Mu Presentation Jitesh Chawla


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Brief overview of EMRs and CMS Incentive Program

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  • Poll #1Do you understand the meaningful use concept and what the requirements are to get incentive payments?Yes, I understand fully No, I don’t understand at allI understand somewhat but need to learn a lot more
  • Many of you may wonder, where did MU come from? Here’s a brief overview and this may allow you to make sense of why right now is a very crucial time for your practices.On February 17, 2009, President Barack Obama signed the American Recovery and Reinvestment Act (ARRA) which came from amendments of the Social Security Act and called for incentive monetary payments through CMS to eligible providers/hospitals who use a certified HER in a meaningful way (will discuss what MU consists of in upcoming slides) Health IT for Economic and Clinical Health Act (HITECH) is composed of different provisions of the ARRA legislation and allocated $19.2 billion toward health IT. Under this Act providers can get assistance, tools, and resources to allow for implementation and utilization of electronic health records.The next logical question is then:Why is the federal government investing money into healthcare IT?The thought is that the structured use of data in a meaningful way can help in achieving the optimal delivery of healthcare, largely indicated by the 5 key goals indicated in the slide. Namely those are:Ensuring safety and quality, ensuring patient engagement, improving the health status of populations, improving coordination of care and enhancing safety, quality and efficiency in patient care. Take for example, the MU objective of updating allergy to medication. If a medication list of a particular patient indicates s/he had anaphylaxis reaction to penicillin then you wouldn’t give that drug (improves safety and quality) and neither would your nurses or a subsequent provider (efficiency).Another MU objective is demonstrating the ability to exchange key clinical information. In example could be a multidisciplinary team taking care of a diabetic patient with an ulcer. The family doctor could be attending the patient but needs help from the surgeon and wound care nurse, both of which may not see the patient till later. Thus, coordination of care is needed and exchanging key clinical information may be crucial for that to occur.
  • Refers to using the electronic health record in a “meaningful way” which is done by satisfying criteria in objectives and measures.The electronic health record must have certain functional features and qualified through certain certify bodies.These objectives can be “core” which are the main ones and 15 to satisfy. Additionally “menu set” which are optional picked a menu of 10 different ones of which 5 must be satisfied. There are 3 core measures which all need to be satisfied and 3 out of 38 additional quality measures of which X need to be satisfied.The reporting will be done to CMS. In the year 2011 only need to attest –aggregate data will be accepted. Starting in 2012 data on individual patients will need to be electronically sent.CMS will pay the incentive money through additional reimbursement. Must choose to get money through Medicare or Medicaid. For Medicare will be allowed up to 75% of allowable charges thereby must see a certain number of Medicare patients to get benefit.
  • CMS defines the eligible providers under Medicare or Medicare. As you can see in the Venn diagrams it is very clear which incentive program you would qualify under depending on your title. Some fall in either – MDs, DO s or DMDs. For Pas under Medicaid you must work in a federally qualified health center or rural assistance center
  • From a logistic standpoint, practices must be wondering what are my resources as undertake this project of getting a certified HER and then using it in a meaningful way. Therefore, it is important to understand who the key organizations are that you will be interacting with.CMS- of course, will be the one you will be reporting to. They outline the criteria you need to fulfill and monitor compliance. The incentive money will come from them (and we will discuss how you get the money and how much in the following slides)Authorized and testing certification bodies. So far, the ONC (which is the federal government agency overseeing national health IT activities) has approved 3 ATCBs. Your EHR must be certified through them. A lot of vendors will alreadyHave them certified before selling to you. Some companies such as Patagonia are building MU compliant EHRs and so certification is very quick and easy. Basically, the ATCB will check your HER for certain functional features (which we won’t get into during this presentation but I will be happy to mention these during the Q and A.)Finally, the ONC has set up Regional Extension Centers throughout the country. They are support centers that answer questions about HER implementation, MU and related topics. They guide through implementation and help you comply with MU requirements.
