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Making Sense of EHRs and the EHR Incentive Program (HITECH). Northern California ACP Chapter San Jose, CA October 29, 2011. Michael S. Barr, MD, MBA, FACP Senior Vice President Division of Medical Practice, Professionalism & Quality 202-261-4531 [email protected] Disclosures.

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Making sense of ehrs and the ehr incentive program hitech

Making Sense of EHRs and the EHR Incentive Program (HITECH)

Northern California ACP Chapter

San Jose, CA

October 29, 2011

Michael S. Barr, MD, MBA, FACP

Senior Vice President

Division of Medical Practice, Professionalism & Quality

202-261-4531

[email protected]


Disclosures
Disclosures

  • Grants for program development (ACP) from:

    • Pfizer

    • UnitedHealth Care

    • NovoNordisk

    • Endo Pharmaceuticals

    • Merck

    • Sanofi

    • Wyeth


Goals
Goals

  • Focus on patient-centered care

  • Highlight key provisions of the HITECH Act

  • Examine Meaningful Use & its relation to PCMH

  • Explore a road map for building technology-enabled practices

  • Introduce resources available

HITECH = Health Information Technology for Economic and Clinical Health Act 2009


Patient-Centered Medical Home

Health Care Home

Person-Centered Health Care Home

Meaningful Use

Certified EHR Technology

Complete EHRs

EHR Modules

Accountable Care Organizations

Affordable Care Act (PPACA, ACA)

Maintenance of Certification

Physician Quality Reporting Initiative - PQRI

HITECH

E-prescribing Incentive Program


What is Patient-Centered Care?

  • One of IOM’s six domains of quality

  • “Nothing about me without me”

  • The right care, the right way, at the right time

  • Providing the care that the patient needs in the manner the patient desires at the time the patient desires

Shaller, D. Patient-Centered Care: What Does It Take?

http://www.pickerinstitute.org/documents/PI%20Shaller%20Final%20Report.pdf


The Joint Principles of the PCMH

Team-based care:

NP/PA

RN/LPN

Medical Assistant

Office Staff

Care Coordinator

Nutritionist/Educator

Pharmacist

Behavioral Health

Case Manager

Social Worker

Community resources

DM companies

Others…

  • Personal physician

  • Physician directed medical practice

  • Whole person orientation

  • Care is coordinated and/or integrated

  • Quality and safety

  • Enhanced access to care

  • Payment to support the PCMH


Strategy without tactics

is the slowest route to victory.

Tactics without strategy

is the noise before defeat.

Sun Tzu – Chinese Military General


Strategy

Berwick, Nolan & Whittington; Health Affairs 2008


Tactics

Berwick, Nolan & Whittington; Health Affairs 2008


Tactics

Berwick, Nolan & Whittington; Health Affairs 2008



Labs

Radiology

Suppliers

Referral Requests

Vendors & Suppliers

Clinicians

Home Health

Hospitals

Families/Pts

Rx

Payers/

Prior Auths

Front Desk = Link to the “World”



The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.

Bill Gates

640K ought to be enough for anybody. Bill Gates

http://www.brainyquote.com/


Quality Pyramid automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.


Quality Pyramid automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.


  • Right number, skill sets, competencies automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.

    • Clinical & administrative

    • Cross-trained

  • Assessment of readiness for change

  • Recognize potential “threats” to staff

  • Assess satisfaction with job activities

  • Remove barriers to working at level of training

Personnel/Training/Competency


Organization/Infrastructure


Workflow/Logistics


Technology yet critical pathways

  • Right product(s)

  • Right prep & training

  • Right implementation

  • Right support

  • Right optimization

  • Right maintenance


Service yet critical pathways

  • Organized, pro-active, responsive, accountable and accessible

  • Culturally competent

  • Addresses health literacy/numeracy

  • Focused on quality & safety

  • Addresses needs of individuals and the population

  • Incorporates patient preferences, stated needs/desires in formulating care strategies and follow-up

  • Uses health information technology to facilitate care


Bending the Curve Towards Transformed Health yet critical pathwaysAchieving Meaningful Use of Health Data

  • Improved outcomes

  • Advanced clinical processes

  • Data capture and sharing


Hitech act medicare provisions
HITECH Act yet critical pathways(Medicare Provisions)

  • Provides monetary incentives for adoption of health IT ($44,000 per physician over 5 years)

  • Introduced concept of “Meaningful Use”

  • Decreasing incentives if start after 2012

  • Must begin by 2014 to receive any payment

  • Reimbursement Penalty begins 2015

HITECH = Health Information Technology for Economic and Clinical Health Act 2009

http://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_081010.pdf


Hitech act medicaid provisions
HITECH Act yet critical pathways(Medicaid Provisions)

  • Medicaid – EPs who adopt, implement, upgrade, or meaningfully use certified EHR technology in their first year of participation in the program and successfully demonstrate meaningful use in subsequent years may be eligible for an incentive payment amount, subject to an annual limit.

