“Meaningful Use”
of
Computers in Medicine
How Will NICUs Fit In?
Willa H. Drummond, MD, MS (Informatics) Professor of Pediatrics & Physiology University of Florida College of Medicine
Disclosures
Relevant financial relationships
Nothing to disclose
FDA
Seven years ago...
3
George W. Bush, April 26, 2004 “…Within 10 years, every American must have a
personal electronic medical record.
That's a good goal for the country to achieve.
The federal government has got to take the lead in order to make this
“ARRA” Legislation
(“Stimulus Bill”)
• American Recovery & Reinvestment Act
• Passed & signed; Feb 2009
• Anticipated HIT budget $45 Billion • Final “Meaningful Use” Incentive
Criteria Published - July 2010
...17 Months Later !
• STIMULUS Bill incentives start @ 2011
Fiscal Year. Thus, so do the MU
timelines.
• Hospitals’ 2011 Fiscal Year started in
October, 2010
• Lead time was very short (2.5 months!)
• Usual development time for software
upgrades, testing<> installation is about 18 months.
Certification Process NPRM Released Comments on NPRM due (60 days) Final Rule Released (60 days to draft final rule) Final Rule effective (60 days after release) Federal process to recognize certification entities established (60 days after effective date) First certification entities recognized by federal government (60 days after established) Significant number of products certified (6 months after first entity recognized) Hospitals select products and establish contracts (6 month process) Vendor places hospital on schedule (6 month wait time) Installation (18 to 24 month process) Achieve meaningful
use for the first time
(90 day reporting
period)
Timeline for Meaningful Use
(What took so long?)
Mar 2010 May 2010 July 2010 Sep 2010 Nov 2010 Jan 2011 June 2011 July – Dec 2011 Jan – June 2012 July 2012 - Dec 2013 Jan – Mar 2014 Incentive Program To Start – FY 2011 Amount of incentive drops for newly eligible hospitals – FY 2014 Penalties begin – FY 2015 FINAL RULE T
Total Federal Health IT Spending (through “ONC”) before the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act:
$300,000,000
Total expected gross outlays through HITECH (up to):
$45,000,000,000
15,000% increase >>>>>>
Historical Look at Spending in Health IT
6
Meaningful Use - DOB July, 2009
860+ page document for the Final Rule Only discusses STAGE ONE
15 core requirements, 10 menu requirements
Quality Measures are not Pediatric appropriate
Eligibility Based on Medicare/Medicaid Patients 20% to 30% Medicaid patient encounters
Inpatient physicians, some with > 50% Medicaid patients…. ….are excluded from incentive payments.
Infants under age 2 are also excluded
(both Inpatient and Outpatient)
NEED for Advocacy and Advising
Office of the National Coordinator (www.healthit.gov )
Center for Medicare and Medicaid Services (www.cms.gov )
Multiple Standards and Policy Agencies
“The Meaningful Use framework will be about
the goals of care, not the technology.”
“The HITECH Act makes clear that the adoption
of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.”
David Blumenthal, MD National Coordinator, ONCIT
Improve quality, safety, efficiency and reduce
disparities
Engage patients
Improve coordination of care
Ensure privacy & security of PHI
Improve population health and interact with
public health programs
Stage
Focus
Date RangeStage 1 Electronic data capture, track & communicate
key conditions, clinical decision support (CDS), quality measure & public health data reporting
Starting in 2011
Stage 2 Expands on Stage 1, covers disease
management dimensions, information
exchange in the most structured format
possible (CPOE and diagnostic study results
like Labs & Rads)
Starting in 2013
Stage 3 Promotes improvements in quality, safety &
efficiency as well as population health, focuses on CDS for national high priority conditions & Patient self-management tools
(Subject to great change & many refinements)
Starting in 2015
What is MU & Who determines it?
The three basic requirements for
“Meaningful Use” as defined in the new
law, include:
Use of “certified” EHR technology.
Electronic exchange of health information
Use EHR to report clinical and process-based
quality measures
Medicare & Medicaid patient mix defines
Vendor Certification Processes
Two Certification Programs
Temporary certification program to test and certify
Complete EHRs and/or EHR Modules (until Q1 2012) To Assure availability of Certified EHR Technology in time to
meet MU incentives (for 2012 and beyond).
Permanent certification program to replace the
temporary certification program
Separate the responsibilities for performing testing and certification
Introduce accreditation requirements
Establish requirements for certification bodies.
3 Certifying Agencies approved 12/2010
21 Certified products as of Oct 1, 2010 Still a Work in Progress.
HITECH's Framework for MU $$$s
MU Operational Plans:
Regional Extension Centers (RECs)
$
650 million funded by the HITECH Act
Creating a network of ~70 Regional Health
Information Technology Extension Centers
Focusing initially on primary care providers in small practices
Assists and advises physicians and hospitals
in gaining “Meaningful Use” of EHRs.
