Austin

Meaningful Use Stage 2 and Meaningful Use
Audit Insight
Liz Johnson, MS, FHIMSS, CPHIMS,
RN-BC

December 12, 2013
...
TOPICS
Meaningful Use Stage 2 Core Measures
- A road to success

2014 Clinical Quality Measures
- The challenges and sol...
Supporting Continuous Quality
Improvement

Stage 3
Stage 2
Stage 1
Data capture
and sharing

Advanced Clinical
Processes &...
Highlights - Stage 2 Meaningful Use
Impact on MU Program
–
–
–
–

Reporting Periods for FFY 2014 changed
Penalties defini...
Stage 2 Core Measures
Core Objective
1. CPOE for Med,
Lab and Rad Orders

Measure is Changing
From “this” to “this”
•

Thr...
Stage 2 Core Measures
Core Objective

Measure is Changing
From “this” to “this”

Managing the
Change at Tenet

Increase fr...
7
Stage 2 Core Measures
Core Objective
5. Implement
Clinical Decision
Support
Interventions

Measure is Changing
From “this”...
Requirements
– Implement five clinical decision support interventions
related to four or more clinical quality measures at...
Requirements: Interventions and Triggers
 An intervention is evidence-based and is linked to referential supports.
 The ...
Stage 2 Core Measures
Core Objective

Measure is Changing
From “this” to “this”

Managing the
Change at Tenet

Challenges
...
Stage 2 Core Measures
Core Objective

Measure is Changing
From “this” to “this”

9. Provide
patients the
ability to view
o...
Current Workflow for “View and Download”
Each patient will be
asked at admission if
they would like to set
up a portal (op...
Stage 2 Core Measures
Core Objective

10. Patient specific education

Measure is Changing
From “this” to “this”
•

•
•

No...
Patient Specific Education
Change in Requirements – Only count education if identified by CEHRT
Patient Education Form Rev...
Stage 2 Core Measures
Core Objective
11. Medication
Reconciliation

Measure is Changing
From “this” to “this”
•

•

No cha...
Stage 2 Core Measures
Core Objective
12. Transition of
Care Summary
(Summary of
Care)

Measure is Changing
From “this” to ...
Electronic Summary of Care Document
Work with
your vendor

HUB 1
Cerner
HISP *

OPS Job
Creates CDA
document on
scheduled ...
Stage 2 Core Measures
Core Objective
13. Capability to
submit
immunizations
data to registries
or immunization
information...
Stage 2 Core Measures
Core Objective

Measure is Changing
From “this” to “this”

Managing the
Change at Tenet
Tenet is imp...
Stage 2 Core Measures
Core Objective
16. Security Risk
Analysis

Measure is Changing
From “this” to “this”
•

Managing the...
Stage 2 Menu Measures (3 of 6 required)
Core Objective

Measure is Changing
From “this” to “this”

Managing the
Change at ...
Stage 2 Menu Measures (3 of 6 required)
Core Objective

Measure is Changing
From “this” to “this”

Managing the
Change at ...
TOPICS
• Meaningful Use Stage 2 Core Measures
- A road to success

• 2014 Clinical Quality Measures
- The challenges and s...
2014 Clinical Quality Measures - Key Themes
• Beginning in 2014, reporting of Clinical Quality Measures (CQM) will
be inde...
Clinical Quality Measure Changes
Domains

# of

New

Existing •

Measures

EHs and CAHs must report on 16 of the 29
CQMs

...
Tenet’s MU CQMs Chosen for 2014 Reporting
VTE

Stroke

ED

VTE-1: Prophylaxis within 24 hours
of admission

Stroke-2: Disc...
TOPICS
Meaningful Use Stage 2 Core Measures
- A road to success
2014 Clinical Quality Measures
- The challenges and solu...
Tenet

29
Just the Facts
The Center for Medicare and Medicaid have established a process for program
audits under the final rule:
CM...
Have the documents of
evidence always at the
ready:
CMS recommends that eligible hospitals, eligible professionals and cri...
Who are the Auditors?
Medicare - CMS and its contractor, Figliozzi and Company, are

performing audits on Medicare and dua...
The Audit Request Letters
Dear Tenet…

33
What we are seeing in the letters:
Proof required for attestation items:
– Screen shots of dictionary settings to show eve...
What we are seeing in the letters:
Specific to Medicaid:
• Must prove you completed your adoption, implementation or
upgra...
36
Contact Information
LIZ JOHNSON, MS, FHIMSS, CPHIMS, RN-C
Vice President, Applied Clinical Informatics and CCIO
Tenet Heal...
APPENDIX

