The document discusses a survey conducted by eHealth Initiative on regional extension centers and meaningful use of electronic health records. Key findings from the survey include: - Regional extension centers should be flexible and not constrained by state or regional boundaries in order to best meet local needs. There should be 10-100 centers. - Quality improvement organizations are best suited to run the extension centers based on their experience. - Extension centers should focus on disseminating best practices, providing technical assistance to clinicians, and assisting primary care practices and those in rural/underserved areas.

1. Welcome! Thursday, October 22, 2009

2. The Global Opportunities and Legal Challenges Posed by Health Information Technology: Presented by Robert D. Marotta October 1, 2009 A Domestic Perspective

3. Speaker Bio Robert D. Marotta, Esq. Senior Vice-President and Chief Regulatory Counsel, HLTH/WebMD Health Corp. President, eHealth Foundation, New York, NY October 1, 2009

4. Building a Health IT Technical Assistance Capability at the Regional Level The new “regional extension centers,” launching in 2010, will play a significant role in enhancing technical assistance capabilities at the state and local levels. These centers will provide technical assistance and disseminate best practices and other information to support and accelerate efforts to adopt, implement and effectively utilize health IT. October 1, 2009

5. Building a Health IT Technical Assistance Capability at the Regional Level The Office of the National Coordinator for Health IT (ONC) recently published a draft description of these regional centers. Solicitation for hosting applications will be released this summer. ONC proposed that each regional center prioritize direct assistance first to the following: Public or not-for-profit hospitals, or critical-access hospitals Federally-qualified health centers Entities located in rural and other areas that serve uninsured, underinsured and medically underserved individuals (regardless of whether area is urban or rural) Individual or small-group practices that are primarily focused on primary care. October 1, 2009

6. Building a Health IT Technical Assistance Capability at the Regional Level ONC proposed that regional centers furnish direct, individualized and (as-needed) on-site assistance to individual providers. This on-site assistance will be a key service and will represent a significant portion of the centers’ activities. The extension program should provide at least a minimal level of technical assistance across the nation. October 1, 2009

7. Building a Health IT Technical Assistance Capability at the Regional Level It is expected that each regional center will provide technical assistance within a defined geographic area, and that each area will be served by only one center. It is required that centers be affiliated with any U.S.-based nonprofit organization, or group thereof, that applies and is awarded financial assistance; awards shall be decided on the basis of merit. ONC proposes a number of other requirements and preference criteria. October 1, 2009

8. eHealth Initiative Survey on HIT Regional Extension Centers In May, eHI surveyed its member and partner organizations to assess perceptions and expectations about the HIT Regional Extension Centers. Results were shared in late May with the Administration and the public. October 1, 2009

9. The Results: Survey on HIT Regional Extension Centers 65% of respondents believed that the federal government should lay out an operational outline for the centers and allow each to adopt its own region-specific practices. 49% believed that the centers should cover a geographic area designed to meet need; 26% supported centers adhering to state boundaries. 62% of respondents felt that the centers, once created, should not overlap geographically or otherwise compete to provide services. 41% of respondents supported the creation of 10-50 centers; 24% supported 50-100. 64% of respondents thought that quality improvement organizations were the most appropriate hosts of such centers; no other type of organization received comparable support. 71% of respondents thought vendors were poorly-suited to host or help fund a center due to conflicts of interest. At the same time, many respondents supported a coalition of organizations supporting a center. Desired a truly competitive application process. October 1, 2009

10. The Results: Survey on HIT Regional Extension Centers Respondents most strongly supported the centers providing the following services: Dissemination of best practices and research – 96% Technical assistance for implementation with clinicians – 92% Workflow modification guidance for clinicians – 91% Vendor-neutral advice on purchasing decisions – 80% Health information exchange support – 80% Survey respondents felt that the centers should initially focus on assisting the following organizations: Providers focused on primary care – 94% Providers located in rural or underserved areas – 92% Public, not-for-profit and/or Critical Access hospitals – 90% Federally-qualified health centers – 89% October 1, 2009

11. Summary: Survey on HIT Regional Extension Centers Regional extension centers should not be constrained to a specific metropolitan or state boundary and should be uniquely designed to meet the needs of the chosen coverage area. There should be established between 10 and 100 centers, which should be non-competitive with each other. Quality improvement organizations are best-suited to run the extension centers based on previous experience; numerous respondents cited HIEs as well. Ultimately, there should be a competitive process that selects the organization or organizations best suited to host each center. October 1, 2009

12. Summary: Survey on HIT Regional Extension Centers Extension centers’ primary services need to include: Dissemination of best practices and research Technical assistance and workflow guidance for clinicians Also popular: HIE support Vendor-neutral purchasing advice Liaison between public and private efforts Centers should focus their attention on: Primary care practices Public, not-for-profit, and/or CAHs Entities located in rural/underserved areas FQHCs October 1, 2009