Which Health Care Professionals
Are Eligible for MU Incentives?
Under the HITECH Act, an eligible
professional is defined as, “a physician,
as defined in section 1861(r)” of the
Social Security Act; which includes:
Physician Excludes Hospitalists Dentists Podiatrists Optometrists Chiropractors
Medicare & Medicaid Services:
EHR Incentive Program
Defines Eligible Hospitals (EH) & Eligible Professionals (EP)
Establishes payment years & reporting periods
Creates 3 Stages of implementation;
Provides details on Stage 1 Goals & requirements for
2011 and 2012.
Includes hospitals, but…..
Inpatient Physicians (IPs) are bystanders in the mandate
... Excluded from financial incentive eligibility,
Few adequate computer tools exist for complex venues,
No pediatric-designed Inpatient systems yet exist, and;
What is required for MU?
Provider
Must use the certified EHR as the primary
record of care for patients
Reports certain clinical quality measures
to CMS (or the State under Medicaid)
Provides certain attestations regarding
How will physicians prove MU?
Demonstration of Meaningful Use and
information exchange may be satisfied by:
An attestation (2011) ~ like IRS forms
Submission of claims with appropriate coding
After code sets are stabilized during ICD10 roll-out in 2013
Electronic reporting of clinical quality measures
Increasing percentages at each stage
“Quality measures” now are challenged as “not data based” Or as unlikely to change behavior, or improve care (e.g. the
Eligibility Under Medicaid: Providers
Any Provider with a National Provider Identifier
Who over a continuous, representative 90-day
period in the calendar year prior to reporting:
Has at least 30% of all patient encounters as
Medicaid patients; or,
Is a PEDIATRICAN and has at least 20% of
Being a Pediatrician is an Advantage:
Medicare providers will have $ penalties as
early as 2015 for failing to meet MU criteria
No MU penalties (after 2015) for Medicaid
participants
Proposes implementation schedules and MU
criteria for 2013 are in the public comment period
Comment Deadline for 2013 MU criteria is
2/28/2011 (www.healthit.gov)
Please speak your minds & voice your
opinions re excluding infants and children < 2 years old, and inpatient docs ...TODAY.
Medicaid Providers
Users of Certified EHR Technology in 2011
Do NOT need to demonstrate – Attestation ONLY!
Registration requires State
CMS office readiness.
Earliest Payment:
Register: January 2011
Attest: April 2011
MU “Registration” Began Jan 3, 2011
Registration is Administered by the Centers for
Medicare & Medicaid Services (CMS).
State by State Basis
As of Februqry 2011 (about 2 dozen) states
were ready to process incentive applications.
Florida was not
First checks have already been sent out, in
Core Set - 2011
Use CPOE
Denominator: Unique patients with at least
one medication
Numerator: Number of patients with at least
one medication order in CPOE
Core Set - 2011
Drug-Drug & Drug-Allergy Check
Functionality enabled 100% of the time
Unintended Consequences: Physician
workarounds for “over-alerting” and “alert fatigue”
ePrescribing
Denominator: permissible prescriptions
Numerator: prescriptions transmitted
electronically using the EHR
Core Set - 2011
Record Demographics
Date of Birth (needs Time), Preferred
Language, Gender, Race, Ethnicity, (2010 census definitions)
Denominator: Unique patients
Numerator: Patients with recorded
demographics
Core Set - 2011
Recording of Smoking Status
Denominator: Unique Patients >= 13 years
Numerator: patients with recorded smoking
status
Core Set - 2011
Clinical Decision Support
Implement one CDS rule
Report Ambulatory Clinical Quality
Measures
2011 – attestation
2013 – electronic submission
Core Set - 2011
Electronic Copy of Health Information
Diagnostic test results, problem list, medication list, medication allergy list
Denominator: All unique patients who
requested a copy
Numerator: Patients who received a copy
within 3 business days
Core Set - 2011
Clinical Summary
May include updated medication list, test
results, procedures and instructions
Denominator: All unique patients
Numerator: Patients who received a Clinical
Summary within 3 business days
Core Set - 2011
Capability to exchange key
clinical information
Perform 1 test of EHR’s capacity to
exchange electronically
Protect EHR information
Security risk analysis, implement security, correct deficits
2011 Menu Set - select 5 of 10
1.
*
Implement drug-formulary checks Functionality enabled and access to 1 or more or
formularies
2.
*
Incorporate lab results >40% of laboratory results are incorporated in
EHR
3.