38
Objectives from Stage 1 to Stage 2

Although total number of objectives stay the same between Stages, the number
of measur...
Stage 2 CQM Measures (14)
Hearing screening prior to hospital discharge (EHDI-1a)
AMI-2: Aspirin Prescribed at Discharge f...
Care
Coordination
Domain
Efficient Use of
Healthcare
Resources
Domain

Stage 2 CQM Measure (2)
Stroke-10: Ischemic or hemo...
Stage 2 CQM Measure (6)
VTE-1: Venous Thromboembolism Prophylaxis *

Patient Safety
Domain
*Stage 1 CQM currently tracked
...
EH Audit Response
This is How Tenet Does It

43
Tenet Audit Response Process (Medicare)
• Receive notification of Audit
Alert!

Take
Action

• Communicate Audit to Tenet ...
Tenet EH Audit Response
First request for additional information
Approximately 3 weeks after submitting initial materials,...
Tenet EH Audit Response
Second request for additional information
Approximately one month later, Tenet received another re...
Success!
Determination letter received on October 23, 2012 approximately 3 weeks
after the last information request, 3 mon...
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Health IT Summit Austin 2013 - Keynote Presentation "Meaningful Use Stage 2 and Meaningful Use Audit Insight"

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Keynote Presentation "Meaningful Use Stage 2 and Meaningful Use Audit Insight"

Think far beyond just threshold increases. The differences between Meaningful Use (MU) Stage 1 and Stage 2, including the 2014 Clinical Quality Measures, are technically and clinically challenging. And just when you thought you could safely look at Stage 1 in the rearview mirror, here come the audits! I will highlight the Stage 1 and Stage 2 differences and talk about the challenges they have initiated at Tenet. I will touch on the impact of Quality measures and will also provide you with insight into the basics of MU Audits and will take you through the actual audit experience at Tenet.

Learning Objectives:

∙ Review the program and measure changes from Stage 1 to Stage 2 and how the changes are being managed at Tenet
∙ Provide insight into the 2014 Clinical Quality Measures chosen by Tenet, the challenges posed, solutions that work and a little about the overall
impact of Quality measures
∙ Discuss Meaningful Use Audits, covering the basics as well as providing the benefit of the Tenet experience

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Health IT Summit Austin 2013 - Keynote Presentation "Meaningful Use Stage 2 and Meaningful Use Audit Insight"

