Meaningful Use          Stage One           OverviewJessica JacobsOctober 8, 2010
Medicare                                              Clinical                                                    CoreHist...
It all started with ARRA• The Health Information  Technology for Economic and  Clinical Health (HITECH) Act  of 2009 was a...
Why “Meaningful Use”?• ARRA gives out money, with some caveats:  1. Use of certified EHR in a meaningful manner  2. Use of...
The Five Pillars of Meaningful Use   Ensure Privacy and Security   Improve Population Health   Improve Safety and Quality ...
Basic Timeline    2009             2010             2011               2012               2015             2016           ...
Medicare                                              Clinical                                                    Core    ...
Eligible Providers (EPs)                                                    Medicare                                      ...
Medicaid Eligibility       Entity                       Minimum                             Formula                       ...
Medicare                                              Clinical                                                    CoreHist...
Ambulatory Incentive Structure  – Medicare: $44k/physician     • Bonuses, up to $4,400 for EPs in Health Provider       Sh...
Medicare EPs  Year MUer                                   2011                                2012                       ...
Medicare HPSA EP Bonuses     Year MUer                                2011                             2012              ...
Medicaid EPs  Year MUer                      2011                   2012                     2013                       2...
Hospital Incentive Structure• The Money:   • Two Million Dollar Base + Variable Based on     Discharges (Medicare/Medicaid...
Medicare                                              Clinical                                                    CoreHist...
Certification• Temporary Certification              Vendors Planning to Achieve  Program is in place (set to              ...
Medicare                                              Clinical                                                    CoreHist...
The Core Objectives• You Gotta Have:  – Ambulatory Providers = 15  – Hospitals = 14  – All Hospital Criteria Overlap with ...
Core Objectives – Gotta Do „em All              Maintain/Record                                           Do/Implement    ...
Menu Sets – Pick Five           Maintain/Record                           Do/Implement                         Provide/Rep...
Medicare                                              Clinical                                                    CoreHist...
Clinical Reporting Measures•   Many selected from the Physician Quality Reporting Initiative (PQRI)*     – CMS intends to ...
EP CQM• CORE SET:                       • Hemoglobin A1c Poor Control     • Heart Failure (HF): Angiotensin-        • Brea...
EP CQM• Prenatal Care: Screening for   • Smoking and Tobacco Use        • Asthma Pharmacologic        • Primary Open Angle...
Hospital CQM Requirements• Ischemic stroke – Discharge on anti-thrombotics       • Emergency Department Throughput – admit...
Medicare                                            Clinical                                                    CoreHistor...
Overview                                Medicare                          Medicaid   Implementers            Federal Level...
Overview - Requirements                           EPs80% of                      15 Core +    3 Core + 3             Certi...
Overview - Pursuit and Achievement     Providers Planning to Pursue                             Providers who will Achieve...
The Point…• This was only the first stage    – Stages Two: expected 2011, menu set becomes core, new parameters,      more...
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Meaningful Use Stage One Overview

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Overview of Meaningful Use, Stage One. Presented to Georgetown's Graduate Health Information System's class on 10/9/10.

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Meaningful Use Stage One Overview

  1. 1. Meaningful Use Stage One OverviewJessica JacobsOctober 8, 2010
  2. 2. Medicare Clinical CoreHistory v.s. Incentives Certification Quality Summary Objectives Medicaid MeasuresTHE BACK STORY 2
  3. 3. It all started with ARRA• The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was a part of ARRA Money Talks …• HITECH allocated funds to spur the adoption of electronic health records - approximately $20.8 Billion• While they’re starting with Graph Source: HIMSS Analytics Survey, September 2010, carrots, there will be sticks http://www.himss.org/content/files/vantagepoint/vantagepoin t_201009.asp?pg=1
  4. 4. Why “Meaningful Use”?• 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]
  5. 5. The Five Pillars of Meaningful Use Ensure Privacy and Security Improve Population Health Improve Safety and Quality Engage Patients and Families Coordinate Care
