Final Rule,” Federal Register, 45 CFR Part 170.13. HHS/CMS, Final R ule, op. cit.14. Chris Silva, “EMR Meaningful Use Rules Need to Be More Flexible, Doctor Groups Say,” American Medical News, March 22, 2010.15. MGMA letter to Dr. David Blumenthal, re: “Proposed Establishment of Certification for Health Information Technology,” April 8, 2010, accessed at http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=33320.16. David Blumenthal and Marilyn Tavenner, “The ‘Meaningful Use’ Regulation for Electronic Health Records,” New England Journal of Medicine, July 13, 2010, accessed at http://healthcarereform.nejm.org/?p=3732&query=home.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 5
  6. transferred to the optional menu, and the However, HHS has made it clear that all ofthreshold for meaningful use is now 40 the original meaningful use criteria that havepercent of results. Also, the number of quality been scaled back or made optional will bemeasures on which physicians must report requirements in stage 2 or stage 3. At adata has been reduced to six; three are press conference, David Blumenthal, MD,mandatory and the rest must be selected National Coordinator of Health Informationfrom a list of 38 measures. 17 Technology, said that the criteria that involveThe final rule on EHR certification and electronic connectivity have been relaxedstandards allows the certification of modular temporarily until the nation’s health ITcomponents of EHRs that can qualify for infrastructure is equal to the task. But, atmeaningful use. This allows the certification that conference and in later Congressionalof various non-traditional EHRs and testimony, Blumenthal noted that thosesupplemental technologies that can aid criteria would become more stringent in thephysicians in improving quality and obtaining later stages.20government incentives. While the later requirements have yet to be drawn up, the final rule for stage 1 showsThe AMA, praised the increased flexibility in the meaningful use criteria, thechanges in the quality reporting mandate, and the elimination of requirementsrelated to claims submission and eligibility checking.Industry reaction to these changes has that HHS remains on course to deploybeen generally positive. The AMA, for meaningful use as a lever to get physiciansexample, praised the increased flexibility to use EHRs for quality improvement andin the meaningful use criteria, the changes population health management. So, inin the quality reporting mandate, and the devising strategies to meet these criteria,elimination of requirements related to claims physician groups and healthcare systemssubmission and eligibility checking.18 And the must keep the government’s ultimate goalsMGMA lauded HHS’ willingness to address in mind.industry concerns about the regulations.1917. Ibid.18. AMA press release, “AMA Pleased With Improvements to EHR Meaningful Use Requirements, But Challenges Remain to Widespread Adoption,” July 21, 2010.19. MGMA press release, “MGMA Responds to ‘Meaningful Use’ Final Rule,” July 13, 2010.20. iHealthBeat, “Administration Officials Defend ‘Meaningful Use’ Before Congress,” July 21, 2010.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 6
  7. The timeline for showing meaningful use in Stage 1 is as follows: Registration for the Medicare program begins. January 2011 For Medicaid providers, states may launch their programs if they choose. April 2011 Attestation of meaningful use begins, using data from previous three months. May 2011 EHR incentive payments begin. November 2011 Last day for eligible hospitals to register and attest to receive incentives for 2011. February 2012 Last day for eligible professionals to register and attest to receive an incentive payment for 2011.Major Barriers to Meaningful UseAlthough the final rule on EHR certification covers the technical standards required to support the meaningfuluse regulations, it does not describe how EHRs will be certified; but final temporary certification criteria havebeen established so that meaningful use can be accomplished in 2011. HHS and the certification entities itchooses will determine that. EHR vendors, naturally, are working overtime to upgrade their software to meet therequirements, and many have promised customers and potential buyers that they will able to show meaningfuluse. Unfortunately, that will not be true for most existing EHRs, unless they’re supplemented by adjunctivetechnologies.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 7
  8. Part of the problem is that today’s EMRs were outside of office visits, because only a subset physician practice decides to avoid the morenot designed for quality improvement or for of patients register on these portals and/or difficult requirements on the optional menu inmanaging the health of populations.21 For provide their e-mail addresses. stage 1, the practice will eventually be forcedexample, one of the optional requirements Other meaningful use areas in which to comply with them to show meaningful use.stipulates that eligible providers send alerts many EHRs fall short include the ability toabout needed care to 20 percent of their generate lists of patients with specific chronicpatients who are 65 or older and five or conditions or preventive-care needs; theyounger. The EHR that a particular physician ability to collect and report quality data; anduses might be able to generate these reports the ability to generate condition-specificon patients who have come into the office in educational materials for patients.recent months. But it will not be able to help Each EHR has its own strengths andthe doctor identify the patients for whom weaknesses, of course, and the ways