  1. 1. Austin Meaningful Use Stage 2 and Meaningful Use Audit Insight Liz Johnson, MS, FHIMSS, CPHIMS, RN-BC December 12, 2013 VP of Applied Clinical Informatics and CCIO Tenet Healthcare Corporation ONC Health Information Technology Standards Committee Member Modern Healthcare Top 25 Clinical Informaticist 2010, 2011 & 2012
  2. 2. TOPICS Meaningful Use Stage 2 Core Measures - A road to success 2014 Clinical Quality Measures - The challenges and solutions Meaningful Use Audits - The basics 2
  3. 3. Supporting Continuous Quality Improvement Stage 3 Stage 2 Stage 1 Data capture and sharing Advanced Clinical Processes & decision support Improved Outcomes Enabling:  Better clinical outcomes  Patient Engagement  Improved population health  Increased transparency 3
  4. 4. Highlights - Stage 2 Meaningful Use Impact on MU Program – – – – Reporting Periods for FFY 2014 changed Penalties definition clarified Limited options for menu (5/10 vs. 3/6) Expansion of CQMs to 29 (select 16) and linked to Clinical Decision Support Impact on Measures – – – – – – – – Patient Engagement is real eMAR is now required eRx and Progress notes are now options CPOE increased thresholds and definition Medication Reconciliation is now part of Core Rolled up multiple measures (problem list, med list, med allergy list into other measures) Expanded Summary of Care document with electronic exchange component (beyond the sandbox) Eliminated “capability to exchange key clinical information” measure Impact on Standards and Certification – New 2014 Edition of Certified EHR Technology (CEHRT) – Standard changes for Smoking Status, new standard for Preferred Language 4
  5. 5. Stage 2 Core Measures Core Objective 1. CPOE for Med, Lab and Rad Orders Measure is Changing From “this” to “this” • Threshold increased from 30% to 60% for use of CPOE for medication orders, 30% of laboratory, and 30% of radiology • Denominator changed from “unique patient” and “at least one medication” to “all medications orders” Managing the Change at Tenet Challenges Continuing to use our dashboard reporting and adoption strategy (corporate –to- hospital – to- user approach) A logic change to the CPOE calculations to incorporate additional order types to better represent lab and radiology workflows resulted in drops in CPOE rates for many facilities. As new workflows were incorporated, results recovered. 5
  6. 6. Stage 2 Core Measures Core Objective Measure is Changing From “this” to “this” Managing the Change at Tenet Increase from 50% to 80%. Structured data (ISO standard) for preferred language Adjusted workflows as necessary and provided additional training for registration staff and nursing. Confirmation that the new preferred language codes are in place for registration Increase from 50% to 80%. Changed from 2 years of age to 3 years of age for BP recording Record height/length and weight on all patients Made adjustments to the measure calculations to incorporate the threshold percentages. No notable challenges Increase from 50% to 80%. Structured data required for type of smoker (Light vs. Heavy and record cigarettes per day) This required a new build, workflow adjustments and training. All have been completed. Conclude how we would measure light versus heavy smoking. Cigarettes per day: <10 is light >10 is heavy 2. Record Demographics • 3. Record Vital Signs • • • • 4. Record Smoking Status • • Challenges 6
  7. 7. 7
  8. 8. Stage 2 Core Measures Core Objective 5. Implement Clinical Decision Support Interventions Measure is Changing From “this” to “this” • Increased from 1 to 5 clinical decision support (CDS) interventions implemented and must be related to 4 or more CQMs. • Also incorporated the drug/drug and drug/allergy interaction measure into this measure. Managing the Change at Tenet Challenges CDS rule list was analyzed against the requirements. All of the rules trigger off problems or diagnoses as interventions target patient populations or groups of patients. This effort has clearly been impacted by the selection of rules as related to CQMs triggered by diagnoses coding. Workflows and operational processes may need to be addressed in future. 5 CDS choices will also require increase in documentation kept for audit purposes. Good to know: The 4 or more CQMs chosen to relate to the 5 CDS interventions can be any of the 29 from the final rule and not limited to the 16 CQMs chosen for the required reporting. 8
  9. 9. Requirements – Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. – In addition, the clinical decision support interventions must be related to high-priority health conditions. – CMS also “suggests” that 1 of 5 be related to improving healthcare efficiency. (CDS support to avoid unnecessary or inappropriate care) To Do: Choose 5 -7 CDS interventions related to 4 CQMs and high priority conditions. 1 could be related to improving healthcare efficiency 9
