Understanding the CMS EHR Incentive Programs

Understanding the CMS EHR Incentive Programs Adele Allison National Director of Government Affairs

Understanding the CMS EHR Incentive Program Overview Final Rule – Stage 1 Registration Stage 2 – Forecasting Project Management Practice Redesign Questions

Summing-up HITECH goals Push Provider adoption/use of approved (certified) EHR Technology Capture DATA Move DATA – Interoperability Report DATA $27B in “Carrots” - incentives : Up to $48,400 through Medicare Up to $63,750 through Medicaid

Stage 1 – Objectives & Measures Objectives are broad spanning goals/activities Measures are specific task(s) requirements Meeting the measures = meeting the Objectives for that Stage Stage 1 MU 15 Core Measures required by all EP’s 10 “Menu” Measures from which EP’s choose 5 e Claims and e Eligibility removed

Stage 1 – Objectives & Measures cont. 13 Exclusions Clause – Exclusions will reduce the number of Objectives required by EP Stage 2 MU 31 Proposed measures (includes expansion of 25 Stage 1 Measures) Minimum additional 6 or more could be added Illustrates importance of implementing Stage 1 now!

Medicare Incentive Payments: Fee-For-Service Paid out over 5-year period Equivalent to 75% of allowables for EP Payment Year Capped at HITECH statutory EHR Payment Year amounts Reduced for late initiation Increased 10% if practicing in a “shortage” area (§ 495.102)

Potential Medicare Incentives Calendar Year First Calendar Year in which the EP Receives an Incentive Payment 2011 2012 2013 2014 2015 and subsequent years 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 $0 2016 $2,000 $4,000 $4,000 $0 TOTAL $44,000 $44,000 $39,000 $24,000 $0 Shortage Area Totals* $48,400 $48,400 $42,900 $26,400 $0 * Providers practicing in a federally identified shortage area are eligible for a 10% increase .

Medicaid Incentives Types of Providers - §495.100 : Medicaid: Physicians, Dentists, Certified Nurse Midwives, Nurse Practitioners, Physician Assistants (in FQHC/RHC led by a PA) Year 1 - Adopt, Implement, Upgrade - §495.302 : Acquire, purchase, or secure access to certified EHR technology; Install/use certified EHR technology capable of MU; or Expand functionality of certified EHR solution at the practice with: Staffing, Maintenance, Training, or Upgrading from existing EHR to certified EHR technology. Year 2 – MU for 90 continuous days Years 3 through 6 – MU for full year

Meaningful Use Medicaid Definitions Needy Individual is a patient who - §495.302 (FQHC/RHC) : Receives Medicaid or CHIP assistance, Receives uncompensated care by the provider, or Services provided at no cost or reduced cost based on sliding scale and ability to pay.

Meaningful Use Medicaid Definitions Hospital-based Provider Exclusion - §495.4 – (RHC) : Hospital-based EP’s DO NOT qualify for ‘Care / ‘Caid incentives Previously was excluding “owned” RHC’s 4.15.2010 -> Revision under Jobs Bill (Continuing Extension Act of 2010) – includes only EP’s with 90% services done inpatient and in ED’s Does not apply to Medicaid-EP practicing >50% in a FQHC or RHC (§495.304)

Meaningful Use Medicaid Definitions Must meet the individual state requirements for volume threshold 20% for Pediatricians 30% for FQHCs and RHCs (can include “needy”) 30% for all others Defined in the State’s SMHP - Methods available: By Encounter By Panel By Group Other

Meaningful Use Medicaid Definitions Formula 1 : Medicaid Encounter Approach (Total Medicaid encounters in a representative continuous 90-day period in the preceding calendar year) ___________________________________________ X 100 = % (Total Patient Encounters in the same 90-day period) Formula 2 : Managed Care / Medical Home Approach (Total Medicaid patients assigned to the provider in a representative continuous 90-day period in the preceding calendar year with at least 1 encounter in the year preceding the start of the 90-day period) + (Unduplicated Medicaid encounters in that same 90-day period) ________________________________________________________________________ X 100 = % (Total patients assigned to the provider in the same 90-days with at least 1 encounter in the year preceding the start of the 9-day period) + (All unduplicated encounters in that same 90-day period)