13. Improving Healthcare Using EHRs and Other Healthcare Data: Meaningful Use In order to improve healthcare using data, we need to successfully define and transition to the meaningful use of EHRs and health data. eHI surveyed its membership on meaningful use of EHRs in April 2009. Results were shared with NCVHS and the public. October 1, 2009

14. Improving Healthcare Using EHRs and Other Healthcare Data: Meaningful Use Survey/discussion results: members, including broad range of healthcare stakeholders, recognized that the definitions of “meaningful use” and “meaningful user” must not set the bar too high or too low. Consistent theme of flexibility. Though members differed on details, all emphasized the need for flexibility to allow: Continued innovation; Any provider who puts in significant time and effort to be able to qualify as a meaningful user; and For the definition of meaningful use to evolve as technology and health care systems evolve. October 1, 2009

15. Improving Healthcare Using EHR and Other Healthcare Data: Meaningful Use Majority of respondents (58%) recommended that ‘meaningful user’ definition take into account differences between various practice sites and specialties. When asked to review a list of actions that could be considered elements of ‘meaningful use,’ responses varied widely: Functions with most support were: e-prescribing (88%); viewing lab and imaging results (79%); warning of drug interactions (76%); and problem lists and diagnoses, computerized orders and allergies (all exactly at 72%). Functions with least support were: clinical messaging (47%); reminders (42%); and exchanging data with patients and consumers (38%). Significant majority (68%) opposed requiring providers to perform all the functions that would eventually become part of meaningful use. Half of those respondents supported HHS creating a defined set of basic functions, while leaving others optional until there is broader adoption and use of HIT. October 1, 2009

16. Thank You! Robert D. Marotta, Esq. Senior Vice-President and Chief Regulatory Counsel, HLTH/WebMD Health Corp. President, eHealth Foundation [email_address] (614) 462-5435 October 1, 2009

17. October 22, 2009 The Impact of Federal HIT Policy and the State of Ohio Jennifer Covich Bordenick Chief Operating Officer and Interim Chief Executive Officer

18. About the eHealth Initiative Independent non-profit based in Washington, DC. Focused on informing, educating and advocating for the use of health information and health information technology to drive improvements in the quality, safety, and efficiency of healthcare. 170 member organizations Coalition of 260 state and local organizations working on health information exchange October 22, 2009

19. What Does eHI Do? Public Policy Organization: Monitor, Assess and Influence Public Policy Convener and Consensus-Builder Research and Support Efforts Related to HIT and Quality: Medical Product Safety Chronic Care Management Consumer Engagement Health Information Exchange at State Level Education and Awareness about state of the field October 22, 2009

20. Multi-Stakeholder Membership Consumer and Patient Groups Clinicians, Hospitals and other providers Employers and healthcare purchasers Health Plans Health Information Technology Suppliers Pharmacy Organizations Pharmaceutical and medical device manufacturers Public Health agencies Laboratories and other ancillary providers Quality organizations Academic Institutions State, regional and community based organizations October 22, 2009

21. Today’s Discussion The National eHealth Landscape Developing and Rewarding Meaningful Use The State of Health Information Exchange (HIE) in the Nation The Role of States and Regions October 22, 2009

22. Overview of National Landscape October 22, 2009

23. Federal HIT Policy Enactment of the American Recovery and Reinvestment Act in February, included a 100+ page section on HIT titled the “HITECH Act” Most significant legislative effort ever introduced in its affect on HIT Roll out of its provisions is underway, but will continue to directly impact the industry for the next decade October 22, 2009

24. Federal HIT Policy What does the HITECH Act do? Develops a permanent federal governance structure for HIT Provides $2 billion in direct funding to support: State HIE grants Regional Extension Centers HIT Work Force Rewards Meaningful Use of EHRs with $30-$40 billion for Targeted Providers Revamps HIPAA Privacy and Security October 22, 2009

25. Basic Federal HIT Structure in 2009 October 22, 2009 HITSP CCHIT + ? Office of the National Coordinator HIT Policy Committee HIT Standards Committee Chief Privacy Officer National Institute of Standards and Technology

26. HIT Policy and Standards Committee HIT Policy Committee Recommend a policy framework for development and adoption of a nationwide health information technology infrastructure Recommend and prioritize areas in which standards, implementation specifications, and certification criteria are needed HIT Standards Committee Recommend to National Coordinator standards, implementation specifications, and certification criteria React to Policy Committee recommendations of areas where standards are needed Will, as appropriate, provide for testing by NIST October 22, 2009

27. Regional Extension Centers 70 Regional Extension Centers will be established to furnish assistance (education, outreach, and technical) to help providers adopt HIT, become meaningful users, and achieve health information exchange Will focus on primary care providers Federal government is providing $598 million to help these centers get off the ground. Centers will receive $3-$30 million each. October 22, 2009

28. State HIE Grants The government will award contracts to states that are seeking to develop a comprehensive, multi-stakeholder plan to advance appropriate and secure health information exchange (HIE). The federal funding is intended to help states continuously improve and expand HIE services to reach all health care providers, and should be used to develop governance policies, technical services, business operations, and financing mechanisms for HIE over a four year performance period with milestones for the states to meet, including support for meaningful use. Government will provide $564 million to support the states and territories. States will receive $4-$40 million each. October 22, 2009

