Final Rule CCHIT EHR Certification - http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdfChanges to the Final Rule? Meaningful Use Objectives Clinical Quality Measures Hospital-based EPs Medicaid acute care hospitals Medicaid patient volume Medicaid programs can start in 2011 More clarification throughout
Hospital-based EPs do not qualify for Medicare or Medicaid EHR incentive payments. The Continuing Extension Act of 2010 modified the definition of a hospital-based EP as performing substantially all of their services in an inpatient hospital setting or emergency room. The rule has been updated to reflect this change.A hospital-based EP furnishes 90% or more of their services in either the inpatient or emergency department of a hospital. Clarify Medicare vs Medicare advantage charges, reimbursement, HIT difference for EHR MU impact…
Confirm 90 day rule for incentive payment initiation.
The Recovery Act specifies the following 3 components of Meaningful Use:Use of certified EHR in a meaningful manner (e.g., e-prescribing)Use of certified EHR technology for electronic exchange of health information to improve quality of health careUse of certified EHR technology to submit clinical quality measures(CQM) and other such measures selected by the Secretary Statistics – Hospitals, Medicare - Medicaid
Eligible Professionals Drug-formulary checks Incorporate clinical lab test results as structured data Generate lists of patients by specific conditions Send reminders to patients per patient preference for preventive/follow up care Provide patients with timely electronic access to their health information Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate Medication reconciliation Summary of care record for each transition of care/referrals Capability to submit electronic data to immunization registries/systems* Capability to provide electronic syndromic surveillance data to public health agencies* *At least 1 public health objective must be selected
Eligible Hospitals Drug-formulary checks Record advanced directives for patients 65 years or older Incorporate clinical lab test results as structured data Generate lists of patients by specific conditions Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate Medication reconciliation Summary of care record for each transition of care/referrals Capability to submit electronic data to immunization registries/systems* Capability to provide electronic submission of reportable lab results to public health agencies* Capability to provide electronic syndromic surveillance data to public health agencies*
January 2011 –Registration for the EHR Incentive Programs begins•January 2011 –For Medicaid providers, States may launch their programs if they so choose•April 2011 –Attestation for the Medicare EHR Incentive Program begins•May 2011 –EHR incentive payments begin•November 30, 2011 –Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011•February 29, 2012 –Last day for EPs to register and attest to receive an incentive payment for CY 2011•2015 –Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology•2016 –Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program•2021 –Last year to receive Medicaid EHR incentive payment
Meaningful Use (MU) July 2010
Meaningful Use Objectives To improve the quality, safety, and efficiency of care while reducing disparities; To engage patients and families in their care; To promote public and population health; To improve care coordination; and To promote the privacy and security of EHRs.
Final Rule Overview American Recovery & Reinvestment Act (Recovery Act) –February 2009 Medicare & Medicaid Electronic Health Record (EHR) Incentive Program Notice of Proposed Rulemaking (NPRM) Publication – January 13, 2010 NPRM Comment Period Closed March 15, 2010 CMS received 2,000+ comments Final Rule on Display –July 13, 2010 Final Rule Published –July 28, 2010http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf
EHR Incentive Final Rule Content Definition of Meaningful Use (MU) Clinical Quality Measures (CQM) Definition of Eligible Professional (EP) and Eligible Hospital/Critical Access Hospital (CAH) Definition of Hospital-based EP Medicare Fee-For-Service (FFS) EHR Incentive Program Medicare Advantage (MA) EHR Incentive Program Medicaid EHR Incentive Program Collection of Information Analysis (Paperwork Reduction Act) Regulatory Impact Analysis
Eligible Providers (EP) Medicare *Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or Washington, DC (including Maryland)
What an EP Needs to Know Providers will need to understand the meaningful use objectives and metrics, and to determine whether they’re on an EHR adoption path that will lead to Stage 1 meaningful use and beyond. Providers will need to understand the quality metric requirements, and the additional data elements their certified EHR will ultimately need to capture in order to calculate quality measure results. Providers will need to understand which incentives (Medicare, Medicaid, or both) they qualify for, and how the timing of implementations may affect their incentive value. Providers will need to know when they can expect to receive their incentive payments.