*
Patient List by condition Generate at least 1 report of patients with a
specific condition
2011 Menu Set - select 5 of 10
4
. Preventive or Follow-Up Care
>20% of patients >=65 years or <=5years received an appropriate reminder
5
. *
Timely Electronic Access
>10% of unique patients are provided electronic access to health information within 4 business days
Providers may withhold information
MU Measurement
Even though incentives are paid by
Medicare or Medicaid, the requirements
for MU apply to ALL patients.???
MU measurements are based on a
Measure Reporting Rules for Kids
Pediatricians required to report
3 “core” measures
3 “alternate core” measures
If the denominator is 0 for any core measure, replace with alternate core measures
If the denominator is 0 for all core and
alternate core measures, then report on 3 of the “additional” measures
Is this kid over or under 2? Does he count as a person?
Additional Measures = 0 for NICU
% of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) and prior myocardial infarction (MI) that were prescribed beta-blocker therapy.
% of patients 65 years of age and older who have ever received a pneumococcal vaccine.
% of women 40-69 years of age who had a mammogram to screen for breast cancer.
% of adults 50-75 years of age who had appropriate screening for colorectal cancer.
% of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy.
% of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD (LVEF < 40%) and who were prescribed betablocker therapy.
The % of patients 18 years of age and older who were diagnosed with a new episode of
major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment.
% of patients aged 18 years and older with a diagnosis of primary open angle glaucoma (POAG) who have been seen for at least 2 office visits who have an optic nerve head evaluation during one or more office visits within 12 months.
% of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.
•
Meaningful Quality Reporting Measures for Pediatrics ……are limited.•
Reporting Measures are of little use to sub-specialists•
Many measures could have been expanded to include .pediatric-appropriate health concernsMU: Demographics & Opinions
23% Do Not Intend To Pursue Stimulus
Incentives
23% Do Not Intend To Pursue Stimulus
Incentives
17% Do Not Plan On An EMR
What’s the Problem With EMRs?
Source: TMA survey, 2009
50% 38% 32% 31% 27% 23% 13% 12% 6%
So – what to do?
Certified EHR – talk to your vendor!
National Provider Identifier – get yours, if necessary
Assess Your Medicaid Population
Your Inpatients may boost the hospital’s overall eligibility
Hospital-based practices, NICUs, PICUs and their
physicians, may suffer rapid implementations of software systems not designed to support the teamwork-based, real-time critical workflow for infants.
Source and nature of rewards for
NICU and Hospitalist docs is unclear.
Much Thanks To Many Sources
Medicare and Medicaid Programs; Electronic Health Record Incentive Program - Notice ofProposed Rule Making. http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf
Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology - Interim Final Rule
http://edocket.access.gpo.gov/2010/pdf/E9-31216.pdf
Diamond L, Bates M. Quality Metrics Requirements for Obtaining Meaningful Use: Developing a Plan for Implementation. (HIMSS web site)
Minnesota health: http://www.health.state.mn.us/e-health/hitech/ht052009faqprov.pdf
HIMSS: One stop for all ARRA information www.himss.org/economicstimulus
ONC: http://healthit.hhs.gov
CMS: www.cms.hhs.gov
Tennessee Office of eHealth Initiatives
California Center for Connected Health
Dr. Joseph Schneider, Past-Chair, AAP Council on Clinical Information Technology
Dr. Eugenia Marcus, Past Vice-Chair, AAP COCIT
Ms. Joy Kuhl, Alliance for Pediatric Quality/HL7 Peds SIG
Ms. Beki Marshall & Ms. Jennifer Mansour, AAP Council Staff Extrordinaire
Acronyms Dictionary
AQA – Ambulatory Care Quality Alliance LINK
ARRA – American Recovery and Reinvestment Act (a.k.a. the “stimulus bill”) LINK
CCHIT – Certification Commission on Health Information Technology
CDS – Clinical Decision Support LINK, Text Book (link)
CPOE – Computerized Provider Order Entry
CPI – Continuous Process Improvement
EH - Eligible Hospital as defined by the CMS EHR Incentive Program (Internal Link)
EHR – Electronic Health Record
EP – Eligible Provider as defined by the CMS EHR Incentive Program (Internal Link)
HIE – Health Information Exchange
HIT – Health Information Technology
HITECH - Health Information Technology for Economic and Clinical Health Act
HQA – Hospital Quality Alliance (LINK)
IFR – Interim Final Rule LINK
MU – Meaningful Use LINK
NACHRI – National Association of Children’s Hospitals and Related Institutions
NPRM– Notice of Proposed Rule Making LINK
NQF – National Quality Forum LINK
ONC – The Office of the National Coordinator for Health Information Technology LINK
PHI – Protected Health Information LINK
PI – Process Improvement LINK
PQRI – Physician Quality Reporting Initiative LINK
QuIIN – Quality…..
RECs – Regional Extension Centers
