M-HITECH ACT• Medicare and Medicaid Health Information Technology for Economic and Clinical Health Act - Page 665 of 2009 ARRA• 19 Billion dollars for medicare/medicaid EHR HIT incentive funding• 2 Billion dollars in grants through the Ofﬁce of the National Coordinator (ONC)• comparative effectiveness research 1.1 billion
complimentary HITECH Programs• Beacon Community Program• State HIE Coop Agreement program• Healthcare IT extension program• Strategic Health IT Advanced Research Projects (SHARP) program• Community College Consortia to educate HIT pros.• Curriculum Deveopment Centers Program• Program of Assistnace for University-Based Training• Competency Examination for individuals Completing Non- Degree Training Program
conceptual approach Conceptual Approach to Meaningful Use 45&(31)+$ 3#%35), 0+1"*%)+$ %2.*.%"2$ !"#"$ &(3%),,), %"&#()$ "*+$,-"(.*/89:;2:69 67
Stage 1 priorities • Improve quality, safety, efﬁciency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health • Ensure adequate privacy and security protections for personal health informationAdapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.
I. Meaningful use of certiﬁed EHR technologyII. Information ExchangeIII. Reporting on measures using EHR Meaningful EHR User
other points• based on 75% of Medicare part B claims up to maximums, 3K bonus to qualify by 2012• must qualify by 2012 to receive max incentives• Penalties begin in 2015 1% medicare
Eligibility Requirements for Professionals• Hospital-based eligible professionals are not eligible for incentive payments. An eligible professional is considered hospital-based if 90% or more of his or her services are performed in a hospital inpatient (Place Of Service code 21) or emergency room (Place Of Service code 23) setting.https://www.cms.gov/EHRIncentivePrograms/15_Eligibility.asp#BOOKMARK1
Medicaid eligibility• Physicians - Nurse practitioners - Certiﬁed nurse-midwife - Dentist• Physician assistant who furnishes services in a Federally Qualiﬁed Health Center or Rural Health Clinic that is led by a physician assistant.• To qualify for an incentive payment under the Medicaid EHR Incentive Program, an eligible professional must meet one of the following criteria: • Have a minimum 30% Medicaid patient volume* • Have a minimum 20% Medicaid patient volume, and is a pediatrician* • Practice predominantly in a FQHC or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals• * Childrens Health Insurance Program (CHIP) patients do not count toward the Medicaid patient volume criteria.
I. Meaningful use of certiﬁed EHR technologyII. Information ExchangeIII.Reporting on measures using EHR Meaningful EHR User Stage I
certiﬁed platform• temporary certiﬁcation program - stage speciﬁc • CCHIT • Drummond group • InfoGaard• permanent cert program to follow, ? 2012• self certiﬁcation - homegrown systems
ONC-Authorized Testing andCertiﬁcation Body (ONC-ATCB)• inpatient/ambulatory• complete certiﬁcations- provides all the technologies to completely comply with MU rules• Modular certs- break down to subsets, have to have complete solution of certiﬁed “modules” http://onc-chpl.force.com/ehrcert/CHPLHome
years, but the majority (53 percent, or 1,436) said they ROBERT L. EDSALL AND KENNETH G. ADLER, MD, MMM with this Ehad up to three years of experience with the system they 11. I am The 2011 EHR Userreported on. Another 43 percent (1,169) reported more and qualif Satisfaction Survey RESPONSES FROM 2,719 FAMILY PHYSICIANSAbout the AuthorsRobert Edsall is editor-in-chief of Family Practice Management. Dr. Adler is a prac If you’re shopping for an EHR system, you might appreciate this advice fromtion technology for Arizona Community Physicians in Tucson, Ariz., a Certiﬁed Pro several hundred colleagues.ment Systems, a juror for the Certiﬁcation Commission for accepted responses Information Tec ability of the survey instrument, we Health only from AAFP members as a way of avoiding frivolouscare IT. He holds a Master of Medical Management degree and a Certiﬁcate in H responses, multiple responses per individual and other such potential sources of bias. The results are not intended to be a statistically accu-the Family Practice Management Board of Editors. Author disclosure: no relevant rate picture of EHR use among AAFP members; rather, our intent was simply to collect opinions from as many users of as many EHR systems as possible and to convey the range of responses as clearly as we could in an easily digestible form. Article Web Address: http://www.aafp.org/fpm/2011/0700/p23.html Survey results We were able to collect a total of 3,427 responses, far W more than in previous surveys. Of those, 603 were excluded because the respondents said they did not use EHR systems; 99 were excluded because they either did ith government incentive checks for not name the system they use, named a practice man- meaningful use of electronic health agement system rather than an EHR system, named a record (EHR) technology already in “home-grown” proprietary system or named something24 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | July/August 2011 the hands of some physicians and with the concomitant acceleration of computerization, it that we could not verify to be an EHR system; ﬁnally, six were excluded because the respondents indicated that seems high time for another survey of user satisfaction they had a signiﬁcant ﬁnancial interest in or afﬁliation with EHR systems. As with our three earlier surveys,1-3 with a manufacturer or vendor of an EHR program (e.g., Our intent was simply to collect opinions from instrument in an issue of Family we published the survey an ownership interest, a sizable stock purchase or involve- as many users as possible and to convey the and made an online version avail- Practice Management ment in development of the software). That left 2,719 range of responses as clearly asthrough the FPM web site.4 Again this year, in an able we could. responses for analysis. effort to maximize responses, we kept the survey short Respondents in the analysis group reported a total of