  • Everything electronic so time saved- no pulling charts, transcription costs saved 2. Not only CMS will provide money now but private insurers moving in that directionDesktop can show schedule, who checked in, view of chart, different screens – results, demographics, toggle betweenb. Data in codes- diagnosis (ie. diabetes ICD-9 250), procedures CPT, linked to medications NDC, labs LOINC. Good for retrievel.Coded data vs. free text argument. Former good for reporting, latter emulates natural tendency. Note writer. NLP?3. Physician do one thing, nurse another at same time b. help make tough diagnosis, treatment decisions (esp if information resource links), also reminders (50 with HF, need colon cancer test); (21 y/o worried about STD, need PAP); correct errors (case of BP 10/826), pop up, flashing, u choose mediumc. During assessment diagnosis with code given. E/M coding easy. Some program guide through if enough data elements (ie. level 4 visit). Can check off stuff. Medication list updated will satisfy MU. (Zip thru medicare physical (ROS) vs. benefit to sometimes go through such as complicated HPI for not missing stuff)
  • Templates provide fields to put in data needed for documenting certain conditions –ie. diabetes. Interfaces provide lab data directly into 2. Provider inputs vs. what the nurse would do.2. Point over certain features –tells what features. Vendors provide good IT support3. Buttons that will lead you to do perform certain functions, less clicks, PatagoniaPoll question #2What is your greatest challenge with satisfying the requirements to get incentive payments?CostWorkflowNot enough staff to input data, generate reportsToo complicated to use HER softwareStaff resistanceOther
  • After this slide- poll question #3You are still using a primarily paper based system?1. Yes, not convinced on changing to an EHR 2. Yes, in process of changing to an EHR 3. Using an EHR currently
  • EHRs organize can see snapshot of one patient or the panel of patients (latter important for reporting numerator/denominator – MU)Information is all there. Can run reports- thereby the important of linking data (through codes)
  • Going to do this for a clinical indication anyway. Why not get credit for it anyways
  • (need to finish today before meeting)
  • Last polling questionWhy is change so difficult?FearDon’t feel the need toLazyOther
  • These are the amounts that would be added to the Medicare payments shared in the earlier slide. Sometimes, practices in rural areas say they have financially tougher time with additional investments such as electronic records, but this additional income hopefully, this should help them with that.
  • Some key differences in Medicaid as compared to Medicare reimbursement are:The total doesn’t change depending when you startDon’t have to satisfy the MU criteria in a given year, can start over in another year and still get the moneyCan skip years, ie. start in 2011, take 2012 off and then re-start in 2013To qualify must have certain amount of patient panel as Medicaid pts. (20% for everyone, except pediatricians which would be 30%).
  • This is a table from the ONC that lists the functional features that are tested by the certifying bodies when approving your EHR. Notice that many of the functionalities directly address the objectives or measure criteria you must achieve in order to get the money. Additionally, several technological features such as security measures (that HITECH requires) are included.
  • (planning to add a nice screen shot here and website link to CMS)All providers must: • Register via the EHR Incentive Program website • Be enrolled in Medicare FFS, MA, or Medicaid (FFS or managed care) Be enrolled in the CMS Provider Enrollment, Chain and Ownership System (PECOS) for Medicare• Have a National Provider Identifier (NPI) • Use certified EHR technology to demonstrate Meaningful Use
  • Mu Presentation Jitesh Chawla

    1. 1. SATISFYING MEANINGFUL USE REQUIREMENTS Focus on Logistic Concerns In Physician Practices By: Jitesh Chawla, MD Chief Medical Information Officer Patagonia Health, Inc.
    2. 2. IMPORTANCE OF THIS DISCUSSION Facilitators to Broad Adoption of Health IT
    3. 3. TOPICS TO COVER1 Quick recap of MU2. Common Concerns regards to achieving MU objectives3. Solutions to these Concerns4. Where MU fits into regular care5. Why change is difficult
    4. 4. WHERE MEANINGFUL USE CAME FROM AND WHY THE FEDS CARE ABOUT THISSocial Security Act ARRA (stimulus bill) HITECH Safety, Quality and Efficiency Privacy and Coordination of Patient Five Key Goals in the US Security Engagement Care Healthcare System (Hersh, 2010) Health Status of Populations
    5. 5. HOW DOES THIS INCENTIVE PROGRAM WORK?• Usage of the electronic health record• Certification through accreditation bodies• Compliance tracked through CMS• Money given through EHR incentive program
    6. 6. HOW MUCH MONEY CAN I GET? (source: CMS)• Under Medicare: Maximum of $42,000• Under Medicare in areas of shortage: Maximum of $4,400• Under Medicaid: Maximum of $63,750