Incentive Payments for Eligible Hospitals Federal Fiscal Year $2M base + per discharge amount (based on Medicare/Medicaid share) There is no maximum incentive amount Hospitals meeting Medicare MU requirements may be deemed eligible for Medicaid payments Payment adjustments for Medicare begin in 2015 No Federal Medicaid payment adjustments Medicare hospitals: No payments after 2016 Medicaid hospitals: Cannot initiate payments after 2016
MU Modifications from Interim Rule to Final Rule 1 of 2NPRM vs Final Rule States could propose requirements above/beyond MU floor, but not with additional EHR functionality States’ flexibility with Stage 1 MU is limited to seeking CMS approval to require 4 public health-related objectives to be core instead of menu Core clinical quality measures (CQM) and specialty measure groups for EPs Modified Core CQM and removed specialty measure groups for EPs 90 CQM total for EPs 44 CQM total for EPs –must report total of 6 CQM not all electronically specified at time of NPRM All final CQM have electronic specifications at time of final rule publication 35 CQM total for eligible hospitals and 8 alternate Medicaid CQM 15 CQM total for eligible hospitals 5 CQM overlap with CHIPRA initial core set 4 CQM overlap with CHIPRA initial core set
MU Modifications from Interim Rule to Final Rule 2 of 2NPRM vs Final Rule Meet all MU reporting objectives (“all or nothing”) Must meet “coreset”/can defer 5 from optional “menu set” (flexibility) 25 measures for EPs/23 measures for eligible hospitals 25 measures for EPs/24 for eligible hospitals Measure thresholds range from 10% to 80% of patients or orders (most at higher range) Measure thresholds range from 10% to 80% of patients or orders (most at lower to middle range) Denominators –To calculate the threshold, some measures required manual chart review Denominators –No measures require manual chart review to calculate threshold Administrative transactions (claims and eligibility) included Administrative transactions removed Measures for Patient-Specific Education Resources and Advanced Directives discussed but not proposed Measures for Patient-Specific Education Resources and Advanced Directives (for hospitals) included
MU Core Set Objectives (EP)EPs –15 Core Objectives Computerized physician order entry (CPOE) E-Prescribing (eRx) Report ambulatory clinical quality measures to CMS/States Implement one clinical decision support rule Provide patients with an electronic copy of their health information, upon request Provide clinical summaries for patients for each office visit Drug-drug and drug-allergy interaction checks Record demographics Maintain an up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients 13 years or older Capability to exchange key clinical information among providers of care and patient- authorized entities electronically Protect electronic health information
MU Core Set Objectives (Hosp)Eligible Hospitals –14 Core Objectives CPOE Drug-drug and drug-allergy interaction checks Record demographics Implement one clinical decision support rule Maintain up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients 13 years or older Report hospital clinical quality measures to CMS or States Provide patients with an electronic copy of their health information, upon request Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request Capability to exchange key clinical information among providers of care and patient- authorized entities electronically Protect electronic health information
Core Sets & Measurements 1 of 4 MU Objective Core Set MU Objective MeasureRecord patient demographics (sex, race, ethnicity, More than 50% of patients’ demographic data recordeddate of birth, preferred language, and in the case as structuredof hospitals, date and preliminary cause of death datain the event of mortality)Record vital signs and chart changes (ht, wt, BP, More than 50% of patients 2 years of age or older haveBMI, growth charts for children) ht, wt, and BP recorded as structured dataMaintain up-to-date problem list of current and More than 80% of patients have at least one entryactive diagnoses recorded as structured dataMaintain active medication list More than 80% of patients have at least one entry recorded as structured dataMaintain active medication allergy list More than 80% of patients have at least one entry recorded as structured dataRecord smoking status for patients 13 yrs of age More than 50% of patients 13 years of age or olderor older have smoking status recorded as structured dataFor individual professionals, provide patients with Clinical summaries provided to patients for more thanclinical summaries for each office visit; for 50% of all office visits within 3 business days; more thanhospitals, provide an electronic copy of hospital 50% of all patients who are discharged from thedischarge instructions on request inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it
Core Sets & Measurements 2 of 4 MU Objective Core Set MU Objective MeasureOn request, provide patients with an electronic More than 50% of requesting patients receivecopy of their health information (including electronic copy within 3 business daysdiagnostic test results, problem list, medicationlists, medication allergies, and for hospitals,discharge summary and procedures)Generate and transmit permissible prescriptions More than 40% are transmitted electronically usingelectronically (does not apply to hospitals) certified EHR technologyComputer provider order entry (CPOE) for More than 30% of patients with at least one medicationmedication orders in their medication list have at least one medication ordered through CPOEImplement drug–drug and drug–allergy Functionality is enabled for these checks for the entireinteraction checks reporting periodImplement capability to electronically exchange Perform at least one test of EHR’s capacity tokey clinical information among providers and electronically exchange informationpatient-authorized entitiesImplement one clinical decision support rule and One clinical decision support rule implementedability to track compliance with the ruleImplement systems to protect privacy and security Conduct or review a security risk analysis, implementof patient data in the EHR security updates as necessary, and correct identified security deficiencies