  6. 6. Basic Timeline 2009 2010 2011 2012 2015 2016 2021•Feb: •Jan: NPRM •Jan: States •Feb 29th: Last •Payment •Last year to •Last year to ARRA/HITECH Published can begin to day for EPs to Adjustments receive receive Become Law •March: launch their register/attest (Penalties) Medicare Medicaid•Dec: NPRM on Comment programs for FFY 2011 Begin for EPs Incentive Incentive Display Period Closes •~Jan: and eligible Payment Payment (2000 Registration hospitals comments •~March: received) Attestation •July: Final •~May: Rule Payments •August: •Nov 30th: Last Certifying day for Bodies Hospitals/CAH to register for FFY 2011
  7. 7. Medicare Clinical Core QualityHistory v.s. Incentives Certification Summary Objectives Medicaid MeasuresDO I QUALIFY? 7
  8. 8. Eligible Providers (EPs) Medicare Medicaid Eligible Professionals (EPs) Eligible Professionals (EPs) • Ambulatory MD/DO • Ambulatory Physicians (Pediatricians • Doctor of Dental Surgery or Dental have special eligibility & payment rules) Medicine • Nurse Practitioners (NPs) • Doctor of Podiatric Medicine • Certified Nurse-Midwives (CNMs) • Doctor of Optometry • Dentists • Chiropractors • Physician Assistants (PAs) who lead a • Medicaid Advantage (20 hours/week of Federally Qualified Health Center (FQHC) patient-care services for employees, or rural health clinic (RHC) 80% of time for partners) Eligible Hospitals* Eligible Hospitals • Acute Care Hospitals • Acute Care Hospitals • Critical Access Hospitals (CAHs) • Critical Access Hospitals *Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC • Children’s Hospitalshttps://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
  9. 9. Medicaid Eligibility Entity Minimum Formula Threshold Physicians 30% Pediatricians 20% Total Medicaid Encounters Dentists 30% in a 90-Day Period CNMs 30% _________________________ PAs (at FQHC) 30% Total Encounters NPs 30% in same 90-Day PeriodAcute Care Hospitals 10% Source: http://www.cms.gov/MLNProducts/downloads/EHR_Final_Rule-Childrens Hospitals -- Medicaid.pdf
  10. 10. Medicare Clinical CoreHistory v.s. Incentives Certification Quality Summary Objectives Medicaid MeasuresTHE MONEY 10
  11. 11. Ambulatory Incentive Structure – Medicare: $44k/physician • Bonuses, up to $4,400 for EPs in Health Provider Shortage Areas (HPSAs) – Medicaid: $63,750k/physician• Switching between programs: – Allowed, but only once
  12. 12. Medicare EPs 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 $24,000Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf
  13. 13. Medicare HPSA EP Bonuses 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 $2,400Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf
  14. 14. Medicaid EPs 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 $63,750Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf
  15. 15. Hospital Incentive Structure• The Money: • Two Million Dollar Base + Variable Based on Discharges (Medicare/Medicaid Share)• 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 15
  16. 16. Medicare Clinical CoreHistory v.s. Incentives Certification Quality Summary Objectives Medicaid Measures ARE YOU LEGAL? 16
  17. 17. Certification• Temporary Certification Vendors Planning to Achieve Program is in place (set to Certification expire December 2011)• Handled by external bodies• Currently there are three certifying agencies: – CCHIT – Chicago, IL. (8/30/10) • Had offered preliminary certification Graph Source: HIMSS Analytics Survey, September 2010, – Drummond Group – Austin, TX. http://www.himss.org/content/files/vantagepoint/vantagepoin (8/30/10) t_201009.asp?pg=1 – InfoGard – San Luis Obispo, CA. (9/17/10)
  18. 18. Medicare Clinical CoreHistory v.s. Incentives Certification Quality Summary Objectives Medicaid MeasuresTHE HEART OF IT 18
  19. 19. The Core Objectives• 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
  20. 20. Core Objectives – Gotta Do „em All Maintain/Record Do/Implement Provide/Report • Maintain an up-to-date • Computerized physician • Report clinical quality problem list of current and order entry (CPOE) (30%) measures to CMS or States active diagnoses (50%) • E-Prescribing (Ambulatory (2011 Attestation, 2012 • Maintain active medication Only, 40%) Electronically) list (80%) • Drug-drug and drug-allergy • Provide Patients with an • Maintain active medication interaction checks (enabled electronic copy of their allergy list (80%) whole period) health information, upon • Record and chart changes • Clinical decision support (1 request (50% within 3 days) in vital signs (50%) rule) • Provide clinical summaries • Record smoking status for • Protect electronic health for patients for each office patients 13 years or older information (whole period) visit/at each discharge (50%) (50% within 3 days) • Record demographics • Capability to exchange key (50%) clinical information among providers of care and patient-authorized entities electronically (perform at least one test)Source: http://healthpolicyandreform.nejm.org/?attachment_id=3742
  21. 21. Menu Sets – Pick Five Maintain/Record Do/Implement Provide/Report • Drug-formulary checks (whole• Incorporate clinical lab test results period) • Generate lists of patients by (50%) specific conditions (at least 1 list) • Medication reconciliation (50%)• Record advanced directives for • Summary of care record for each patients 65 years or older (Acute transition of care/referrals (50%) Only, 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)
