Meaningful Use (MU) Update

1. Meaningful Use (MU)Update January 2010

2. Proposed MU Rules • HHS released 2 proposed rules 12/30/2009: • CMS Notice of Proposed Rule Making • Medicare and Medicaid: Electronic Health Record Incentive Program • Published in federal register 1/13/2010 which starts a 60-day public comment period • Final rule expected May/June 2010 timeframe • ONC Interim Final Rule • Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology • Published in federal register 1/13/2010 effective 30 days later • Awaiting NPRM on EHR certification process 2

3. The MU Basics • Eligible professionals (EP) and hospitals can earn significant Medicare and Medicaid incentives for demonstrating “meaningful use” (MU) of certified electronic health record (EHR) technology • Incentive program timeframe: • Medicare: 2011- 2015 (EPs and hospitals) • Medicaid: 2011 – 2021 (EPs) • Proposed rules specify Stage 1 (2011/2012) MU requirements, standards, and reporting criteria • Stages 2 & 3 (2013 & 2015) subject to future federal rule making and public comment, to be released end of 2011 and 2013 • Penalties for non-adoption begin in 2015 • Hospital potential= $2M base + discharge-related amt. per year. Total PHS adoption value of $114 M over the next 10 years through incentive payments and penalty avoidance. • EP potential = $44K per EP Medicare; $63.7K per EP Medicaid 3

4. 2011 Medicare Eligibility • Eligible Professionals (EPs) • MD, DO, Dentist, Podiatrist, Optometrist, or Chiropractor. • Must demonstrate MU of EHRs in more than 50% of patient encounters to be considered a MU user. • All physicians must report on core quality measures, and specialists must report on a second set of specialty-specific measures. • Hospitals • CMS Certification Number is the ‘cleanest’ definiton of an eligible hospital. • An “eligible hospital” is a “sub-section (d)” hospital that is paid under the hospital IPPS system, must reside in 50 states or DC, and has an average LOS < 25 days • Designated Critical Access Hospitals that meet the definition of an acute care hospital as defined above are eligible for Medicare incentives. 4

5. 2011 Medicaid Eligibility • Eligible Professionals (EPs) • MDs, Dentists, NPs, Certified Midwives, Physician Assistants practicing predominantly in FQHC/RHC directed by PA. • 30% of volume must be Medicaid (20% for pediatricians) • EPs who have already adopted, implemented, or upgraded certified EHR technology and can meaningfully use this technologyin the first incentive payment year can qualify for same maximum incentives as EPS who merely adopt, implement, or upgrade. • Hospitals • CMS Certification Number is the ‘cleanest’ definiton of an eligible hospital. • Acute care hospitals with avg LOS <25 days and 10% of volume attributable to Medicaid • Children’s hospitals are eligible for the Medicaid incentive whether free-standing or part of a delivery system that predominantly treats people under 21 years of age. 5

6. Exclusions • Hospital-based EPs who furnish 90% or more of their allowed services in a hospital setting (including inpatient, outpatient, and ED) are NOT eligible for Medicare EHR incentives. • Hospital setting is defined as facilities and equipment supplied by the hospital in the inpatient and outpatient setting. • Site of service determines the provider’s primary location. • An example would be traditional hospital-based MDs such as anesthesiologists, pathologists, and radiologists who practice in the hospital setting. • Not sure about PCPs or group practices practicing in a hospital setting*. • There has been a lot of public comment on this already (including PHS) and yet we still do not have an understanding about the eligibility of our hospital based Practices (such as BIMA at BWH and IMA at MGH) 6

7. Staging MU Years • HIT Policy Committee recommended an “adoption year” approach. • CMS proposes a “staged” approach, creating a steep ‘climb’ for late adopters: • *Avoids payment adjustments only for EPs in the Medicare HER Incentive Program • ** Stage 3 criteria of MU or a subsequent update to the criteria if one is established • If Stage 1 MU is demonstrated in 2011 or 2012, have 2 years (2013 and 2014) to achieve Stage 2; must achieve Stage 3 in 2015. • If Stage 1 MU is demonstrated in 2013, have 1 year to achieve Stage 2; must still achieve Stage 3 in 2015. • If Stage 1 MU is demonstrated in 2014, no option to achieve Stage 2; must achieve Stage 3 in 2015. • No option to achieve Stage 1 or Stage 2 in 2015. Stage 3 required. 7

