Presented by: Donna Garwood, RN, BSN, CPHQ KFMC HITREC Educator April 8, 2011 KAOM Overland Park, KS
EHRs and Meaningful Use:
Benefits and Challenges for EPs
Acronyms
REC Regional Extension Center
ONC Office of National the Coordinator
HITRC Health Information Technology Research Center MU Meaningful Use
RHIO Regional Health Information Organization HIE Health Information Exchange
ARRA American Recovery and Reinvestment Act
HITECH Health Information Technology for Economic and Clinical Health Act
eHAC e-Health Advisory Council
PPCP Priority Primary Care Provider CAH Critical Access Hospital
RH Rural Hospital
ARRA and HITECH
• The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009.
• Title XIII of Division A and Title IV of Division B, together are cited as the Health Information Technology for Economic and Clinical Health Act (HITECH Act).
• HITECH includes provisions to promote meaningful use of health information technology to improve the quality and value of American health care.
• Established the Office of the National Coordinator for Health
Information Technology (ONC) within the Department of Health and Human Services.
• ONC is principally responsible for coordinating the effort to implement a nationwide health information technology infrastructure that allows for the use and exchange of electronic health information in electronic format.
EHRs & HIE
The HITECH Act’s Framework
HITECH Act Paper records
Blumenthal D. Launching HITECH. N Engl J Med posted online Dec 30 2009. http://healthcarereform.nejm.org/?p=26691
HIT Presentations at KAOM
KAOM Speakers
•
Kansas Health Information
Network (KHIN)
•
Informatics Corporation of
America (ICA)
•
CMS
•
KFMC – Health Information
Technology Regional
Extension Center
5KHIN
The big picture
Three Separate Programs
•
Physician Quality Reporting System (formerly PQRI)
– 1% incentive for satisfactory reporting in 2011
– Payment adjustments begin in 2015
•
eRx Incentive Program
– 1% incentive for successful electronic prescribers in 2011
– Payment adjustments begin in 2012
•
EHR Incentive Program
– Incentives dependent on registration category
– Medicare and Medicaid Programs
Breast Cancer Screening Rate
Jen Brull, MD (shared with permission Dec 2010)
This baseline data reflects a 2 year period beginning 1/1/07 thru 12/31/08 and then updated quarterly. 65% 76% 82% 86% 97% 94% 99% 0% 20% 40% 60% 80% 100% Base Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
Improvement is attributed to having accurate, reliable data available at point of care and involvement of a care team, nurse and doctor to address gaps. Initial large gain is due to proactive campaign by nursing staff which involved ordering mammogram and notifying patient if overdue. This method required patient to actively decline
Colo-Rectal Cancer Screening Rate
Jen Brull, MD (shared with permission Dec 2010)
43% 43% 44% 54% 68% 74% 81% 0% 20% 40% 60% 80% 100% Base Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
This baseline data reflects a 2 year period beginning 1/1/07 thru 12/31/08 and then updated quarterly.
Improvement is attributed to having accurate, reliable data available at point of care and involvement of a care team, nurse and doctor to address gaps. Starting Quarter 3, nurse suggested intervention to place stool hemoccult kit in patient room to trigger physician discussion with patients not current. During Quarter 5, the referral process for colonoscopy was streamlined to allow the provider to complete the referral kit at the point of care which eliminated an existing barrier.
Goals for Value-Based Purchasing
• Financial Viability —where the financial viability of the traditional Medicare
fee-for-service program is protected for beneficiaries and taxpayers.
• Payment Incentives —where Medicare payments are linked to the value (quality and
efficiency) of care provided.
• Joint Accountability —where physicians and providers have joint clinical and
financial accountability for healthcare in their communities.
• Effectiveness —where care is evidence-based and outcomes-driven to better manage
diseases and prevent complications from them.
• Ensuring Access —where a restructured Medicare fee-for-service payment system
provides equal access to high quality, affordable care.
• Safety and Transparency —where a value based payment system gives beneficiaries
information on the quality, cost, and safety of their healthcare.
• Smooth Transitions —where payment systems support well coordinated care across
different providers and settings.
• Electronic Health Records —where value driven healthcare supports the use of
information technology to give providers the ability to deliver high quality, efficient, well coordinated care.