Core Sets & Measurements 3 of 4 MU Objective Core Set MU Objective MeasureReport clinical quality measures to CMS or states For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measuresImplement drug formulary checks Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting periodIncorporate clinical laboratory test results into More than 40% of clinical laboratory test results whoseEHRs as structured data results are in positive/negative or numerical format are incorporated into EHRs as structured dataGenerate lists of patients by specific conditions to Generate at least one listing of patients with a specificuse for quality improvement, reduction of conditiondisparities, research, or outreachUse EHR technology to identify patient-specific More than 10% of patients are provided patient-specificeducation resources and provide those to the education resourcespatient as appropriatePerform medication reconciliation between care Medication reconciliation is performed for more thansettings 50% of transitions of careProvide summary of care record for patients Summary of care record is provided for more than 50%referred or transitioned to another provider or of patient transitions or referralssetting
Core Sets & Measurements 4 of 4 MU Objective Core Set MU Objective MeasureSubmit electronic immunization data to Perform at least one test of data submission and follow-immunization registries or immunization up submission (where registries can accept electronicinformation systems submissions)Submit electronic syndromic surveillance data to Perform at least one test of data submission and follow-public health agencies up submission (where public health agencies can accept electronic data)Additional choices for hospitals and critical access hospitalsRecord advance directives for patients 65 years of More than 50% of patients 65 years of age or olderage or older have an indication of an advance directive status recordedSubmit of electronic data on reportable laboratory Perform at least one test of data submission and follow-results to public health agencies up submission (where public health agencies can accept electronic data)Additional choices for eligible professionalsSend reminders to patients (per patient More than 20% or patients 65 years of age or older or 5preference) for preventive and follow-up care years of age or younger are sent appropriate remindersProvide patients with timely electronic access to More than 10% of patients are provided electronictheir health information (including laboratory access to information within 4 days of its being updatedresults, problem list, medication lists, medication in the EHRallergies)
MU / HIE Requires 7 different HIE interactions (in bold) Stage 1 Meaningful Use and implies at least 10 othersCore (14 “must meet” requirements for Hospitals, 15 for other “Eligible Providers”)Use CPOE for medication orders Implied (especially for EPs - otherwise order would not be transmitted)Implement drug-drug, drug-allergy checking No requirement, but easier with HIE ServicesGenerate and transmit e-Rx (not required for hospitals) E-prescribing, direct or third partyRecord demographicsMaintain up-to-date problem/diagnosis listMaintain active medication list No requirement, but easier with HIEMaintain active medication allergy listRecord and chart vital signsRecord smoking statusImplement 1 clinical decision support ruleReport ambulatory quality measures to CMS Submission required in 2012Provide patients w/electronic copy of records on request Not specified, but implied for non-tethered PHRProvide patients w/visit summaries / discharge instructions Not specified, but implied for non-tethered PHRCapability to exchange key clinical info Perform a single valid testProtect EHR information / conduct a security risk analysisMenu (all providers must select 5 to meet from a list of 10)Implement drug formulary checks No requirement, but easier with e-prescribingRecord advance directives for patients 65 or olderIncorporate clinical lab test results into EHR No requirement, but easier with HIEGenerate patient lists by conditionSend patient reminders Implied (based on patient preference)Provide patients with timely electronic access to their health records Not specified, but implied for non-tethered PHRProvide patient-specific education resourcesPerform medication reconciliation No requirement, but easier with HIEProvide summary care record for transition/referral Send, receive and display readable CCD/CCRCapability to submit immunizations Perform a valid test if enabled by registryCapability to submit reportable lab results Perform a valid test if enabled by public health agencyCapability to provide syndromic surveillance Perform a valid test if enabled by public health agency
Meaningful Use Summary 1 of 5 Supports the management of medication orders,Computer Provider Order Entry (CPOE) provider referrals, blood bank orders, provider consults and more. Supports real-time alerts at the point of care for drug contraindications; formulary or preferred drug list Drug/allergy checks checks; modifiable user rights; and tracking user actions. Records, modifies, and retrieves a patient’s problem list Maintain a problem list of diagnoses (based on ICD-9-CM “ICD-10-CM 2013” or SNOMED CT®) over multiple visits. Enables the provider to electronically transmit E-prescribing prescriptions. Records, modifies, and retrieves a patient’s active Medication list medication list.