29. Key Dates in 2009 December 2009 Proposed rule released to govern Meaningful Use Dec 11, 2009 First Regional Extension Center contracts awarded Dec 15, 2009 State HIE Grants awarded Dec 31, 2009 HHS adopts an initial set of standards, implementation and certification criteria to guide adoption of EHRs for the Medicare and Medicaid incentives October 22, 2009

30. Developing and Rewarding Meaningful Use October 22, 2009

31. Developing and Rewarding Meaningful Use HITECH lays out the guidelines for physicians and hospitals to be rewarded or punished based on their willingness and ability to show that they are achieving meaningful use of a qualified electronic health record A meaningful user is an eligible provider that: Shows meaningful use of a qualified HER Reports on required clinical quality measures Exchanges health information electronically October 22, 2009

32. Paying for Meaningful Use Payments to reward meaningful use through Medicare until 2015 (physicians) or 2016 (hospitals), then penalties kick in Medicaid provides a different track of payments over a longer time frame with no penalties Most hospitals are eligible to try for Medicare and Medicaid payments, physicians have to choose one or the other Most eligible providers can earn maximum amounts of $44,000 (Medicare) or $65,000 (Medicaid), hospitals can earn millions – based on patient population and other factors October 22, 2009

33. Paying for Meaningful Use – Example - Medicare for Professionals October 22, 2009 Year Maximum Benefit per Provider using EHR Total Payment Reduction for Not Using EHR First Year $15,000 (If 2011 or 2012, $18,000) 0% Second Year $12,000 0% Third Year $8,000 0% Fourth Year $4,000 0% Fifth Year $2,000 2015: 1% (in some cases, 2%) Sixth Year 0 2016: 2% 2017 0 2017: 3% Beyond 0 Beyond: 3% (or more)

34. Meaningful Use Policy HIT Policy Committee has been holding public meetings since May to develop the objectives and measures to judge meaningful use in 2011, submitted final recommendations in August October 22, 2009

35. Meaningful Use 2011 - Example October 22, 2009

36. Meaningful Use – Next Steps CMS is developing a proposed rule to govern the actual process of meeting and assessing meaningful use Proposed rule expected out in December Will be followed by 60-day comment period Final rule out spring 2010 Proposed rule will cover the 2011 criteria, future criteria for more advanced years will be developed as the program rolls out October 22, 2009

37. The State of Health Information Exchange (HIE) in the Nation October 22, 2009

38. October 22, 2009

39. Quick Background on eHI Survey Since 2004, eHI has conducted an annual survey to look at activities and maturation of health information exchange (HIE) initiatives Data used by public agencies such as ONC, AHRQ, CDC and HHS to inform strategies related to health IT Responses to the survey are self-reported Report provides detailed look at what is working and where it is working October 22, 2009

40. How Many Initiatives Are There? The number of initiatives involved in health information exchange is growing. 67 health information exchange initiatives responded to the eHI survey for the first time. There are at least 193 active initiatives involved in health information exchange. 150 initiatives responded to the survey. eHI identified 43 additional initiatives from the 2008 survey which are still functioning, but did not complete this year’s survey. Directly of all exchanges is available online at www.ehealthinitiative.org October 22, 2009

41. October 22, 2009

42. October 22, 2009

43. Who Is Exchanging Health Information? October 22, 2009

44. October 22, 2009 Stakeholder Organizations Exchanging Data 2008 2009 Change (+/-) Hospitals 31 48 +17 Primary care physicians 24 42 +18 Community and/or public health clinics 20 32 +12 Specialty care physicians 21 30 +9 Independent laboratories 14 26 +12 Outpatient/Ambulatory surgery centers 11 22 +11 Pharmacies 8 20 +12 Behavioral or mental health providers 12 19 +7 Health plans 14 19 +5 Local Public Health Department 13 19 +6 Independent radiology centers 10 18 +8 Pharmacy benefit management companies 7 18 +11 Healthcare IT suppliers 9 15 +6 State Public Health Department 5 15 +10 Medicaid 5 13 +8 Consumers 3 10 +7 Employers or health care purchasers 5 9 +4

45. What and How is Health Information is Exchanged? October 22, 2009

46. October 22, 2009 Data Currently Exchanged 2008 2009 Change (+/-) Laboratory 26 49 +23 Medication data (including outpatient prescriptions) n/a 48 n/a Outpatient laboratory results 25 45 +20 Outpatient episodes 23 43 +20 Radiology results 23 39 +16 Emergency Department episodes 27 36 +9 Inpatient diagnoses & procedures 27 35 +8 Care summaries n/a 34 n/a Inpatient discharge summaries n/a 32 n/a Pathology 18 32 +14 Dictation / transcription 20 31 +11 Cardiology 15 27 +12 Claims: pharmacy, medical, and/or hospital n/a 27 n/a Enrollment / eligibility 17 25 +8 Pulmonary 13 23 +10