Medicaid Payments Started
• As of 4/6/11 - $64 million in Medicaid incentive payments have paid to Eligible Professionals and Hospitals by 4 states
– Oklahoma, Kentucky, Louisiana, and Iowa
• Additional payments are in process in the states above as well as in Alaska, Michigan, Mississippi, North Carolina, South
Carolina, Tennessee and Texas
• Medicare providers will be able to attest to meaningful use in mid- to late April, and issuance of Medicare payments is
Who are Eligible Professionals
•
Eligibility determined in law
•
Hospital-based EPs are not eligible for
incentives
–
Definition: 90% or more of their covered
professional services in either an inpatient (POS
21) or emergency room (POS 23) of a hospital
–
Definition of hospital-based determined in law
•
Incentives are based on the individual,
not the practice
Who are Eligible Professionals
•
Medicare Eligible Professionals include:
–
Doctors of medicine or osteopathy
–
Doctors of dental surgery or dental medicine
–
Doctors of podiatric medicine
–
Doctors of optometry
–
Chiropractors
•
Specialties are eligible if meet one of above
criteria
ARRA Medicare Payment
Incentives for EPs
Note: The above table represents the maximum potential incentive unless the EP also qualifies for the HPSA bonus of 10%.
Medicare Incentives/Penalties for Eligible Professionals
EHR Adoption Year
2011- 2012 2013 2014 2015+ Pay m en t Year 2011 $ 18,000 $ - $ - $ - $ - 2012 $ 12,000 $ 18,000 $ - $ - $ - 2013 $ 8,000 $ 12,000 $ 15,000 $ - $ - 2014 $ 4,000 $ 8,000 $ 12,000 $ 12,000 $ - 2015 $ 2,000 $ 4,000 $ 8,000 $ 8,000 -1% 2016 $ - $ 2,000 $ 4,000 $ 4,000 -2% 2017 $ - $ - $ - $ - -3% 2018 $ - $ - $ - $ - -4% 2019 $ - $ - $ - $ - -5% Total $ 44,000 $ 44,000 $ 39,000 $ 24,000
Who are Eligible Professionals
•
Medicaid Eligible Professionals include:
–
Physicians
–
Nurse practitioners
–
Certified nurse-midwives
–
Dentists
–
Physician assistants working in a Federally
Qualified health Center (FQHC) or Rural Health
Clinic (RHC) that is so led by a physicians
assistant
Who are Eligible Professionals
•
Medicaid Eligible Professionals must also
meet one of the three patient volume
thresholds:
–
Have a minimum of 30% Medicaid patient volume
–
Pediatricians ONLY: Have a minimum of 20%
Medicaid patient volume
–
Working in an FQHC or RHC ONLY: Have a
minimum of 30% patient volume attributed to
needed individuals
•
CHIP, sliding scale, free care only count towards
thresholds if working in RHC or FQHC
ARRA Medicaid Payment
Incentives for EPs
Note: Payment years do not have to be consecutive to receive all incentive payments available through 2021.
Regional HIT Extension Program
• $640 Million dollars to fund ~62 RECs
– Goal is to help 100,000 providers
– $6400 per provider
• Awarded in two cycles
– At least one REC in each region during first round of funding
KS REC Objectives
Provide hands on expertise to assist providers in leveraging
HIT and moving towards MU.
• Help at least 1,200 PPCPs move towards MU
• Onsite tailored assistance from experienced staff
• MU resource – Q&A available on website
• CAH/RH support – 95 facilities qualify
• Partnership with KHERF/KHA
• Education and tools to help these facilities move towards MU
• Assistance to Non-PPCPs also available
• Onsite tailored assistance is also available to non-subsidized providers
Priority Primary Care Providers
For purposes of the REC cooperative agreements, a “primary-care provider” is any MD or DO, any ARNP, Nurse mid-wife, or PA with prescriptive privileges in the locality where s/he actively practices in one of the following specialties: family, internal, pediatric, obstetrics and gynecology, or geriatric.