  10. 10. Requirements: Interventions and Triggers  An intervention is evidence-based and is linked to referential supports.  The measure requirements state that the hospital is to: enable a limited set of identified users to select (i.e., activate) one or more electronic clinical decision support interventions (in addition to drug-drug and drug-allergy contraindication checking) based on each one and at least one combination of the following data: (A) Problem list; (B) Medication list; Examples Stroke 6 - CDS rule to fire when ischemic (D) Demographics; stroke patient has LDL lab value greater than 100, or no value (not tested) within the first 24 hours of admission. Confirm patient is discharged with medication of Statin (E) Laboratory tests and values/results; Stroke 5 - CDS rule to fire when ischemic (C) Medication allergy list; (F) Vital signs. stroke patient is admitted. Confirm patient is administered medication of an antithrombotic by end of day 2. To Do: Document what triggers the CDS interventions we choose and who enters the data 10
  11. 11. Stage 2 Core Measures Core Objective Measure is Changing From “this” to “this” Managing the Change at Tenet Challenges 6. Incorporate Lab Results into EHR • • Increase from 40% to 55% Moved from a menu to a core measurement No change for Tenet except for the increased threshold. Continue to monitor the dashboard Good to know: LOINC is the standard when transmitting lab results to outside entities (i.e. CDA docs) 7. Generate Patient Lists • • No change in objective Moved from a menu to a core measurement No change No notable challenges 8. Automatically track medications from order to administration (eMAR) • • New Core Measure eMAR is implemented and used for more than 10% of medication orders and tracking of the administration of all doses of the medications using computer assisted technology (required) Monitoring of reports for all aspects of eMAR and bar coding is in progress. There is ongoing review of eMAR dashboards by each hospital and the IMPACT team Address workflow for system downtime and also how documentation of barcoding occurs. Use operational reports to monitor and apply corrective action. • Good to know: if an event prevented the ability to complete the administration, (i.e. meds not barcoded) the order would not count in the numerator. Also, if med admin is completed but with a response from the patient (i.e. patient vomited), the patient response is not considered a part of the measure and the order would count in numerator. 11
  12. 12. Stage 2 Core Measures Core Objective Measure is Changing From “this” to “this” 9. Provide patients the ability to view online, download and transmit their health information New Core Measure Consolidates/Replaces these two Stage 1 measures: • eCopy of HI measure • Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request • 50% threshold remains New requirements : • More than 5% of all patients will view, download or transmit to a third party their information during the reporting period • Required data elements for summary of care are now satisfied by using the Consolidated CDA standard. Managing the Change at Tenet • • • Implementation of the Patient Portal has been a major design, build, test and workflow adjustment effort. Strong operational support and process adjustments are necessary to engage patients. Built reports to monitor each step of all processes to ensure measurement objectives. Challenges Organization will now be required to attest for the “patients” adoption and use of EHR. We developed a report to monitor “opt in”, “opt out” in order to gage patient engagement and plan patient education. Clarify who will provide instructions/access to the portal for the patient (registration, nursing or both) Address portal content requirements related to sensitive information (HIV results, etc.) 12
  13. 13. Current Workflow for “View and Download” Each patient will be asked at admission if they would like to set up a portal (opt in/out) If patient says yes (opt in), staff enter information into ADT and EHR systems. If patient says no (opts out) The hospital will provide information describing how to opt in to patient portal at a later date Once registered, a email invitation is sent. A link in the invite takes the patient to a page with instructions to verify information and enter a password. Access is granted with ability to view, download, and transmit information. 13
  14. 14. Stage 2 Core Measures Core Objective 10. Patient specific education Measure is Changing From “this” to “this” • • • No change in threshold in using the EHR to identify and provide education resources for more than 10% of all unique patients Moved from a menu to a core measurement Removal of “if appropriate” from the objective and replaced with “are provided patient-specific education resources identified by Certified EHR Technology” Managing the Change at Tenet The build and workflows required adjustments along with targeted education for nursing. Challenges Our vendor suggested education resource is triggered by entry of ICD 9 diagnoses codes. Nurses can enter problems but not diagnoses codes (only physicians). Mapping from problem list to ICD 9 code is available with our vendor and is being tested. We continue to monitor. 14
  15. 15. Patient Specific Education Change in Requirements – Only count education if identified by CEHRT Patient Education Form Revised 15