    7. 7. AM I ELIGIBLE? (SOURCE: CMS) Medicare Doctor of MedicineDoctor of Optometry, Doctor of Osteopathy Doctor of Dentistry Medicaid Doctor of Podiatry, or Dental Surgery Nurse Practitioners, Chiropractor Certified Midwives, Physician Assistants in FQHC or RAC
    9. 9. STAGES OF MEANINGFUL USE (SOURCE: CMS) • Data Capture and SharingStage 1 • 2011-2013 • Advanced Clinical ProcessesStage 2 • 2013-2015 • Improved Quality Measure ReportingStage 3 • 2015 and Beyond
    10. 10. ACHIEVING THE OBJECTIVES Common Concerns Include:Cost of EHR (NEJM, 2009) or MU implementation 1. Cuts other costs 2. Plans starting to reimburse for using EHRHampering proper workflow (CSC, 2009) 1. EHRs organize a. Partitioned chart b. Codified data 2. Improves efficiency a. Allows multiple users b. Decision Support c. Documentation at point of care d. Smart text
    11. 11. ACHIEVING THE OBJECTIVESNot enough staff 1. Auto populated data 2. Provider main userToo complicated (HIMSS, 2010) 1. Data prompting 2. Help screens / IT support 3. MU compliant EHR
    12. 12. CASE EXAMPLE: CORE OBJECTIVE 12 (PAPER BASED VS. EHR) Objective: Provide Patients with electronic copy of their health information upon requestTask or Constraint Paper Based Using EHRGathering information Multiple charts, staff time Click of a buttonCompiling information Staff time, prone to error Click of a button3 day time limit Interrupts work flow Not an issueNeed HIPPA consent Consent form passed At point of care around
    13. 13. HOW MUCH EXTRA WORK IS IT, REALLY? (SOURCE: CMS)Objective # Task Most Doing already8 Record Demographics X10 Maintain Active Medication List X11 Maintain Active Allergy List X12 Record Vital Signs XObjective # Benefit to you Additional investment2 E-prescribing Less Rx errors iPad, PDA, EHR module9 Record Smoking Represents 2 minutes status quality6 Provide clinical Happy patient Few clicks of a button summaries to patient
    14. 14. ACHIEVING AN OBJECTIVE/MEASURE: SUGGESTED SOLUTION Quality Measure Diabetic patients from 18 to 75 years old with high levels of hemoglobin A1c Patients more than 50 years old who received a flu vaccine Patients older than 18 with diagnosis of diabetic retinopathy with documentation or absence of macular edemaIssues:Where do I get all this information? Lab report screen, Immunization Screen, Document notes screenWho gathers the information? Provider – no need for staff helpHow do I incorporate this into workflow? Little to no change-at point of care
    15. 15. IS MU PART OF ROUTINE CARE?Scenario Task Staff MU Criteria ResponsibleLast A1c 3 months ago. Fasting 140s, PP 250. Record A1cs Lab Tech AdditionalHere for routine check and ER F/U QualityGot new lipid medication as LDL was >100, not Update Provider/ Coreon ASA, d/c metformin Medication List Nurse Objective 5New dx of post MI and started on beta blockerPatient has rapidly rising creatinine but needs Use Clinical Provider CoreACEI due to CHF most MI. Needs to help to Decision Support Objectivedecide if should use ACEI and, if yes, what dose 12to start with
    16. 16. “The EHR should not duplicate (ofteninefficient) paper‐based workflow butinstead be implemented to achieve new efficiencies as well as quality and safety of care” (Kilo)
    17. 17. SUMMARY1. Utilizing EHRs can help, not hinder your practice2. Achieving MU is not difficult if you leverage the EHR’s capabilities3. Time to start is now, money is on the line4. Help is available, just call
    19. 19. QUESTIONS ?• Jitesh Chawla, MD Chief Medical Information Officer• Abhi Muthiyan Chief Technology Officer
    20. 20. APPENDIX: ADDITIONAL PAYMENT FOR MEDICARE EPS IN HEALTHCARE SHORTAGE AREAS (Source: CMS)Year 2011 2012 2013 2014 20152011 1,800 - - - -2012 1,200 1,800 - - -2013 800 1,200 1,500 - -2014 400 800 1,200 1,200 -2015 200 400 800 800 02016 - 200 400 400 0Total 4,400 4,400 3,900 2,400 0
    21. 21. APPENDIX: HOW MUCH MONEY CAN I GET?Under Medicaid: (Source: CMS)Year 2011 2012 2013 2014 2015 20162011 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 21,2502016 8,500 8,500 8,500 8,500 21,2502017 8,500 8,500 8,500 8,500 8,5002018 8,500 8,500 8,500 8,5002019 8,500 8,500 8,5002020 8,500 8,5002021 8,500Total 63,750 63,750 63,750 63,750 63,750 63,750
    22. 22. Federal EHRCertificationRequirements
    23. 23. APPENDIX: HOW DO I GET STARTED?• Information Needed:• 1. Name of the Eligible Provider• 2. National Provider Identifier (NPI)• 3. Business address and business phone• 4. Taxpayer Identification Number (TIN) to which the provider would like the• incentive payment made to• 5. Medicare or Medicaid program selection (may only switch once after• receiving an incentive payment before 2015) for EPs• 6. For Medicaid providers, selecting which state want to file under.
    24. 24. HOW DO I GET STARTED? 1. Enroll in CMS payment programs 2. Enroll in PECOS 3. Register for EHR Incentive program