Priority primary care providers function in the following settings:
– Individual and small group practices (ten or fewer professionals with prescriptive privileges) primarily focused on primary care;
– Public and Critical Access Hospitals
– Community Health Centers and Rural Health Clinics; and
– Other settings that predominantly serve uninsured, underinsured, and medically underserved populations
Kansas REC Participating Practices
579 Kansas Physicians/Practitioners Receiving Assistance
516 Priority Primary Care Providers (PPCPs) and 63 Specialists
Hays (1) Kansas City (2) Lansing (1) Leavenworth (1) Clay Center (1) Chanute (1) Fredonia (3) Lawrence (5) T opeka (2) Hutchinson (1) Hesston (1) Moundridge (1) Ellinwood (1) Great Bend (1) McPherson (1) Hoisington (1) Lindsborg (1) Jetmore (1) Pittsburg (2) Wichita (12) Wellington (1) Medicine Lodge (1) Goodland (1) Oakley (1) Arkansas City (1) Atchison (1) Atwood (1) Augusta (1) Belleville (1) Colby (1) Dighton (1) Eureka (1) Garden City (2) Greensburg (1) Hanover (1) Hoxie (1) Iola (1) Junction City (3) Kinsley (1) Larned (1) Manhattan (4) Marion (1) Meade (1) Neodesha (2) Newton (1) Osborne (1) Ottawa (1) Phillipsburg (1) Plainville (4) Quinter (2) Ransom (1) Sabetha (1) Saint Francis (1) Salina (1) Scott City (1) Spring Hill (1) Winfield (1)
Rural Health Clinic Community Health Center Private Practice (1-10)
As of 4/5/2011 Specialty Practice
MU Stage 1 Health
Outcome Priorities*
•
Improve quality, safety, efficiency, and reduce health
disparities
•
Engage patients and families in their healthcare
•
Improve care coordination
•
Ensure adequate privacy and security protections for
personal health information
•
Improve population and public health
*Adapted from National Priorities Partnership National Priorities and Goals: Aligning our Efforts to Transform America’s Health Washington DC: National Quality Forum, 2008.
Basic Overview of MU Final Rule
•
Stage 1 (2011 and 2012)
–
To meet certain objectives/measures, 80% of patients
must have records in the certified EHR technology
–
EPs have to report on 20 of 25 MU objectives
(15 core and 5 menu set)
–
EHR Reporting Period – 90 days for first year; one
year subsequently
–
Medicaid – for the 1
stparticipation year there is no
EHR reporting period. MU can be met through A/I/U
–
Reporting by attestation required in 2011, electronic
reporting to CMS required in 2012
MU Final Rule Measures – Core Set
Objective
1. Use computerized order entry for medication orders
2. Implement drug-drug and drug-allergy checks
3. Generate and transmit permissible prescriptions electronically (EPs only) 4. Record patient demographics-gender,
race, ethnicity, date of birth, preferred language. Hospitals add mortality date & cause of death
5. Maintain an up-to-date problem list of current and active diagnoses
6. Maintain active medication list
Measure
1. More than 30% of patients with at least one medication in their
medication list have at least one medication ordered through CPOE 2. Functionality is enabled for these
checks for the entire reporting period 3. More than 40% are transmitted
electronically using certified EHR technology
4. More than 50% of patients’ demographic data recorded as structured data
5. More than 80% of patients have at least one entry recorded as
structured data
6. More than 80% of patients have at least one entry recorded as
MU Final Rule Measures – Core Set
Objective
7. Maintain active medication allergy list
8. Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth charts for <20yo)
9. Record smoking status for patients 13 years old or older
10. Implement one clinical decision support rule and ability to track compliance with the rule
11. Report Clinical Quality Measures (CQMs) to CMS or the States
Measure
7. More than 80% of patients have at least one entry recorded as
structured data
8. More than 50% of patients 2 years of age or older have height, weight and blood pressure recorded as
structured data
9. More than 50% of patients 13 years of age or older have smoking status recorded as structured data
10. One clinical decision support rule implemented
11. 2011: provide aggregate numerator and denominator through attestation; 2012: electronically submit measures
MU Final Rule Measures – Core Set
Objective
12. Provide patients with an electronic copy of their health information upon request-diagnostic test results,
problem list, medication lists,
medication allergies. Hospitals add discharge summary and procedures 13. Provide patients with an electronic
copy of their discharge instructions at time of discharge, upon request
(hospital only)
14. Provide clinical summaries to patients for each office visit (EPs only)
Measure
12. More than 50% of requesting patients receive electronic copy within 3 business days
13. More than 50% of all patients who are discharged who request an electronic copy of their discharge instructions are provided it
14. Clinical summaries are provided to patients for more than 50% of all office visits within 3 business days
MU Final Rule Measures – Core Set
Objective
15. To exchange key clinical information electronically among providers and patient authorized entities
16. Protect electronic health information (privacy & security)
Measure
15. Perform at least one test of EHR’s capacity to electronically exchange information key clinical information 16. Conduct or review a security risk
analysis; implement security updates as necessary; correct identified
MU Final Rule Measures – Menu Set
Objective
1. Implement drug-formulary checks
2. Incorporate clinical lab-test results into certified EHR as structured data
3. Generate lists of patients by specific conditions to use for quality
improvement, reduction of
disparities, research, and outreach 4. Send reminders to patients per
patient preference for preventive/ follow-up care (EPs only)
Measure
1. Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period
2. More than 40% of clinical laboratory test results whose results are in
positive/negative or numerical format are incorporated into EHRs as
structured data
3. Generate at least one listing of patients with a specific condition