MU stage 1(2011-2012)• 90 day qualiﬁcation period in ﬁrst year • multiple practices? paper/EMR?• 1. core set (15/15 items required)- exceptions can be established ie chiropracter doesn’t prescribe, etc (limited per items with allowed exceptions) • 1-A. within core set- 3 core/alt CQM, 3 additional CQM• II. menu set - 5/10 menu items, 1 of which must be a public health item (2 choices)
Core set 1-15• 1. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. • >30% of all patients seen during the reporting period who have a medication on their medication list • exclusions: provider who writes less than 100 scripts in reporting period • has to be person capable of responding to decision support, doesn’t have to transmit ERX
• 2. Drug-Drug, Drug-allergy checks (yes/no)• 3. Active problem list in structured data • Free text doesn’t count, “no active problems” per EHR structure entry does• 4. 40% of prescriptions II-V sent electronically (faxes via EMR count) - controlled substances? • exception <100 scripts sent in 90 days
• 5. Active medication list -80%, “no active meds” counts• 6. Allergies - 80%, “no known allergies” structured counts• 7. Record demographics - 50% of unique patients, structured data • Preferred Language, Gender, Race, Ethnicity, DOB (standard nomenclature)
• 8. Record and chart changes in vital signs >50% • Height, Weight, Blood Pressure, BMI, growth charts from age 2-20 • allows attestation to exclusion if you feel out of your scope of practice• 9. Smoking status of ages 13 and older >50%• 10. submit clinical quality measures to CMS/State (medicaid)
• 11. implement one clinical decision support tool, and track compliance • yes/no • left open ended (purposefully) • in addition to drug-drug, drug-allergy checks
• 12. share health information with patient electronically (>50%) • Problem List • Diagnostic Test Results • Medication List • Medication Allergy List • 3 business days from request - calculated based on receipt of patient request • Form and format should be human readable and comply with the HIPAA Privacy Rule, as speciﬁed at 45 CFR 164.524(c). The media could be any electronic form such as patient portal, PHR, CD, USB fob, etc. EPs are expected to make reasonable accommodations for patient preference as outlined in 45 CFR 164.522(b). (ENCRYPTION!)https://questions.cms.hhs.gov/app/answers/detail/a_id/10663
• 13. provide clinical summaries for patients after each visit * • >50% of patients, within 3 business days• Clinical Summary – An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s ofﬁce contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the ofﬁce visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.
• The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certiﬁed EHR technology.• The provision of the clinical summary is limited to the information contained within certiﬁed EHR technology.• The clinical summary can be provided through a PHR, patient portal on the web site, secure e- mail, electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request.• If an EP believes that substantial harm may arise from the disclosure of particular information, an EP may choose to withhold that particular information from the clinical summary.• Providers should not charge patients a fee to provide this information.• When a patient visit lasts several days and the patient is seen by multiple EPs, a single clinical summary at the end of the visit can be used to meet the meaningful use objective for “provide clinical summaries for patients after each ofﬁce visit.• The EP must include all of the items listed under “Clinical Summary” in the above “Deﬁnition of Terms” section that can be populated into the clinical summary by certiﬁed EHR technology. If the EPs certiﬁed EHR technology cannot populate all of these ﬁelds, then at a minimum the EP must provide in a clinical summary the data elements for which all EHR technology is certiﬁed for the purposes of this program (according to §170.304(h)): o ProblemList o DiagnosticTestResults o MedicationList o MedicationAllergyList
• 14. Capability to exchange key clinical information • Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results), among providers of care and patient authorized entities electronically. • Must be separate legal entity • Patient Authorized Entities – Any individual or organization to which the patient has granted access to their clinical information. Examples would include an insurance company that covers the patient, an entity facilitating health information exchange among providers, or a personal health record vendor identiﬁed by the patient. A patient would have to afﬁrmatively grant access to these entities. • TEST ONLY. FAILING COUNTS
• 15. Protect Health Information • HIPAA security audit • can be done prior to reporting period • will require being re-evaluated per reporting period • yes/no
Menu sets• 1. implement drug-formulary checks• 2. Incorporate clinical lab-test results into EHR as structured data. (>40% of tests with numeric value or pos/neg state) • exclusion: no tests ordered during period with pos/neg or numeric value• 3. Generate patient lists by speciﬁc conditions to use for quality improvement, reduction of disparities, research, or outreach.• 4. Send patient reminders per patient preference for preventive/follow-up care. • More than 20% of all patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period.