  16. 16. Stage 2 Core Measures Core Objective 11. Medication Reconciliation Measure is Changing From “this” to “this” • • No change in threshold for medication reconciliation for more then 50% of patients upon transitions of care Moved from a menu to a core measurement Managing the Change at Tenet Challenges Ongoing refinement of workflow, continuous education and regular monitoring of adoption continues. Promotion of adoption of medication reconciliation at individual hospital has highlighted challenges based on local nuances. Reports developed to monitor daily activity , MU thresholds, and Tenet thresholds. Good to know: regulation does not provide when the reconciliation occurs (admit versus discharge); only that it occurs 16
  17. 17. Stage 2 Core Measures Core Objective 12. Transition of Care Summary (Summary of Care) Measure is Changing From “this” to “this” Managing the Change at Tenet Challenges No change in threshold for providing a summary of care document for more than 50% of transitions of care and referrals . • Moved from a menu to a core measurement New Requirements: • 10% of the SOC documents must be provided via electronic transmission using Consolidate CDA standard • Conducts one or more successful electronic exchanges of a SOC with a recipient who has different EHR technology than the sender's EHR technology, OR conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. Tenet has the content of the SOC almost completed Process includes multiple workflows to address transition of care to various organizations. • Electronic SOC transmission at 10% is new and the referral transfer from provider to provider takes some work to figure out. Direct exchange addresses (are needed for this measure. Analysis for performing successful electronic exchange is well underway. Our vendor designed this to be a physician workflow. Many external organizations are not able to receive electronic content and thus must create workflow to address various modes of transmission (paper, fax, and direct email) Important to recognize caretaker / ownership of the record for release of information (HIM, Quality, etc..) 17
  18. 18. Electronic Summary of Care Document Work with your vendor HUB 1 Cerner HISP * OPS Job Creates CDA document on scheduled Basis Receiver HISP 3rd Party External Recipient Cerner Millennium 3rd User selects from a list of Direct addresses to transmit summary to. CDA Cerner Care Aware Multimedia Manager (CAMM) NOTE: If party is outside of our vendor AND NOT part of Tenet organization – Counts for Measure 3 * HISP – Health Information Service Provider 18
  19. 19. Stage 2 Core Measures Core Objective 13. Capability to submit immunizations data to registries or immunization information systems Measure is Changing From “this” to “this” Managing the Change at Tenet • Moved from a menu to a core measurement • Went from a test to successful ongoing transmission of immunization data Tenet continues to work with all hospitals and all state agencies to get regular reporting instituted. This has required an increase in oversight, control and monitoring. Challenges • • Actual contracted vendor solutions proving unacceptable to evolving technical state connectivity message protocol requirements. State laws that exceed MU requirements (e.g. SC law requires all immunizations be reported even those not in EHR; like HR captured employee immunizations). For stage 2, vendor ability to handle ongoing evidence requirements is an issue. 19
  20. 20. Stage 2 Core Measures Core Objective Measure is Changing From “this” to “this” Managing the Change at Tenet Tenet is implementing Health Sentry. We are working with our vendor to get a transmission report for audit evidence. Also working with all hospitals and all state agencies to get regular reporting instituted. • Tenet is implementing Health Sentry. We are working with our vendor to get a transmission report for audit evidence. • 14. Capability to submit electronic data on reportable lab results to public health agencies • Moved from a menu to a core measurement • Went from a test to successful ongoing submission of reportable laboratory results 15. Capability to submit electronic syndromic surveillance data to public health agencies • Moved from a menu to a core measurement • Went from a test to successful ongoing submission of electronic syndromic surveillance data Also working with all hospitals and all state agencies to get regular reporting instituted. Challenges • • For stage 2, vendor ability to handle ongoing evidence requirements is an issue. Confirm CEHRT is capable of populating LOINC codes for all required labs reported. State laws that exceed MU requirements (e.g. NC law requires real time and more robust data set). For stage 2, make sure that vendor is providing you the ability to support ongoing evidence requirements. Example, there is no report reflecting actual daily submission everyday. 20