4. More than 20% of patients ≥65 years old or ≤5 years old are sent
MU Final Rule Measures – Menu Set
Objective
5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) (EPs only)
6. Use certified EHR to identify patient-specific education resources and provide to patient if appropriate
7. Perform medication reconciliation as relevant (between care settings)
8. Provide summary care record for transitions in care or referrals
9. Record advance directives for patients 65 years old or older (Hospitals only)
Measure
5. More than 10% of patients are provided electronic access to information within 4 days of its being updated in the HER
6. More than 10% of patients are provided patient-specific education resources
7. Medication reconciliation is performed for more than 50% of transitions of care
8. Summary of care record is provided for more than 50% of patient transitions or referrals
9. More than 50% of patients will have an indication of advance directive status recorded
MU Final Rule Measures – Menu Set
Objective
10. Capability to submit electronic data to immunization registries and actual submission*
11. Capability to provide electronic
syndromic surveillance data to public health agencies and actual
submission*
12. Capability to submit electronic data on reportable lab results to public health agencies and actual
submission* (Hospitals only)
* At least one public health objective must be selected.
Measure
10. Perform at least one test of data
submission and follow-up submission (where registries can accept
electronic data)
11. Perform at least one test of data submission and follow-up
submission (where public health agencies can accept electronic data)
12. Perform at least one test of data submission and follow-up
submission (where public health agencies can accept electronic data)
CQMs – Eligible Professionals
Core CQM (must report on all 3*)
• Hypertension: Blood Pressure Management (NQF 0013).
Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded.
• Preventive Care and Screening Measure Pair: Tobacco Use Assessment and Tobacco Use Intervention (NQF 0028).
Percentage of patients aged 18 years or older who have been seen for at least 2 office visits, who were queried about tobacco use one or more times within 24 months. And percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention.
• Adult Weight Screening and Follow-Up (NQF 0421).
Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.
* If the denominator of 1 or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures.
CQMs – Eligible Professionals
Alternate Core CQM
• Preventative Care and Screening: Influenza Immunization for Patients ≥50 Years Old (NQF 0041)
Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)
• Weight Assessment and Counseling for Children and Adolescents (NQF 0024)
Percentage of patients 2-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.
• Childhood Immunization Status (NQF 0038)
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or more rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.
CQMs – Additional set for Eligible
Professionals (select 3 of 38)
1. Diabetes: Hemoglobin A1c Poor Control
2. Diabetes: Low Density Lipoprotein (LDL) Management and Control
3. Diabetes: Blood Pressure Management
4. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
5. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with prior Myocardial Infarction (MI)
6. Pneumonia Vaccination Status for Older Adults
CQMs – Additional set for Eligible
Professionals (select 3 of 38)
8. Colorectal Cancer Screening
9. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD
10. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
11. Anti-depressant Medication Management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment
12. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
13. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
CQMs – Additional set for Eligible
Professionals (select 3 of 38)
14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
15. Asthma Pharmacologic Therapy
16. Asthma Assessment
17. Appropriate Testing for Children with Pharyngitis
18. Oncology Breast Cancer: Hormonal Therapy for State IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer patients
CQMs – Additional set for Eligible
Professionals (select 3 of 38)
21. Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco use Cessation Medications, c)
Discussing Smoking and Tobacco Use Cessation Strategies
22. Diabetes: Eye Exam
23. Diabetes: Urine Screening
24. Diabetes: Foot Exam
25. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol
26. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation
CQMs – Additional set for Eligible
Professionals (select 3 of 38)
27. Ischemic Vascular Disease (IVD): Blood Pressure Management
28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
29. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment; a) Initiation, b) Engagement
30. Prenatal Care; Screening for Human Immunodeficiency Virus (HIV)
31. Prenatal Care: Anti-D Immune globulin
32. Controlling High Blood Pressure
CQMs – Additional set for Eligible
Professionals (select 3 of 38)
34. Chlamydia Screening for Women
35. Use of Appropriate Medications for Asthma
36. Low Back pain: Use of Imaging Studies
37. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
CQMs – Eligible Professionals
•
Summary
– EPs must report on 6 total measures
• 3 required core measures (substituting alternate core measures where necessary)
• 3 additional measures
– CQMs align with Physician Quality Reporting Initiative (PQRI)
– Alignment between 4 HITECH CQM and the CHIPRA initial core set that providers report to States
More Information
Meaningful Use – Beyond Stage 1
• Stage 2 would expand upon the Stage 1 criteria in the areas of disease management, clinical decision support, medication management,
support for patient access to their health information, transitions in care, quality measurement and research, and bi-directional communication with public health agencies. CMS may consider applying the criteria more broadly to both the inpatient and outpatient hospital settings.