• 5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP. • At least 10 percent of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certiﬁed EHR technology) electronic access to their health information- subject to the EP’s discretion to withhold certain information according to HIPAA.
• 6. Use certiﬁededucation resources and provide patient-speciﬁc EHR technology to identify those resources to the patient if appropriate. • >10% unique patients received patient information based on “EHR logic” to identify and suggest information based on info in EHR
• 7. The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. • >50% of transitions of care • comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. • “relevant” (provider discretion) - vs referral, patient referral, discharge, etc.
• 8. The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. • >50% of referrals have summary record
Menu set(must include one of these public health items) • 9. capability to submit data to immunization registries TEST ONLY (one of 2 public health items) • 10. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice. • *Biosense program
immunizations details• Contact Lori Sprock, MSN, APRN, Missouri Public Health Information Exchange (MoPHIE) Project, Missouri Department of Health and Senior Services at firstname.lastname@example.org (573) 526-3021. This request must come from the provider, not the vendor.• The provider should state they are preparing to apply for Meaningful Use and want to test an exchange with the Immunization Information System.• Lori will provide information on conducting the test.• The provider will need to contact their vendor to enable their system to transmit HL7 messages. The vendor should be able to provide instructions on how to do this.• The test should then be conducted with the vendor and DHSS assistance.• It is highly unlikely that the test will be successful. However, DHSS will send a letter to the provider stating they completed the test. This should satisfy the Meaningful Use requirements for 2011.• DHSS will continue working with providers and their vendors to eventually get everyone participating in successful IIS exchange. http://ehrhelp.missouri.edu/?q=node/73
Clinical Quality measures• Must include 3 core items, if those 3 don’t qualify then must use core alternates.• also select 3 additional clinical quality measures.
Core quality measures• NQF 0421 | PQRI 128 Adult Weight Screening and Follow-Up• NQF 0013 Hypertension: Blood Pressure Measurement• NQF 0028 Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention
Alternate Core - if core not germaine• NQF 0041| PQRI 110 Preventive Care and Screening: Inﬂuenza Immunization for Patients ≥ 50 Years Old• NQF 0024 Title: Weight Assessment and Counseling for Children and Adolescents• NQF 0038 Title: Childhood Immunization Status
still need 3 quality measures!• some onerous(ish) - NQF0001/PQRI 64 • Percentage of patients aged 5-40 with a diagnosis of asthma who were seen for at least 2 ofﬁce visits, who were evaluated during at least one ofﬁce visit for the frequency (number) of daytime and nocturnal asthma symptoms• some straightforward • (% of patients with A1C >9)
Attestation• 2011 is completion by individual attestation• no “automated upload” of performance/ compliance data
data thus far • >77K registrations for medicare/Medicaid• CMS presentation to • 3500 EP’s + EH’s paid via HIP policy committee medicaid incentives• data as of July 2011 • approx 1000 EP’s have been paid via medicare incentives http://ahier.blogspot.com/2011/08/ehr.html
Robert Tagalicod Director, Office E-Health Standards & Services (OESS) HIT Policy Committee August 3, 2011!""#$%%&&&()*+,-%./012(32"4-356,+67)*%
• On average, all thresholds were greatly exceeded, but every threshold had some providers on the borderline Most popular menu objectives: Drug formulary, incorporating lab test results & patient list Least popular menu objectives: Medication reconciliation & summary of care record • Little difference between Eligible Professionals (EP) & Hospitals • Little difference among specialties in performance, but differences in exclusions !"##$%&&()*+(,-.&/0123)43#5.467-,78*+&
• 2383 EPs had attested 2246 Successfully 137 Unsuccessfully • 100 Hospital had attested All successfully NOTE: This data-only analysis shows our earliest adopters who have attested, but does not inform us on barriers to attestation. !"##$%&&()*+(,-.&/0123)43#5.467-,78*+&