  21. 21. Stage 2 Core Measures Core Objective 16. Security Risk Analysis Measure is Changing From “this” to “this” • Managing the Change at Tenet Conduct or review security analysis and incorporate in risk management process; added encryption and data at rest Having gained recent experience with the Figliozzi (CMS Medicare) audit , they are now asking that if any security issue or corrective action is planned, to provide plan and completed dates (new). Challenges MU Audits now looking to confirm remediation plan and completion dates identified in risk analysis are being addressed. Need to include remediation plans in documentation. 21
  22. 22. Stage 2 Menu Measures (3 of 6 required) Core Objective Measure is Changing From “this” to “this” Managing the Change at Tenet Challenges 1. Imaging Results New - more than 20% of imaging results are accessible through CEHRT Tenet has achieved this we will be validating this functionality and threshold in January for all hospitals. Confirm definition of images. At a minimum it should include what is reported in the CPOE Radiology denominator.. Can also include (EKGs, video, etc.) 2. Record Family Health History New - record family health history of one or more first degree relatives for more than 20% of unique patients Design changes were needed, as well as workflow and training - all completed. Made use of default field functionality. Address workflow to include capturing family history as it relates to “adoptions” 3. Generate and transmit permissible discharge prescriptions electronically (eRx) New - more than 10% electronic prescribing (eRx) of discharge medication orders. Implement drug formulary checks measure is included in this measure New functionality – go live 10/28. new workflows, training. Multiple reports generated to evaluate performance in progress as well as dashboard monitoring Awareness that not every pharmacy accepts nor does every patient want electronic prescriptions. Schedule II – V drugs require special attention and most cannot be prescribed electronically 22
  23. 23. Stage 2 Menu Measures (3 of 6 required) Core Objective Measure is Changing From “this” to “this” Managing the Change at Tenet Challenges 4. Record Advance Directives Record status of advance directives as structured data for more than 50% of patients 65 years or older. No change. Tenet continues to successfully meet this measure. No notable challenges 5. Provide structured electronic lab results to ambulatory providers New - provide structured electronic lab results to EP(physician practices) for more than 20% Not a chosen menu measure for Tenet but we plan to review this next year Hospital EHR is centralized, but physician offices utilize multiple vendors 6. Record electronic notes in patient records New - enter at least one electronic progress note created, edited and signed for more than 30% of unique patients Good to know: LOINC is the required standard for EPs Not a chosen menu measure for Tenet. We are not live on physician notes yet but this is a major focus in the 2014 IMPACT plan. For some, it will require the acquisition and implementation of physician documentation applications / modules 23
  24. 24. TOPICS • Meaningful Use Stage 2 Core Measures - A road to success • 2014 Clinical Quality Measures - The challenges and solutions • Meaningful Use Audits - The basics 24
  25. 25. 2014 Clinical Quality Measures - Key Themes • Beginning in 2014, reporting of Clinical Quality Measures (CQM) will be independent of MU stage ― CQM measures are the same for Stage 1 or Stage 2 • Measures and reporting align (NOT YET) with other quality reporting initiatives ― PQRS, ACO and NQCA (Patient Centered Medical Home) • Almost all of the CQM’s that are included in the hospital Inpatient Quality Reporting (IQR) program now have electronic equivalents included in the MU program ― There is extensive discussion in the final rule about the intention of CMS to convert the hospital IQR and VBP program to electronic measures, as early as 2015 25
  26. 26. Clinical Quality Measure Changes Domains # of New Existing • Measures EHs and CAHs must report on 16 of the 29 CQMs • Care Coordination Clinical Process/ Effectiveness Efficient Use of Healthcare Resources Patient & Family Engagement Patient Safety TOTAL • 1 Must submit at least one measure from at least 3 of the 5 Domains – Care Coordination – Clinical Processes/Effectiveness – Efficient Use of Healthcare Resources – Patient and Family Engagement – Patient Safety • 2 Must report measures electronically to CMS and/or States Four of the Five Clinical Decision Support interventions will need to address CQMs 1 14 7 7 2 2 0 5 1 4 6 29 3 14 3 15 *Report clinical quality measures to CMS for the States is no longer a separate objective for Stage 2, but providers must still submit CQMs to CMS or the State in order to achieve meaningful use 26
  27. 27. Tenet’s MU CQMs Chosen for 2014 Reporting VTE Stroke ED VTE-1: Prophylaxis within 24 hours of admission Stroke-2: Discharged on antithrombotic therapy ED-1: Median time from ED arrival to ED departure for admitted ED patients VTE-2: Prophylaxis within 24 hours of admission for an ICU patient Stroke-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter ED-2: Admit decision time to ED departure time for admitted patients VTE-3: Overlap therapy Stroke-4: Thrombolytic therapy in 2 hours ED-3: Median time from ED arrival to ED departure for discharged ED patients VTE-4: Platelet monitor Stroke-5: Antithrombotic therapy by end of hospital day 2 VTE-5: Discharge Instructions Stroke-6: Discharged on Statin Medication VTE-6: Potentially Preventable VTE Stroke-8: Stroke Education Stroke-10: Assessed for Rehabilitation The list above meets 4 of the 5 clinical domains as required 27