47. October 22, 2009 Current Functionalities for Data Exchange 2008 2009 Change (+/-) Results delivery (e.g. laboratory or diagnostic study results) 31 44 +13 Connectivity to electronic health records n/a 38 n/a Clinical documentation 38 34 -4 Alerts to providers 26 31 +5 Electronic prescribing n/a 26 n/a Enrollment or eligibility checking 29 25 -4 Electronic referral processing 17 21 +4 Consultation/referral 23 20 -3 Clinical decision support n/a 19 n/a Disease or chronic care management 19 19 0 Quality improvement reporting for clinicians 14 19 +5 Ambulatory order entry n/a 16 n/a Disease registries 11 16 +5 Reminders 14 16 +2 CCR/CCD summary record exchange n/a 15 n/a Public health: case management 7 13 +6 Public health: surveillance 9 13 +4 Quality performance reporting for purchasers or payers 9 12 +3 Connectivity to personal health records n/a 10 n/a

48. What is the Impact? October 22, 2009

49. Cost Savings Cost savings resulting from health information exchange were reported by 40 operational initiatives Reduced staff time spent on handling lab and radiology results (26 operational initiatives). Reduced staff time spent on clerical administration and filing (24). Decreased dollars spent on redundant tests (17). Decreased cost of care for chronic care patients (11). Reduced medication errors (10). October 22, 2009

50. What hurdles exist? October 22, 2009

51. What Are the Challenges? Addressing privacy and confidentiality issues – HIPAA and other (93 initiatives identified this as a pressing challenge). Defining the value that accrues to the users of the health information exchange (92). Developing a sustainable business model (90). October 22, 2009

52. October 22, 2009

53. The Role of States and Regions October 22, 2009

54. The Role of States and Regions States will continue to act as laboratories for innovation in HIT, but now there is a strong federal impetus for states to ensure the success of eHealth within their geographic boundaries Developing a statewide infrastructure for health information exchange State HIE grants Partnering with efforts to promote the adoption and meaningful use of EHRs Regional extension centers Drawing on the purchasing power and influence of state government to promote best practices Example: The Louisiana Rural Health Information Exchange, supported by Louisiana Medicaid October 22, 2009

55. eHealth In Ohio Ohio Health Information Partnership State-designated entity for HIT/HIE leadership State HIE Grant for Ohio: Full application was due Oct 16th Regional Extension Centers in Ohio: Full applications for first round are due Nov 3r Ohio announced in August that it would dedicate $10.1 million to HIT and quality improvement efforts October 22, 2009

56. eHealth In Ohio Other Health Information Exchange Initiatives in Ohio: HealthBridge (Stage 7) Northeast Ohio Regional Health Information Organization (Stage 3) Ohio Osteopathic Association Patient Information Network – Independent Hospital Network (Stage 4) http://www.healthcarereform.ohio.gov/healthit.aspx October 22, 2009

57. Thank You! Jennifer Covich Bordenick [email_address] 202-624-3288 www.eHealthInitiative.org Don’t Miss eHI’s Annual Conference in Washington, DC on January 25 th and 26 th ! October 22, 2009

58. presented by Élise Spriggs Scanning the Legislative Landscape

59. Overview of HIT Provisions Included in the American Recovery and Reinvestment Act (ARRA)

60. What Problems Are We Trying to Solve with HIT? Continued challenges around quality and safety Predominantly fee for service payment system rewards doing more vs. doing better A 2002-2004 study of hospitalizations in the U.S. found that about 83,000 potentially preventable deaths occurred each year 1 1 Health Grades Third Annual Patient Safety in American Hospitals Study, Apr. 2006.

61. What Problems Are We Trying to Solve with HIT? Rising healthcare costs U.S. spending is rising at a rate of almost 7% a year—rapidly outpacing projected growth in GDP (4%) and wages (3%) U.S. spends 16% of total GDP an increase of 6.7% over 2004 spending—growth in spending is projected to average 6.7% annually over the period 2007 through 2017 2 Access issues The U.S. Census Bureau estimates that 45.7 million Americans (about 15.3% of the total population) had no health insurance at some point during 2007 3 2 “National Health Expenditures, Forecast Summary and Selected Tables,” Office of the Actuary in the Centers for Medicare & Medical Services , 2008, retrieved Mar. 20, 2008. 3 “Income, Poverty & Health Insurance Coverage in the United States,” U.S. Census Bureau , Issued Aug. 2008

62. Information technology Reduces medical errors The US Department of Health & Human Services estimates that widespread use of electronic medical records would save 100,000 lives per year by reducing medical errors & lowering healthcare spending by as much as 30% 86% of doctors surveyed said Electric Medical Records (“EMR”) helped reduce medical errors 4 The Role of Information Technology in Improving Healthcare 4 “Electronic Health Records in Ambulatory Care – A National Survey of Physicians,” New England Journal of Medicine , July 3, 2008, p. 54.