  22. 22. Medicare Clinical CoreHistory v.s. Incentives Certification Quality Summary Objectives Medicaid MeasuresCLINICAL QUALITY MEASURES(CQM) 22
  23. 23. Clinical Reporting Measures• Many selected from the Physician Quality Reporting Initiative (PQRI)* – 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/
  24. 24. EP CQM• CORE SET: • Hemoglobin A1c Poor Control • Heart Failure (HF): Angiotensin- • Breast Cancer Screening Converting Enzyme (ACE) Inhibitor or•Preventive Care and Screening • Low Density Lipoprotein (LDL) Angiotensin Receptor Blocker (ARB) • Colorectal Cancer Screening Measure Pair: a) Tobacco Use Management and Control Therapy for Left Ventricular Systolic • Oncology Breast Cancer: Assessment b) Tobacco • Blood Pressure Management Dysfunction (LVSD) Hormonal Therapy for Stage Cessation Intervention (NQF • Diabetic Retinopathy: • Coronary Artery Disease (CAD): IC-IIIC Estrogen 0028) Documentation of Presence Beta-Blocker Therapy for CAD Patients with Prior Myocardial Receptor/Progesterone•Hypertension: Blood Pressure or Absence of Macular Edema Infarction (MI) Receptor (ER/PR) Positive Measurement (NQF 0013) and Level of Severity of • Coronary Artery Disease (CAD): Oral Breast Cancer•Adult Weight Screening and Retinopathy Antiplatelet Therapy Prescribed for • Oncology Colon Cancer: Patients with CAD Follow-up (NQF 0421, PQRI • Diabetic Retinopathy: • Heart Failure (HF): Beta-Blocker Chemotherapy for Stage III 128) Communication with the Therapy for Left Ventricular Systolic Colon Cancer Patients•ALTERNATE SET: Physician Managing Ongoing Dysfunction (LVSD) • Prostate Cancer: Avoidance•Preventive Care and Screening: Diabetes Care • Heart Failure (HF): Warfarin Therapy of Overuse of Bone Scan for Patients with Atrial Fibrillation Influenza Immunization for • Eye Exam • Ischemic Vascular Disease (IVD): Staging Low Risk Prostate Patients > 50 Years old (NQF • Urine Screening Blood Pressure Management Cancer Patients 0041, PQRI 110) • Ischemic Vascular Disease (IVD): • Foot Exam•Childhood Immunization Status Use of Aspirin or Another (NQF 0038) • Hemoglobin A1c Control Antithrombotic (<8.0%) • Coronary Artery Disease (CAD): Drug•Weight Assessment and Therapy for Lowering LDL- Counseling for Children and Cholesterol Adolescents (NQF 0024) • Ischemic Vascular Disease (IVD):• Pneumonia Vaccination Complete Lipid Panel and LDL Control Status for Older AdultsPrevention Diabetes Cardiology Cancer
  25. 25. EP CQM• Prenatal Care: Screening for • Smoking and Tobacco Use • Asthma Pharmacologic • Primary Open Angle Human Immunodeficiency Cessation, Medical Therapy Glaucoma (POAG): Optic Virus (HIV) assistance: a) Advising • Asthma Assessment Nerve Evaluation• Prenatal Care: Anti-D Smokers and Tobacco • Use of Appropriate • Low Back Pain: Use of Immune Globulin Users to Quit, b) Discussing Medications for Asthma Imaging Studies• Prenatal Care: Controlling Smoking and Tobacco Use • Appropriate Testing for High Blood Pressure Cessation Medications, c) Children with Pharyngitis Discussing Smoking and• Cervical Cancer Screening Tobacco Use Cessation• Chlamydia Screening for Strategies Women • 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 TreatmentOBGYN Psychology Respiratory Other
  26. 26. Hospital CQM Requirements• Ischemic stroke – Discharge on anti-thrombotics • Emergency Department Throughput – admitted • VTE prophylaxis within 24 hours of arrival• Ischemic stroke – Anticoagulation for A-fib/flutter patients Median time from ED arrival to ED • Intensive Care Unit VTE prophylaxis• Ischemic stroke – Thrombolytic therapy for departure for admitted patients • Anticoagulation overlap therapy patients arriving within 2 hours of symptom onset • Emergency Department Throughput – admitted • Platelet monitoring on unfractionated heparin• Ischemic or hemorrhagic stroke – Antithrombotic patients – Admission decision time to ED • VTE discharge instructions therapy by day 2 departure time for admitted patients • Incidence of potentially preventable VTE• Ischemic stroke – Discharge on statins• Ischemic or hemorrhagic stroke – Stroke education• Ischemic or hemorrhagic stroke – Rehabilitation assessment Stroke Throughput Surgery
  27. 27. Medicare Clinical CoreHistory v.s. Incentives Certification Reporting Summary Measures Medicaid Measures SO WHAT WAS THE POINT? 27
  28. 28. Overview Medicare 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) 5 types of EPs, acute care hospitals, hospitals and CAHs CAHs, and children’s hospitals 28
  29. 29. Overview - Requirements EPs80% of 15 Core + 3 Core + 3 Certified Alternative MeaningfulPatient 5 Menu EHR UseRecords Objectives CQM Hospitals80% of 14 Core + 5 15 Certified MeaningfulPatient Menu EHR CQM UseRecords Objectives
  30. 30. Overview - Pursuit and Achievement Providers Planning to Pursue Providers who will AchieveGraph Source: HIMSS Analytics Survey, September 2010,http://www.himss.org/content/files/vantagepoint/vantagepoint_201009.asp?pg=1
  31. 31. The Point…• This was only the first stage – Stages Two: expected 2011, menu set becomes core, new parameters, more HIE – Stage Three: expected 2013, likely more patient access• Adjustments are being made by CMS and will be out shortly• 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

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