• Consistent with other provisions of Medicare and Medicaid, Stage 3 would focus on achieving improvements in quality, safety and
efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data, and improving population health outcomes.
If Only
REC Services
– Education and Outreach
– Participate in National Learning Consortium
– Vendor Selection and Group Purchasing Plans
– EHR Implementation and Project Management
– Workflow Redesign
– Functional Interoperability and Health Information Exchange
– Privacy and Security Practices
APS, KFMC and REC Participants
Thanks to a strategic partnership between APS and
KFMC, providers who sign up with the KFMC HITREC
to implement their EHR automatically gain membership
in APS. This means your facility will have access to
powerful group purchasing capabilities that were
previously available primarily to Kansas and Missouri
hospitals. In addition to saving money on your EHR
hardware and software, your membership allows you to
take advantage of many contract areas such as
Technology, Office, Clinical, etc
.
EHR Vendor Partners
Tier I
Cerner
eClinicalWorks
e-MDs
McKesson
Pulse
SuccessEHS
Tier II
NextGen
Sage
VENDOR J VENDOR I VENDOR E VENDOR A VENDOR F VENDOR G VENDOR K VENDOR B VENDOR H VENDOR C VENDOR D 0 5 10 15 20 25 30 $80,000 $100,000 $120,000 $140,000 $160,000 $180,000 $200,000 Wi lli n ge ss to c o m p ly w ith APS stan d ar d c o n tr ac t te rm s / c o n d ition s
10-Yr Cost of Ownership
Price includes “hosted” software cost + interfaces over 10 years for 1 provider, 1 mid-level practitioner, and 1 RN for Electronic Medical Record and Practice Mgmt. software
Hosted (SaaS) EHR & PM
Higher Cost Vendors Lower Cost Vendors
Acceptance Rejection MOST FAVORABLE CONTRACTS LEAST FAVORABLE CONTRACTS
I am delighted to be working
with KFMC, the Kansas
Regional Extension Center!” Dr.
Jen Brull of Prairie Star Family
Practice said. “I anticipate their
team will assist me greatly in
achieving Meaningful Use, and I
look forward to their help.”
“
”
Dr. Brull is a family medicine physician in solo practice in Plainville, Kansas. This is her ninth year of private practice in a rural
community. Special interests include electronic health records, maternal/child care, and preventive medicine.
Kansas Foundation for Medical Care, Inc…
Your Regional Extension Center
• Expertise – invaluable experience working with Kansas
providers on implementation of HIT
• Availability – KFMC staff are located in your area of the state in
order to answer your questions, provide hands-on education, and performon-site analysis
• Costs – are lower. We are a not-for-profit, and federal subsidies
support our technical assistance to Priority Primary Care Providers for adopting and optimizing HIT
• Partners – We have many partners throughout the state of
Kansas to help ensure that the REC is aware and properly aligned with statewide activities
What You Can Do Now
Contact your Regional Extension Center
Phone: 800-432-0770
E-mail:
RECsupport@kfmc.org
Follow our Website at
www.kfmc.org
Sign up for updates on our Blog (link on KFMC website)
Our field staff are scheduling visits today!
This material was prepared by Kansas Foundation for Medical Care, Inc. as part of our work as the Kansas Regional Extension Center, under grant #90RC0003/01 from the Office of the National Coordinator, Department of Health & Human Services. RC_2011_58