Meaningful Use Summary 2 of 5 Records, modifies, and retrieves a patient’s active Allergy list allergy list. Supports electronically recording, modifying, and Record demographics retrieving patient demographic data. Enables a user to electronically record, modify, and Record and chart vital signs retrieve a patient’s vital signs; automatically calculate BMI; and plot growth charts for patients 2-20 years old. Records, modifies, and retrieves the smoking status for Smoking status patients 13 years old or older. Enables the provider to receive clinical lab test results; display test reports and tests that have been receivedIncorporate clinical lab-test results with LOINC® codes; and update a patients record based
Meaningful Use Summary 3 of 5 Allows the provider to create a list of patients and Patient lists patients’ clinical information based on specific conditions. Supports the calculation and display of quality measureAmbulatory quality measures results and electronically submit calculated quality measures. Generates a patient reminder list for preventive or Patient reminders follow-up care. Supports the implementation of clinical decision support rules by specialty; generates real-time alertsClinical decision support rules based upon those rules; and generates a list of alerts responded to by user. Electronically records and displays patients’ insurance Insurance eligibility eligibility and submits insurance eligibility queries.
Meaningful Use Summary 4 of 5 Electronic claims submission Allows a provider to electronically submit claims. Enables a user to create an electronic copy of a patient’s Patient health information clinical information and provide it through electronic means. Provides patients with online access to their clinicalElectronic access to health information information within 96 hours of the information being available. Provides patients with clinical summaries of each office Clinical summaries visit in paper or electronic form. Enables a provider to electronically receive a patient Receive clinical information summary record from other providers and organizations.
Meaningful Use Summary 5 of 5 Enables a provider to electronically transmit a patient Transmit clinical information summary record to other providers and organizations. Generates complete medication reconciliation of two or Medication reconciliation more medication lists into a single medication list that can be displayed in real-time.Electronic submission to immunization Supports the record, retrieval, and transmission of registries immunization information to immunization registries. Supports the recording, retrieval, and transmission ofElectronic syndromic surveillance data syndrome-based (e.g., influenza like illness) public health surveillance information. Allows verified users access to health information in an emergency; terminates after inactivity; encrypts andElectronic health information security decrypts information; tracks a users actions.
EHR Incentive Timeline January 2011 –Registration for the EHR Incentive Programs begins January 2011 –For Medicaid providers, States may launch their programs if they so choose April 2011 –Attestation for the Medicare EHR Incentive Program begins May 2011 –EHR incentive payments begin November 30, 2011 –Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011 February 29, 2012 –Last day for EPs to register and attest to receive an incentive payment for CY 2011 2015 –Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology 2016 –Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program 2021 –Last year to receive Medicaid EHR incentive payment
Acronyms ACA –Patient Protection and Affordable Care Act A/I/U –Adopt, implement, or upgrade CAH –Critical Access Hospital HPSA –Health Professional Shortage Area MA –Medicare Advantage CCN –CMS Certification Number MCMP –Medicare Care Management Performance CHIPRA –Childrens Health Insurance Program Demonstration Reauthorization Act of 2009 MU –Meaningful Use CMS –Centers for Medicare & Medicaid Services NCVHS –National Committee on Vital and Health CNM –Certified Nurse Midwife Statistics CPOE –Computerized Physician Order Entry NP –Nurse Practitioner NPI –National Provider Identifier CQM –Clinical Quality Measures NPRM –Notice of Proposed Rulemaking CY –Calendar Year OMB –Office of Management and Budget EHR –Electronic Health Record ONC –Office of the National Coordinator of Health EP –Eligible Professional Information Technology eRx –E-Prescribing PA –Physician Assistant PECOS –Provider Enrollment, Chain, and Ownership FFS –Fee-for-service System FQHC –Federally Qualified Health Center PPS –Prospective Payment System (Part A) FFY –Federal Fiscal Year PQRI –Medicare Physician Quality Reporting Initiative HHS –U.S. Department of Health and Human Services Recovery Act –American Reinvestment & Recovery Act of HIT –Health Information Technology 2009 RHC –Rural Health Clinic HITECH Act –Health Information Technology for Economic RHQDAPU –Reporting Hospital Quality Data for Annual and Clinical Health Act Payment Update HITPC –Health Information Technology Policy Committee TIN –Taxpayer Identification Number HIPAA –Health Insurance Portability and Accountability Act of 1996