  • Maximum = $63,750

HITECH = Health Information Technology for Economic and Clinical Health Act 2009

http://www.cms.gov/MLNProducts/downloads/EHRIncentivePayments-ICN903691.pdf


Ehr incentive program
EHR Incentive Program yet critical pathways

  • Core Set has 15 measures – need to meet all

  • Menu Set has 10 measures of which 5 have to be met

    • At least 1 of the measures needs to be:

      • Test of reporting to an immunization registry

      • Test of reporting to a public health agency for syndromic surveillance

Blumenthal, D: NEJM, online July 13, 2010; in print, August 4, 2010

Also: http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


Meaningful use in practice
Meaningful Use in Practice yet critical pathways

Use the EHR (and staff) for the following 6 things:

  • Create problem lists

  • Enter allergies

  • Keep track of vaccinations and preventive care

  • Collect basic demographic data (date of birth, gender, race, ethnicity, and preferred language)

  • Check height, weight and blood pressure

  • E-prescribing

AmericanEHR Blog Entry: http://blog.americanehr.com/americanehr-partners/meaningful-use/


And you can
And You Can… yet critical pathways

Satisfy 8 Core Set and 3 Menu Set Measures:

  • Core Set: 1) Computerized Physician Order Entry; 2) Drug-drug/Drug-allergy interactions; 3) Maintain up-to-date problem list; 4) E-prescribing; 5) Active medication list; 6) Active allergy list; 7) Recording of demographics; 8) Record/chart vital signs.

  • Menu Set: 1) Drug-formulary check (at least 1); 3) Generate list of patient with a specific condition; 4) Send reminders for preventive/follow-up care.

AmericanEHR Blog Entry: http://blog.americanehr.com/americanehr-partners/meaningful-use/


Quality measure reporting
Quality Measure Reporting yet critical pathways

  • Six (6) total Clinical Quality Measures

    • 3 Core or Alternate Core, and…

    • 3 out of 38 from menu set

  • Align with PQRS quality measurement set


Quality measure reporting1
Quality Measure Reporting yet critical pathways


Core set alternate core
Core Set/Alternate Core yet critical pathways


Paper | EHR | EHR+MU yet critical pathways


www.healthit.hhs.gov yet critical pathways

www.americanehr.com

http://www.medscape.org/viewarticle/734299

Registration for EHR Incentive Program

http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp#TopOfPage


http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


Case study
Case Studyhttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • 10 physician multi-specialty practice

  • IM, ID, Rheum, Neuro

    Issues

  • Considering CMS EHR Incentive Program

  • Uncertainty about EHR meeting the needs of all specialists

  • Rural area; concerned about health IT support

  • Recently invested in new practice management system


www.AmericanEHR.comhttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


www.AmericanEHR.comhttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


Educational resources
Educational Resourceshttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


Acp medical home builder
ACP Medical Home Builder®http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

www.medicalhomebuilder.org


Modules cover pcmh qi health it
Modules Cover PCMH/QI/Health IT…http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Facilitate Transitions

  • Use of Technology

  • Improve Quality

  • Manage Populations

  • Manage Patients’ Medications

  • Engage Patients

  • Organize Your Practice

  • Work as a Team

  • Communicate with Patients

  • Enhance Patient Access

  • Deliver Patient-Centered Care

  • Coordinate Care


From the ACP Medical Home Builder – Practice Biopsy®http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


From the ACP Medical Home Builder – Biopsy Reporthttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


From the ACP Medical Home Builder –Resource Libraryhttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401


Focus on capabilities of ehr systems
Focus on “Capabilities” of EHR Systemshttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Collect, store, and exchange health info

  • Facilitate team care

  • Collect & report on the processes, outcomes and quality of care

  • Provide clinical decision support

  • Engage patients/consumers in their health care


Collect store and manage data
Collect, Store and Manage Datahttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Collect standardized, accurate and essential data elements and exchange externally:

    • Demographic and clinical data

    • Results reporting to ordering or covering physician

    • Patient notification of lab results

    • Forward appropriate clinical information

    • Online order entry and tracking

    • Identify patients receiving care in another facility


Facilitate team based care
Facilitate Team-Based Carehttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Care Coordination

    • Medication reconciliation

    • E-Prescribing

    • Evidence-based flowsheets

    • Track referrals and labs

    • Send/receive health summary information

    • Structured documentation

    • Create/maintain list of consultants


Report on quality of care
Report on Quality of Carehttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Registry-like reporting and linking to community resources

    • Identify practice-specific important conditions, frequent diagnoses

    • Recommend patient-specific care: chronic conditions, immunizations, preventive health

    • Maintain list of community resources

    • Risk stratification by age appropriate measures


Clinical decision support
Clinical Decision Supporthttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Incorporate clinical guidelines into flow sheets, standing order sets, training …

  • Medication selection and dosing support

  • Prompts/reminders for preventative care services

  • Simple, effective alerts


Patient Engagementhttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

  • Personal Health Records

  • Interactive, personalized educational activities & materials

  • Remote monitoring/telemedicine

  • Web-based visits & consultation

  • Virtual group visits


Michael S. Barr, MD, MBA, FACPhttp://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&[email protected]

202-261-4531


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