8. Payment Year • For a Medicare eligible professional, a payment year is a calendar year starting in 2011. • For a Medicaid eligible professional, a payment year begins in 2010 for adoption, implementation, or upgrading of a certified EHR. Meaningful use begins in 2011. • For an eligible hospital or a critical access hospital, a payment year is the federal fiscal year (October 1 - September 30) starting in fiscal year 2011 (i.e. October 1, 2010) 8

9. EHR Reporting Periods • For an eligible Professional • For the first payment year, any continuous 90-day period within a calendar year • For the second, third, and fourth payment year, the calendar year • For an eligible Hospital or a critical access hospital • For the first payment year, any continuous 90-day period within the Federal fiscal year • For the second, third, and fourth payment year, the Federal fiscal year 9

10. The earliest date to begin the 90-day reporting period is: Hospitals: Oct. 1, 2010 EPs: Jan. 1, 2011 The last date to begin demonstrating MU: Hospitals: July 1, 2011 EPs: Oct. 1, 2011 Key dates/timeframes for collecting the first incentive payments for 2011: 10/1/2010 1/1/2011 4/1/2011 7/1/2011 10/1/2011 Last date for Hospitals to demonstrate MU Last date for EPs to demonstrate MU Earliest date to begin Hospital 90-day reporting Earliest date to begin EP 90-day reporting 10

11. To Realize these Incentives We Must • Achieve “meaningful use” 11

12. To Realize these Incentives We Must • Submit quality data to CMS and Medicaid • Submit quality data to CMS 12

13. To Realize these Incentives We Must • Ensure our electronic health records support data and transaction standards 13

14. Clinical Data Exchange • In Stage 1, hospitals and EPs will not be required to participate in local or regional HIEs, however, they must be able to demonstrate the capability to electronically exchange relevant data with other care providers using distinct EHR technology (not between providers using same EHR technology). 14

15. Quality Measure Reporting • For 2011, hospitals and EPs will be able to meet the reporting requirement through attestation on clinical quality metrics and MU objectives. • In 2012, it is the hope that hospitals and EPs will submit the data electronically to CMS and States (where appropriate) through EHRs (and/or an attestation process, if the EHR functionality has not matured). 15

16. Quality Measures & Reporting • EPs and hospitals will be required to report clinical quality measures and EHR utilization measures to CMS and States (where applicable) to earn incentives • Many PQRI measures, nearly all are NQF-endorsed • EP “core” measures, plus specialty measures for Cardiology, Endocrinology, Gastroenterology, Pulmonology, OB/GYN, Psychiatry, Radiology, Ophthalmology, Proceduralists/Surgery, Neurology, Pediatrics, Oncology, Nephrology, and Podiatry. • ONLY 9 of the 35 hospital quality measures proposed in the regulations are used in the Medicare pay-for-reporting program. Several hospital measure have been developed for future RHQDAPU considerations (electronic submission) 16

17. Certified EHR Overview • EPs and eligible hospitals must demonstrate meaningful use of a Certified EHR • Certified EHR Definition: • Complete EHR or combination of EHR modules that meet the Certification Criteria and have been tested and certified 17

18. Certification Process • ONC Certification NPRM (expected late January 2010) will outline testing and certification process • CCHIT - Offering 3 certification programs to vendors and organizations: • “CCHIT Certified 2011” - Comprehensive (for vendors) • “Preliminary ARRA 2011 Certification” (LMR) • Site Certification - process for self-developed, available in mid 2010 after final HHS requirements are out. (AMCs). • Drummond Group also interested in certifying; possible others TBD 18

19. Timeline for 2011 Certification Process ONC MU Development Phase HHS Certification Process Definition ARRA Federal Rule Making Phase Feb. ‘09 May – Sept. 2009 Sept 2010 12/31/09 Interim Final Rule Spring 2010 Final Rule CCHIT Prelim cert development Final cert development Site Certification LMR Certification Health care organizations perform gap analysis, await final requirements, prepare for 2011 certification Proposed Hospital Certification 19 19

20. EHR Certification • ONC NPRM Proposes: • 27 Certification Criteria (some differences between EPs and hospitals) • Standards • Vocabulary Standards • Content Exchange Standards • Transport Standards • Privacy & Security Standards • Privacy & Security – “HIPAA 2” 20