63. Information Technology Gets the right information to the right person at the right time to support care delivery 85% of the doctors claimed the records improved the delivery of long-term preventative care 5 Reduces administrative costs The Role of Information Technology in Improving Healthcare 5 “Electronic Health Records in Ambulatory Care – A National Survey of Physicians,” New England Journal of Medicine , July 3, 2008, p. 54.

64. The Role of Information Technology in Improving Healthcare Enables more effective methods to improve population health (e.g. quality and efficiency performance measurement, medical product safety, clinical and effectiveness research, public health surveillance) Enables the patient to more effectively engage with the care delivery team

65. Current Adoption Rates are Low Based on findings from a survey conducted in late 2007 and early 2008, 4% of the physicians reported having an extensive, fully functional electronic records system, and 13% of the physicians reported having a basic system 6 1.5% percent of U.S. hospitals have a comprehensive electronic records system and an additional 7.6% have a basic system 7 6 “Electronic Health Records in Ambulatory Care – A National Survey of Physicians,” New England Journal of Medicine : 359;1. July 3, 2008, pg. 50 7 “Use of Electronic Health Records in U.S. Hospitals,” New England Journal of Medicine : 360;16. April 16, 2009.

66. Current Adoption Rates are Low Computerized provider-order entry for medications has been implemented in only 17% of hospitals 8 Larger hospitals, those located in urban areas and teaching hospitals were more likely to have electronic records systems 9 8 “Use of Electronic Health Records in U.S. Hospitals,” New England Journal of Medicine : 360;16. April 16, 2009. 9 “Use of Electronic Health Records in U.S. Hospitals,” New England Journal of Medicine : 360;16. April 16, 2009.

67. Barriers to Adoption Lack of capital to invest (most common reason) Lack of a sustainable business model for health information exchange & interoperability of existing systems Concerns about privacy and security Lack of standards adoption Workflow and organizational change challenges

68. American Recovery and Reinvestment Act Tries to Address the Barriers

69. AARA At a Glance Funds Funding source How funds will be used for healthcare IT $2B Office of the National Coordinator for Health Information Technology (OHCHIT) $300 million for health information exchanges Remainder used at discretion of ONCHIT to promote HIT; portion of funds expected to fund EMR loan & grant programs $34B Medicare & Medicaid EMR incentives Funds awarded to hospitals and non-hospital affiliated professionals Must use certified EMRs and show “meaningful use” of EMRs $1.1B Comparative Effectiveness Research program $300M for Agency for Healthcare Research and Quality $400M for National Institutes of Health $400M to HHS for research grants $7.2B Commerce Department’s National Telecommunications and Information Administration Grants to support deployment of broadband, telemedicine and distance learning services Most funding will be used for broadband deployment, but a significant portion is expected to be used for telemedicine programs

70. AARA At a Glance Funds Funding source How funds will be used for healthcare IT $85M Indian Health Services Equip Indian Health Services with IT, telemedicine equipment and related infrastructure $50M VA Health System Upgrading and expanding healthcare IT infrastructure $500M Social Security Administration Upgrading SSA’s computer system; at least $40M for new system that uses EMRs to speed processing of disability claims $1.5B Health Resources and Services Administration Awarded to federal community health centers for construction, renovation and equipment, including healthcare IT $2.5B Agriculture Department USDA’s Distance Learning, Telemedicine and Broadband program; to bring broadband to rural areas Unspecified portion of funds will be used for telemedicine projects

71. AARA Covers Numerous Areas Codification of the Office of the National Coordinator for Health Information Technology Standards and Policy Significant Incentives for Meaningful Use Grant and Loan Programs Privacy Policy Support for Research Technical Assistance

72. AARA-Office of the National Coordinator for Health Information Technology Establishes the Office of the National Coordinator Appointed by Secretary of Health and Human Services Dr. David Blumenthal, MD, MPP Leads the implementation of a nationwide interoperable, privacy-protected health information infrastructure set forth under AARA

73. Office of the National Coordinator Will play a key role within HHS Two federal advisory committees will provide guidance and recommendations to the National Coordinator HIT Standards Committee Health IT Policy Committee

74. What is the Role of the HIT Standards Committee? HIT Standards Committee makes recommendations to Dr. Blumenthal on standards, implementation specifications and certification criteria for the electronic exchange and use of health information Initial focus on policies developed by HIT Standard Committee’s 8 areas First set of standards have been sent to OMB for adoption by December 31, 2009 (as required by the legislation)

75. HIT Standards Committee Membership Membership consists of broad range of stakeholders: Jonathan Perlin , Hospital Corporation of America, Chair John Halamka , Harvard Medical School, Vice Chair Dixie Baker , Science Applications International Corporation Anne Castro , BlueCross BlueShield of South Carolina Aneesh Chopra , Chief Technology Officer, OSTP Christopher Chute , Mayo Clinic College of Medicine Janet Corrigan , National Quality Forum John Derr , Golden Living, LLC Linda Dillman , Wal-Mart Stores, Inc. James Ferguson , Kaiser Permanente Steven Findlay , Consumers Union Linda Fischetti , Department of Veterans Affairs Douglas Fridsma , Arizona State University Cita Furlani , National Institutes of Standards and Technology