Eligible hospitals!"#$%&($ )$*+,*-./%$0 12%345,/ 6$+$**.3!""#$%&(%)$* +,- ,- ./-012)3(451 64701*#5(* 89- 8+- ::-;<$=3)"%>7;#3?1%55$>1 @A- .- BB-* Performance is percentage of attesting providers who conducted test
Missouri HealthNet Health Information Technology Survey Survey Findings November 3, 2010Adams-Gabbert Proprietary
EHR Adoption Survey Question # 12. Does your organization currently use an EHR system? Yes 604 No 68% No 1285 Yes 32% Total 1889 Note on Physician Counts Yes 5197 No 2932 Note: Question # 12 responses are based on total completed surveysAdams-Gabbert Proprietary 11
Findings and Observations What did we learn? ! Technology Readiness " Technology infrastructure for internet access is available " EDI and web based systems are in use statewide " Email has become the preferred method of contact " Technology support and direction is needed " Very limited use of technology for patient access ! EHR Adoption " EHR solutions today involve a wide variety of software products and tools " More detailed information and education is needed ! What does EHR deliver for my patients and my practice? " Technology support with EHR selection and implementation is needed " Costs, resource requirements to transition from paper are key concernsAdams-Gabbert Proprietary 23
Findings and Observations What did we learn? (continued)! Challenges Reaching Providers (especially physicians) " No e-mail addresses " 409 letters in returned mail for wrong address " Only 50% of records had phone numbers (of those 5% wrong numbers) " No hierarchical structure to the data. So, there was no reliable way to associate groups, clinics, or physicians to hospitals. " Inconsistent use of provider types! Other " More effective communication with providers is needed " Current provider data needs to be updated " Survey findings reinforce the need for a statewide provider repository " Future provider surveys need to be more focused
EHR Planning Survey Question # 28. What is the degree of Electronic Health Record implementation readiness in your organization? 0% 10% 20% 30% 40% 50% Implementation is not planned in the next 2 years 552 Implementation is planned in the next 3 months 34 Implementation is planned in the next 3 - 6 56 months Text Implementation is planned in the next 6 - 9 months 35 Implementation is planned in the next 9-12 months 58 Implementation is planned in the next 1 - 2 years 323 Other 227 0 100 200 300 400 500 600 Number of Responses Note: Question # 28 responses are based on total respondents who do not have EHR systemsAdams-Gabbert Proprietary 17
proposed stage 2 reqs. • most menu items transition to core • some threshold changes, other remain the same • 30% of visits have at least one electronic EP note • 30% of EH patient days have at least one electronic note by a phys., NP, or PA • 30% of EH med orders - EMAR (barcode meds)http://www.emrandehr.com/2011/01/21/great-chart-comparing-meaningful-use- stage-1-with-stage-2-and-3/
Proposed stage 2• 80% of patients offered the ability to view and download via a web based portal, within 36 hours of discharge, relevant info about EH encounters.• EP - online secure messaging in use• Patient preferences for communication medium recorded for 20% of patients• list of care team members (including PCP) available for 10% of patients in EHR• record a longitudinal care plan for 20% of “high priority” conditions
• funded by HITECH, must be sustainable after underwriting/rollout period• contracting negotiations ongoing with Cerner (primary HIE vendor)• interoperation will be an important component for later stages of MU http://www.missourihealthconnect.org/
HIT resources• Ofﬁce of the National coordinator • http://healthit.hhs.gov• Missouri HIT assistance center (REC) • http://assistancecenter.missouri.edu/• Missouri Health Connection • http://www.missourihealthconnect.org/• Attestation calendar • http://www.cms.gov/apps/ehr/
What Happens after You Sign with Missouri Health Information Technology Assistance Center?Introduction:Lorelei SchieferdeckerCenters for Medicare & Medicaid ServicesPresentation:Nancie McAnaugh, MSWCenter for Health PolicyMO HIT Assistance CenterRachel MutruxMissouri Telehealth Network
For More Information: Website: http://ehrhelp.missouri.edu E-Mail: EHRhelp@missouri.edu Phone: 1-877-882-9933