21. Summary of Vocabulary Recommendations • Primary vocabulary standards: • Clinical problems and procedures: SNOMED CT • Drugs and Medication Allergies: RxNorm • Ingredient allergies: UNII • Laboratory tests: LOINC • Units of measure: UCUM • Administrative terminology: ASC X12 and NCPDP Script 21

22. Security • Encryption is now required, for purposes of HIPAA compliance around certain types of data breaches • HIPAA Privacy and Security Rules still apply • Certified EHR must support the 8 Privacy and Security foundational requirements under ARRA. For example: • Assigning a unique user name for each user • Encrypt and decrypt health information for backups, removable media, etc. • Event recording such as deletion of records • Audit review log • Systems to ensure health information has not been altered using a hash algorithm • Record disclosures made for treatment, payment, and operations • Ensure identity management is in place 22

23. Primary contacts for gap analysis • Ambulatory: Jim Fahey • Hospital: Sandy Smith, Eric Poon, Michael Zacks, Ned Kaufman, Jim Anzeveno • Enterprise: Laura Leinen, Carol Broverman, Howard Goldberg, Pat Rubalcaba, John Pappas • Quality Reporting: Jonathan Einbinder • Privacy: Deb Mikels • Security: Jennings Aske 23

24. MU Objective 1: CPOE10% of ALL order types* entered directly by authorizing provider (MD, DO, RN, PA, NP) *10% of medications, laboratory, radiology/imaging, blood bank, physical therapy, occupational therapy, respiratory therapy, rehabilitation therapy, dialysis, provider consultants, and discharge/transfers 24

25. MU Objective 2: Demonstrate functionality for drug-drug, drug-allergy, drug-formulary checking 25

26. MU Objective 3: Maintain up-to-date problem list of current and active diagnosis based on ICD-9 or SNOMED-CT for 80% of patients 26

27. MU Objective 4: Maintain active medication list as structured data* for 80% of unique patients * Proposed Stage 1 vocabulary standard is RxNorm. Stage 1 also requires that medications are stored in the clinical system itself. This may be a sizeable gap. 27

28. MU Objective 5: Maintain active medication allergy list as structured data for 80% of unique patients 28

29. MU Objective 6: Record demographics (preferred language, insurance type, gender, race, ethnicity, and date &cause of death) for 80% of patients 29

30. MU Objective 7: Record and chart changes in vital signs for patients age 2 and over, plot growth charts for children age 2-20 including BMI for 80% of pts. 30

31. MU Objective 8:Record smoking status for patients 13 years and older for 80% of patients 31

32. MU Objective 9: Incorporate clinical lab-test results into EHR as structured data for 50% of lab tests 32

33. MU Objective 10: Generate at least one report listing patients with a specific condition. 33

34. MU Objective 11: Report hospital quality measures to CMS, or the state (if Medicaid hospital) For 2011, provide aggregate numerator and denominator through attestation as discussed in section II(A)(3) of this proposed rule. For 2012, electronically submit the measures as discussed in section II(A)(3) of this proposed rule. 34

35. MU Objective 12: Implement 5 clinical decision support rules relevant to clinical quality metrics 35

36. MU Objective 13: Check insurance eligibility electronically from public and private payers for 80% of unique patients admitted to the hospital Assume NEHEN addresses this 36

37. MU Objective 14: Submit 80% of claims electronically to public and private payers Need to confirm with John Stone but believe we have No gap here 37

38. MU Objective 15: Provide 80% of patients with an electronic copy of their health information (diagnostic test results, problem list, medication list, allergies, discharge summary, and procedures) within 48 hours of request. 38

39. MU Objective 16: Provide 80% of discharged patients an electronic copy of their discharge instructionsand procedures upon request. 39

40. MU Objective 17: Demonstrate at least once, the capability to exchange key clinical information (discharge summaries, procedures, problem lists, medication lists, allergies, diagnostic test results) among providers of care and patient authorized entities. 40

41. MU Objective 18: Perform medication reconciliation for at least 80% of relevant encounters and transitions of care. 41

42. MU Objective 19: Provide summary of care record for at least 80% of transitions of care and referral. 42

43. MU Objective 20: Demonstrate capability to submit electronic data to immunization registries and actual submission where required and accepted. 43

44. MU Objective 21: Capability to provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received. 44

45. MU Objective 22: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission applicable to law and practice. 45

46. MU Objective 23: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities*. Conduct or review security risk analysis and implement updates as necessary. *Conduct or review a security risk analysis per 45 CFR 164.308(a)(1) and implement security updates as needed. 46