76. HIT Standards Committee Membership Membership consists of broad range of stakeholders: C. Martin Harris , Cleveland Clinic Foundation Stanley M. Huff , Intermountain Healthcare Kevin Hutchinson , Prematics, Inc. Elizabeth O. Johnson , Tenet Healthcare Corporation John Klimek , National Council for Prescription Drug Programs David McCallie, Jr. , Cerner Corporation Judy Murphy , Aurora Health Care Nancy J. Orvis , Director, Health Standards Participation, Department of Defense J. Marc Overhage , Regenstrief Institute Gina Perez , Delaware Health Information Network Wes Rishel , Gartner, Inc. Richard Stephens , The Boeing Company Sharon Terry , Genetic Alliance James Walker , Geisinger Health System

77. HIT Standards Committee Areas of Review for Recommendations to National Coordinator Eight Areas for Focus Privacy and Security HIT Infrastructure Certified Health Record Disclosure Audit Improve Quality Individually Identifiable Health Information (IIHI) Unusable Demographic Data Needs of Vulnerable

78. HIT Standards Committee Creation of three subcommittees to analyze recommendations of the HIT Policy Committee Clinical Quality Clinical Operations Privacy & Security Generally meet monthly and can participate via web conference or audio teleconference

79. What is the Relevance of the Standards? As each agency implements, acquires, or upgrades health IT systems, it shall utilize, where available, those systems that meet the standards requirements President shall take measures to assure that federal activities involving the broad collection and submission of health information are consistent with standards within three years of adoption Each agency relating to promoting quality and efficient healthcare in federal government administered or sponsored healthcare programs shall require in contracts or agreements with providers, insurers or health insurance issuers, that as they implement, acquire or upgrade health IT systems, they shall utilize, where available, health IT systems and products that use the standards

80. What is the Relevance of the Standards? To greatest extent practicable, the Secretary shall ensure that where funds are expended for the acquisition of health IT, such health IT shall meet the standards, implementation specifications and certification criteria under the legislation Medicare and Medicaid Incentives for healthcare professionals and hospitals require “meaningful use” of “certified EHR Technology” which must use the standards that are adopted

81. Health IT Policy Committee Makes recommendations to Dr. Blumenthal on an overall policy framework for the development and adoption of a national interoperable health information infrastructure, including standards for the secure and private exchange of patient medical information Generally, meet monthly and can participate via web conference or audio teleconference

82. Health IT Policy Committee Membership Membership consists of broad range of stakeholders: David Blumenthal, HHS/Office of the National Coordinator for Health Information Technology, Chair Paul Tang, Palo Alto Medical Foundation, Vice Chair David Bates , Brigham and Women’s Hospital Christine Bechtel , National Partnership for Women & Families Neil Calman , The Institute for Family Health Richard Chapman , Kindred Healthcare Adam Clark , Lance Armstrong Foundation Arthur Davidson , Denver Public Health Department Connie White Delaney , University of Minnesota/School of Nursing Paul Egerman , Businessman/Entrepreneur Judith Faulkner , Epic Systems Corporation Gayle Harrell , Former Florida State Legislator Charles Kennedy , WellPoint, Inc. Michael Klag , Johns Hopkins University, Bloomberg School of Public Health David Lansky , Pacific Business Group on Health Deven McGraw , Center for Democracy & Technology Frank Nemec , Gastroenterology Associates, Inc. Marc Probst , Intermountain Healthcare Latanya Sweeney , Carnegie Mellon University Scott White , 1199 SEIU Training and Employment Fund Roger Baker , Department of Veterans Affairs CDR Michael S. Weiner , United States Navy Tony Trenkle , Centers for Medicare and Medicaid James C. Borland , Social Security Administration

83. Significant Incentives for Meaningful Use Covered under Mr. Porter’s presentation

84. HIT Grants and Loans $2 Billion for HIT Grants and Loans Five focus areas: Regional Extension Centers (RECs) Technical assistance for providers adopting HIT systems Average award $1-$2 million (max award $12 million) National resource center will share best practices to RECs State Grants to Promote HIT State/state-designated entities (New York eHealth Collaborative) Spur health information exchange (HIE)

85. HIT Grants and Loans Five focus areas, cont.: EHR Adoption Loans Grants to states and Indian tribes Potential loan funds for providers (not focus of ONC until 2010) Workforce Training Grants Assistance to higher education instructions to promote HIT workforce Implementation of HIT in Clinical Education EHR in medial school curricula Not hardware/software funding

86. ARRA Adds New Privacy & Security Develops new and expands current federal privacy and security rules for health information and health information exchange Notification of affected individuals in the event their protected health information is breached New restrictions on the use of protected health information Revised patient rights related to EHRs, including requirements that covered entities maintaining EHRs give individuals copies of their records in electronic form and allows patients to request an audit trail of all disclosures of the EHRs