inhe does not have this data. Nor will it be which it is used in the office environmentable to identify patients who are overdue for will dictate how many of the meaningful usepreventive and chronic care services without criteria physicians can meet. In addition, asa fair amount of customization.22 discussed below, there are problems withSmaller practices are simply not set up bad data, missing data, and non-discreteto send alerts to patients who don’t visit, data that will prevent doctors from achievingbecause it is too time-consuming and meaningful use, no matter what kind ofdifficult to track their population.23 Less technology they use.than half of larger groups are “engaged in EHR vendors will adapt their software tosubstantial activity in the quality and safety satisfy the meaningful use requirements, By combining EHRsdomains focused on the patient (patienteducators, sending patient reminders, but most of them will offer the plain-vanilla with these automatedadministering health risk assessments, and versions of the required functionality in order approaches, physicians to meet the competition. That might not behealth promotion programs).”24 Regardless good enough to achieve the government’s can show meaningfulof practice size, use of patient portals alonecannot ensure that patients receive alerts goals in stages 2 and 3. And, even if a use21. Paul A. Nutting, William L. Miller, Benjamin F. Crabtree, Carlos Robert Jaen, Elizabeth E. Stewart, Kurt C. Stange. Initial Lessons From the First National Demonstration Project onPractice Transformation to a Patient-Centered Medical Home.” Ann Fam Med 2009;7:254-260.22. Rushika Fernandopulle and Neil Patel, “How The Electronic Health Record Did Not Measure Up To The Demands of Our Medical Home Practice,” Health Affairs, April 2010, 622-628.23. Robert A. Berenson, Terry Hammons, David N. Gans, Stephen Zuckerman, Katie Merrell, William S. Underwood, and Aimee F. Williams, “A House Is Not a Home: Keeping Patients atThe Center of Practice Redesign,” Health Affairs, September/October 2008, 1219-1230.24. Diane R. Rittenhouse, Lawrence P. Casalino, Robin R. Gillies, Stephen M. Shortell, and Bernard Lau, “Measuring The Medical Home Infrastructure in Large Groups,” Health Affairs,Health Affairs 27, no. 5 (2008): 1246–1258.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 8
  9. To achieve meaningful use consistently over the five years of the incentives andto advance toward quality and population health management, physicians willhave to use supplemental technologies in conjunction with their EHRsAdjunctive Technologies medical homes and PHM, can then use this information to prepare doctors and nursesTo achieve meaningful use consistently for patient visits. Between visits, they canover the five years of the incentives and to use the population health improvementadvance toward quality and population health technology to make sure that patients getmanagement, physicians will have to use their needs addressed and come back forsupplemental technologies in conjunction follow-ups. The technology solution doeswith their EHRs. These may include the heavy lifting, increasing care managers’electronic registries; multiple outreach and productivity and allowing practices to docommunications methods; and software that more with fewer personnel.can calculate the metrics required for qualityreporting. By combining EHRs with these automated approaches, physicians can show meaningfulWhat all of these methodologies have in use, qualify for medical home certification,common—aside from the analytic software—is obtain pay for performance incentives, andthat they automate the work of monitoring, prepare themselves for the value-basededucating and maintaining contact with the reimbursement systems that are down thepatient population. Especially at a time when road. At the same time, these adjunctiveprimary-care providers are in short supply technologies enable physicians to gatherand stretched thin, it is essential to provide the quality data they will need to report tothis level of automation so that the routine, Medicare and private payers in an automatedrepetitive work can be done in the background, manner. And by giving care teams real-timerather than taking up the valuable time of data on the services that patients needdoctors and nurses. when they’re in the office, these methodsInformation on the care gaps of specific empower physicians and other clinicians topatients can be automatically generated improve quality and engage in productiveand provided to care coordinators and care conversations with patients about how theymanagers within practices. These clinical can maintain or restore their health.staffers, who are key to both patient-centeredPHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 9
  10. Supplemental PHM programs have the capability to clean up data andidentify opportunities for improving information quality.Like any computerized approach, information data will undermine the effectiveness of menu require identification of conditionstechnology designed for population health an electronic registry or another adjunctive using multiple forms of discrete data,improvement depends on the quality and technology. including medications, labs, and diagnoses.consistency of the data it uses. And the data Analytic support may also be required to For these reasons, supplemental PHMin some EHRs is seriously flawed for a variety provide positive identification. programs should have the capability toof reasons. First, some older EHRs allow clean up data and identify opportunities for To attest that a physician has gatheredanybody in a physician practice to create improving information