  28. 28. TOPICS Meaningful Use Stage 2 Core Measures - A road to success 2014 Clinical Quality Measures - The challenges and solutions Meaningful Use Audits - The basics 28
  29. 29. Tenet 29
  30. 30. Just the Facts The Center for Medicare and Medicaid have established a process for program audits under the final rule: CMS states that “an eligible professional (EP), eligible hospital, or critical access hospital (CAH) attesting to receive an incentive payment for either the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program may be subject to an audit” Two types of audits: – Pre-payment audits will be random and may target suspicious or anomalous data through edit checks built in CMS and State systems – Post-payment audits can occur during the course of the program CMS audit process includes the following: – Initial request letters are sent to providers selected for an audit – The initial review process will be conducted using information provided in response to the request letter – In some cases an on-site review at the provider’s location may follow 30
  31. 31. Have the documents of evidence always at the ready: CMS recommends that eligible hospitals, eligible professionals and critical access hospitals retain all relevant supporting documentation, in either paper or electronic format, used to complete the Attestation process.  All attestation evidence of successful compliance with meaningful use objectives and clinical quality measures must be retained for six years post attestation.  Documentation to support payment calculations (such as cost report data) are included in the current documentation retention requirements. 31
  32. 32. Who are the Auditors? Medicare - CMS and its contractor, Figliozzi and Company, are performing audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR Incentive Programs Medicaid - States, and their contractor, are performing audits on Medicaid providers participating in the Medicaid EHR Incentive Program OIG - The Office of Inspector General also has been directed by Congress to provide oversight to the State Program 32
  33. 33. The Audit Request Letters Dear Tenet… 33
  34. 34. What we are seeing in the letters: Proof required for attestation items: – Screen shots of dictionary settings to show everyday compliance and to show proof of the use of a certified system the entire reporting period – Logs or reports showing alerts firing for the reporting period MU measure reports must show CEHRT vendor and system name: – Documentation from other source systems must show calculations, including numerator and denominator, time period and NPI or provider name. No spreadsheets Data exchange proof (CCD and public health) with screen shots from CEHRT: – Date of test, statement of transmission success or failure – Letter or e-mail from receiving provider stating date, name of provider and success or failure of test HIPAA Security Risk Assessment – Must be specific for your EHR modules and release level – Must name each hospital or entity that it covers , ideally by NPI specifically – Report should be dated prior to the end of the reporting period 34
  35. 35. What we are seeing in the letters: Specific to Medicaid: • Must prove you completed your adoption, implementation or upgrade • Must provide contracts, purchase orders and proof of payments 35
  36. 36. 36
  37. 37. Contact Information LIZ JOHNSON, MS, FHIMSS, CPHIMS, RN-C Vice President, Applied Clinical Informatics and CCIO Tenet Healthcare Corporation Headquarters 1445 Ross Avenue, Suite 1400 Dallas, TX 75202 Office 469.893.2039 e-mail: liz.johnson@tenethealth.com 37
  38. 38. APPENDIX 38
  39. 39. Objectives from Stage 1 to Stage 2 Although total number of objectives stay the same between Stages, the number of measures to report increases (number of objectives with multiple measures) 39
  40. 40. Stage 2 CQM Measures (14) Hearing screening prior to hospital discharge (EHDI-1a) AMI-2: Aspirin Prescribed at Discharge for AMI AMI-7a: Fibrinolytic Therapy received within 30 minutes of hospital arrival ** AMI-8a: Primary Percutaneous Coronary Intervention (PCI)** AMI-10: Statin Prescribed at Discharge Clinical Process/ Effectiveness Domain VTE-3: VTE Patients with Overlap of Anticoagulation Therapy * VTE 4: Patients Unfractionated Heparin (UFH) Dosages/Platelet Count Monitoring by Protocol (or Nomogram) * Stroke-2: Ischemic stroke – Discharged on anti-thrombotic therapy * Stroke-3: Ischemic stroke – Anticoagulation Therapy for Atrial Fibrillation/Flutter * Stroke-4: Ischemic stroke – Thrombolytic Therapy * Stroke-5: Ischemic stroke – Antithrombotic therapy by end of hospital day two * Stroke-6: Ischemic stroke – Discharged on Statin Medication * *Stage 1 CQM currently tracked electronically **Value Based Purchasing Elective Delivery Prior to 39 Completed Weeks Gestation Exclusive Breastfeeding at Hospital Discharge 40