87. ARRA Adds New Privacy & Security Requires patient permission to use their personal health information for marketing purposes Prohibits sale of protected health information Patient authorization for fundraising activities Civil penalties will increase over four tiers Heightened HIPAA enforcement mechanisms Enforcement through state attorney generals Application of certain HIPAA Security Rule, Privacy Rule and enforcement provisions to business associates Clarification that health information exchange initiatives and RHIOs are business associates

88. Thank You! Élise Spriggs Director, Kegler Brown [email_address] (614) 462-5451

89. Rex Plouck, Enterprise Health IT Officer, State of Ohio Ohio Health IT Agenda

90. Ohio’s Health IT Agenda A Public Private Partnership Health Information Exchange Enabling Health IT Adoption

91. A True Partnership Designating a non-profit Leveraging resources Encouraging collaboration Creating a nimble organization Coordinating entity for federal stimulus opportunities . Status: The Ohio Health Information Partnership (OHIP) was created by BioOhio, OHIP’s board is being expanded to accommodate broad stakeholder representation, Governor Strickland has designated OHIP as Ohio’s state designated entity for health IT funding opportunities OHIP has broad support from relevant stakeholders

92. Draft OHIP Structure

93. Information Exchange as a Tool Providing access to the right information, at the right time, in any setting The Health Information Exchange Federated data model Standards based Supports population health and research efforts Enables patient participation Status: OHIP has submitted a letter of intent with HHS for federal funding OHIP intends to submit a final application in October 2009 Development of a state strategic plan and operational plan continues

94. Enabling Adoption A state wide extension center as a resource for health care providers Providing cost effective access to electronic medical record technology Integrating technology into the provider specific environment Helping providers become meaningful users of health IT Status: OHIP has submitted a preliminary application with HHS for federal funding OHIP has been invited to submit a complete application Development of a state strategic plan continues OHIP will create local partnership to deliver service to individual healthcare providers

95. Thank You! Rex Plouck, Enterprise Health IT Officer, State of Ohio Status: OHIP has submitted a preliminary application with HHS for federal funding OHIP has been invited to submit a complete application Development of a state strategic plan continues OHIP will create local partnership to deliver service to individual healthcare providers

96. presented by Jeff Porter Establishing Meaningful Use: From the HITECH Act to Improved Quality of Care

97. Role of the Office of the National Coordinator (ONC) Charged with coordinating nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. ONC is working with the Centers for Medicare & Medicaid Services (CMS), through an open and transparent process, on efforts to officially designate what constitutes “meaningful use.”

98. When do we expect formal rules for meaningful use? CMS is expected to publish a formal definition of meaningful use, for the purposes of receiving the Medicare and Medicaid incentive payments, by December 31, 2009. At that time, the public will be able to comment on the definition, and such comments will be considered in reaching any final definition of the term.

99. HIT Policy and Standards Committees The HIT Policy Committee and the HIT Standards Committee are providing recommendations to the National Coordinator that will help CMS develop initial criteria for meaningful use and assist in planning for any criteria expansion for the future incentive programs. Approximately 800 public comments were received on the HIT Policy Committee’s initial recommendations.

100. Defining “Meaningful Use” Federal HIT Policy Committee Meaningful Use Workgroup Working to develop draft definition of meaningful use CMS will consider the HIT Policy Committee’s recommendations as it drafts regulations. Makes recommendations to David Blumenthal, National Coordinator for HIT, on an overall policy framework for the development and adoption of a national interoperable health information infrastructure, including standards for the secure and private exchange of patient medical information. Federal HIT Standards Committee Makes recommendations to Dr. Blumenthal on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information.

101. Defining “Meaningful Use” Must be “meaningful user” to be eligible for HIT incentive payments and avoid payment penalties Criteria not completely defined in HITECH Statute only provides that eligible providers must use a “certified system” that can exchange health information and report on quality measures.

102. Eligible Professionals Generally speaking, for purposes of meaningful use, “eligible professional” is defined in the following ways: Medicare Medicaid

103. Eligible Professionals: Medicare A physician as defined in section 1861(r) of the Social Security Act, which includes the following five types of professionals: Doctor of medicine or osteopathy Doctor of dental surgery or medicine Doctor of podiatric medicine Doctor of optometry Chiropractor

104. Eligible Professionals: Medicaid Physicians Dentists Certified nurse-midwives Nurse practitioners Physician assistants who are practicing in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) led by a physician assistant.

105. Incentives ARRA provides significant incentives for eligible professionals and hospitals…..

106. Medicare Eligible physicians, including those in solo or small practices, can receive up to $44,000 over five years under Medicare Physicians operating in “Provider Shortage Area” receive a 10% bonus

107. Medicaid Eligible physicians, including those in solo or small practices, can receive up to $63,750 over six years under Medicaid for being meaningful users of certified electronic health records. 30% or more of patients must be covered by Medicaid

108. Medicare and Medicaid HIT Incentives Meaningful Use Standards and Privacy/Security Medicare Incentive payments no sooner than Jan. 1, 2011 Medicaid Incentive payments no sooner than Jan. 1, 2011 OR Penalties Begin Calendar Year 2015

109. Medicare Hospitals that become meaningful users could receive up to four years of financial incentive payments under Medicare beginning in 2011. Large hospitals can qualify for up to $11 million dollars over the period.