quality. They should data on at least six of the quality measures,new data fields, leading to inconsistent and also be able to define subpopulations with practices will have to identify the numeratorimproper use of the system. The information chronic conditions, identify gaps in care, and the denominator on each metric. Formay also contain errors because of faulty and report on key quality indicators for the example, if smoking cessation advice isdata entry. Also, information that comes into leading chronic diseases. the measure, an organization must be ablean office in the form of paper documents to identify the number of smokers in theis scanned into the system, rather than Achieving Meaningful Use practice and what percentage of thosebeing entered as discrete data. And in patients received physician counseling. Despite the changes in the meaningfulmany practices with EHRs, some or all of Analytic support that is not available in an use criteria, it will still be very difficult forthe physicians still dictate much of their EHR may be required to collect this data. many physicians, especially those in smallnotes, restricting the amount of discrete practices, to show meaningful use withindata available for quality improvement and the short time frame specified to receive fullreporting. incentives. But supplemental technologiesBad or limited data can directly affect a can help in some very specific ways.physician’s ability to show meaningful use. For instance, of the 15 core measures in theFor example, EHR users are required to final rules, six require discrete, searchableprove that they documented blood pressure data on the percentage of patients who meetand body-mass index for 80 percent of their the objectives. This may be difficult to obtainpatients over 2 years old. If they don’t have because the data is missing or has beencorrect demographic data on all of theirpatients, or if one medical assistant enters entered in non-standard ways, as explained Limited data can earlier. To strengthen the data enough toblood pressure readings or BMI in a different present fairly accurate reports, practices can directly affect away than other clinicians in the practice do,it will be impossible for physicians to show run registry reports and ferret out the bad or physician’s ability to incomplete data.they met these criteria. In addition, bad EHR show meaningful use. Similarly, the patient alerts on the optionalPHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 10
  11. ConclusionThe overarching goal of the meaningful use requirements of ARRA is to facilitate the transition toreal quality improvement and population health management. For most physician practices, thiswill be very difficult to do, even if they have top-of-the-line EHRs. They will need supplementalinformation technology that automates the basic tasks of identifying, contacting, and trackingpatients who need preventive and chronic care services, coupled with reports that care teams canuse for quality improvement and reporting. By using this technology in conjunction with EHRs,physicians should be able to attain the goals of meaningful use.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 11
  12. Appendix: What follows are some examples of how a particular typeof population health management software can help EHR users showmeaningful use in Stage 1.Core Measure SupportAt least 50 percent of all unique patients seen by the EP have A general registry report shows the demographic data on alldemographics recorded as structured data patients who have been seen.For at least 50 percent of all unique patients age 2 and over seen A registry can show how many patients in those age categoriesby the EP, record height, weight, and blood pressure. have recorded blood pressure and other vital signs, including body mass index.Record smoking status for at least 50 percent of all unique patients Use general registry and condition reports generated from EHRwho are 13 or older. data and online health risk assessments.Report ambulatory quality data to CMS or to the states. A quality report can be generated by applying evidence-based protocols to registry data on the entire population and on specific subpopulations.Implement one clinical decision support rule relevant to the clinical Generate reports showing care gaps for all patients who have aquality metrics that the EP is responsible for. condition such as diabetes. Send messages to patients alerting them to contact their doctor. Show results of these efforts in the quarterly quality reports. A pending orders report prompts a specific care manager action to close a particular care gap.Measure on Optional Menu SupportGenerate at least one report listing all unique patients who have a Use condition-specific reports from the registry.specific health condition.Optional Measure SupportReminders are sent to at least 20 percent of all unique patients Evidence-based clinical protocols use registry data (includingseen by the EP who are 65 or older and five or young. problem lists) to trigger outbound messaging to patients by phone, secure email, text messages, etc.Summary of care record is provided for more than 50 percent of Patient clinical summary that includes preventive care gaps,patient transitions or referrals. lab results for chronic conditions, and health risk information is available to care teams and can be shared with patients.More than 10 percent of patients are provided patient specific Web-based, multimedia educational materials tailored to chroniceducational resources. conditions and individual risk factors.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 12

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