  41. 41. Care Coordination Domain Efficient Use of Healthcare Resources Domain Stage 2 CQM Measure (2) Stroke-10: Ischemic or hemorrhagic stroke –Assessed for Rehabilitation * ED-3: Median time from ED arrival to ED departure for discharged ED patients * Stage 2 CQM Measure (2) PN-6: Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients** SCIP-INF-2: Prophylactic Antibiotic Selection for Surgical Patients for discharged ED patients** Stage 2 CQM Measure (5) Home Management Plan of Care Document Given to Patient/Caregiver Patient and Family Engagement Domain *Stage 1 CQM currently tracked electronically ** Value Based Purchasing VTE-5: VTE discharge instructions * Stroke-8: Ischemic or hemorrhagic stroke –Stroke education * ED-1 Emergency Department Throughput – Median time from ED arrival to ED departure for admitted ED patients * ED-2 Emergency Department Throughput –admitted patients – Admit decision time to ED departure time for admitted patients * 41
  42. 42. Stage 2 CQM Measure (6) VTE-1: Venous Thromboembolism Prophylaxis * Patient Safety Domain *Stage 1 CQM currently tracked electronically ** Value Base Purchasing CQM 29 Measures Measure Overlap IQR 12 ACO 1 VBP 7 VTE-2: Venous Thromboembolism Prophylaxis - Intensive Care Unit (ICU) * VTE-6: Incidence of potentially preventable VTE * SCIP-INF-9: Urinary catheter removed on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2) with day of surgery being day zero SCIP-INF-1: Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision** Healthy Term Newborn ** Value Based Purchasing overlaps with 5 of the CQM measures and also includes 2 additional measures: PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital SCIP-INF-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time 42
  43. 43. EH Audit Response This is How Tenet Does It 43
  44. 44. Tenet Audit Response Process (Medicare) • Receive notification of Audit Alert! Take Action • Communicate Audit to Tenet Audit Activation Team (TAAT)* • Convene Audit response meeting within 36 hours • Gather documentation and develop Audit response • TAAT performs final audit of prepared documents/response and then approves Finalize and • Approved response and documents sent to requesting agency Submit * TAAT has senior representation from Applied Clinical Informatics, Audit, Government Programs & Compliance. 44
  45. 45. Tenet EH Audit Response First request for additional information Approximately 3 weeks after submitting initial materials, Tenet received 2 additional questions: • Auditors were unclear as to whether the report provided for measure calculations came from CEHRT; asked for additional documentation • Asked for validation that the CDS rule had been active during the entire reporting period Tenet Audit Activation Team gathered again, reviewed and provided additional material via portal and FedEx within 5 days: • Screen shots from the CHPL site showing Tenet’s self-certification • Screen shots showing activation start and end for the rule 45
  46. 46. Tenet EH Audit Response Second request for additional information Approximately one month later, Tenet received another request asking for: • Confirmation of the percent of patient encounters captured in the CEHRT. Since Tenet captures all encounters in CEHRT, this was answered by simply stating the following: For the EHR Incentive Program, Hospital had 1,638 patient encounters occur (admitted or discharged) during the reporting period. All 1,638 patient encounters were entered into the EHR system, therefore the percentage is 100%. • Documentation that CQMs had been submitted . This request was withdrawn the following day. • A copy of the security risk assessment. This had been provided previously as documentation with the first request but was provided again. 46
  47. 47. Success! Determination letter received on October 23, 2012 approximately 3 weeks after the last information request, 3 months after the initial request. We have completed our meaningful use audit of the certified Electronic Health Record (EHR) technology of your hospital in accordance with Section 13411 of the Health Information Technology for Economic and Clinical Health Act (HITECH Act), as included in Title XIII, Division A, Health Information Technology and in Title IV of Division B, Medicare and Medicaid Health Information Technology of the American Recovery and Reinvestment Act of 2009. The HITECH Act provides the Secretary, or any person or organization designated by the Secretary, the right to audit and inspect any books and records of any organization receiving an incentive payment. We performed a desk review on your facility’s meaningful use attestation for the Program Year 2011 and Payment Year 1. Based on our desk review of the supporting documentation furnished by the facility, we have determined that your hospital has met the meaningful use criteria. This audit does not preclude your hospital from future audits in this payment year or in subsequent years. Thank you for your assistance and cooperation. 47

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