110. Medicaid Hospitals that become meaningful users could receive up to six years of financial incentive payments under Medicaid beginning in October 2010. Eligible hospitals include Children’s hospitals and Acute-care hospitals.

111. Medicare and Medicaid HIT Incentives Meaningful Use Standards and Privacy/Security Medicare Incentive payments no sooner than January, 2011. Medicaid Incentive payments no sooner than October, 2010. AND Penalties Begin Full Fiscal Year 2015

112. Penalties There will be no incentive payments available for those who first become meaningful users after 2015. Penalties begin in 2015.

113. Meaningful Use Workgroup Develops Draft Definition Would define meaningful use in three distinct phases (years) 2011, 2013, and 2015 Approach focuses on how to leverage use of EHR/HIT systems to accomplish five goals Improve quality, safety and efficiency Engage patients and their families Improve care coordination Improve population and public health Reduce disparities Ensure privacy and security protections Each phase would define a meaningful user by tying requirements to measurement criteria.

114. Adoption Progression The three-year adoption progression of meaningful use includes: 2011: Data capture and sharing 2013: Advanced care processes with decision support 2015: Improved outcomes

115. Meaningful Use Workgroup Develops Draft Definition 2011 (first phase) Qualify as meaningful user through: “ Data capture and sharing” of key clinical health information Example: Requirement: CPOE for all order types, including medications (inpatient and outpatient) Measurement: Percent of orders entered directly by physicians through CPOE Unclear if “reporting only” or if providers have to meet certain thresholds

116. Development of Standards and Privacy and Security Standards ONC required to develop initial set of standards by December 31, 2009 Technical standards, exchange standards and functionality requirements Will define “certified EHR” for “meaningful use” ONC relying heavily on output from the federal HIT Standards Committee Privacy and Security Develops new and expands current federal privacy and security rules for health information and health information exchange Breach notification Allows patients to request an audit trail of all disclosures of their EHR Requires patient permission to use their personal health information for marketing purposes Enhances and increases enforcement Adds “business associates” to list of those who need to follow rules

117. “ ARRA 8” Requirements Used to Develop Privacy and Security Standards ARRA Priority Areas of Focus Derived Privacy & Security Services HITSP Standards? 1) Technologies that protect the privacy of health information and promote security in a qualified electronic health record, including for the segmentation and protection from disclosure of specific and sensitive individually identifiable health information Identity management Yes User/entity authentication Yes Identity- / role-based access control Yes Label-based access control No Consent management Partial Transmission integrity protection Yes Transmission confidentiality protection Yes 2) Nationwide HIT infrastructure for electronic use and exchange of EHR Secure communications channel Yes Secure email Yes

118. “ ARRA 8” Requirements Used to Develop Privacy and Security Standards ARRA Priority Areas of Focus Derived Privacy & Security Services HITSP Standards? 3) EHR certification (all) -- 4) Technologies that, as a part of a qualified electronic health record, allow for an accounting of disclosures made by a covered entity Auditing Yes Consistent time Yes Inter-enterprise traceability No Non-repudiation Yes 5) The use of certified electronic health records to improve the quality of health care Document integrity protection Yes Transmission integrity protection Yes Non-repudiation Yes Service availability No

119. “ ARRA 8” Requirements Used to Develop Privacy and Security Standards ARRA Priority Areas of Focus Derived Privacy & Security Services HITSP Standards? 6) Technologies that allow individually identifiable health information to be rendered unusable, unreadable or indecipherable to unauthorized individuals Transmission confidentiality protection Yes Deidentification Yes Anonymization Yes Pseudonymization Partial Limited data set No 7) Demographic data N/A -- 8) Special populations N/A --

120. What’s Next? Over the next several months, the Centers for Medicare and Medicaid Services (CMS) will be working with the Office of the National Coordinator and other parts of HHS to develop regulations to govern the initial year of the incentive programs. Included will be a definition of meaningful use for 2011. The proposed rule regarding meaningful use is targeted for publication in late 2009, with a 60-day public comment period.

121. Meaningful Use Matrix

122. Meaningful Use Matrix

123. Meaningful Use Matrix

124. Meaningful Use Matrix

125. Meaningful Use Matrix

126. Meaningful Use Matrix

127. Meaningful Use Matrix

128. Meaningful Use Matrix

129. Meaningful Use Matrix

130. Meaningful Use Matrix

131. Thank You! Jeff Porter Director, Kegler Brown [email_address] (614) 462-5418

132. presented by Ralph Breitfeller E-prescribing

133. presented by Geoffrey Stern The Ethics of E-Health

134. Thank You for Coming!