Potential Medicaid Incentives Calendar Year First Calendar Year in which the EP Receives an Incentive Payment 2011 2012 2013 2014 2015 2016 2011 $21,250 2012 $8,500 $21,250 2013 $8,500 $8,500 $21,250 2014 $8,500 $8,500 $8,500 $21,250 2015 $8,500 $8,500 $8,500 $8,500 $21,250 2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 2017 $0 $8,500 $8,500 $8,500 $8,500 $8,500 2018 $0 $0 $8,500 $8,500 $8,500 $8,500 2019 $0 $0 $0 $8,500 $8,500 $8,500 2020 $0 $0 $0 $0 $8,500 $8,500 2021 $0 $0 $0 $0 $0 $8,500 TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

Stage 1 – Medicaid Incentive Program States can move 1-4 “Menu” measures to “Core” measures (up to 4 Menu can be moved for hospitals) Generate Lists of patients – can specify condition Reporting to Immunization Registry – can specify testing requirements Reporting Lab Results – can specify testing requirements Syndromic Surveillance – can specify testing requirements

Stage 1 – Medicaid Incentive Program cont. Additional point of variance by state: Additional State Registration Requirements Method(s) for patient volume calculations Program launch date States launch so far: AK, AL, IA, KY, LA, OK, MI, MS, MO, NC, SC, TN, and TX State launching May 2011: CA All Others: www.cms.gov/apps/files/medicaid-HIT-sites/ Requirements to prove A/I/U

Medicare EHR Incentive Enrollment EP registers with CMS at http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp Login – EP’s User ID and Password for National Plan and Provider Enumeration System (NPPES) NPPES is same as Provider Enrollment, Chain & Ownership System (PECOS) – used to verify ‘Care enrollment – for PECOs enrollment go to http://www.cms.gov/MedicareProviderSupEnroll/ November, 2013 is the “trigger” date To enroll in NPPES, go to http://www.cms.gov/NationalProvIdentStand/06a_DataDissemination.asp

Medicare EHR Incentive Enrollment cont. Need: NPI (Type 2 if assigning), TIN, and address from IRS Form CP-575 Select “Start Registration” on the registration tab under Action Answer the questions with a red * including the incentive program selected, type of EP, and whether they have a certified EHR Follow instructions – upon completion, system will display check marks for completed information Select “Begin Submission,” review/validate information, agree to terms and “submit”

Medicare EHR Incentive Enrollment cont. Confirmation / Regis. ID tracking number given KEEP TRACK OF THIS NUMBER Attestation started April 18th, go to: https://ehrincenives.cms.gov/hitech/login.action Attestation EP Meaningful Use Calculator http://www.cms.gov/apps/ehr/

Medicaid EHR Incentive Enrollment, Generally EP must register with CMS Medicaid Programs are run by the state States launched so far: AK, AL, IA, KY, LA, OK, MI, MS, MO, NC, SC, TN, and TX States launching in May: PA, CA and OH States launching in June/July: AZ, CT, KS, ND, NM, RI, WA (possible: AR, DE, IL, MT) Websites: www.cms.gov/apps/files/medicaid-HIT-sites/

Medicaid EHR Incentive Enrollment cont. Required to provide documentation supporting adoption, implementation or upgrade Common forms of documentation: Vendor Receipt, Contract, Service / Performance Agreements, Screenshot of Sign-on, Upgrade Agreement, Vendor Letter, Work-plan, Cost Report, Invoices

Medicaid EHR Incentive Enrollment cont. Common Data Points needed for registration: Provider Name Provider NPI or Organizational NPI (if applicable) Provider Address (should reflect the location of the technology) CMS Certification ID (SuccessEHS’s is 30000001SWGTEAS) ONC Certification number (SuccessEHS’s is CC-1112-909422-1) EP’s Medicaid Provider Number

Since Stage 1 Final Rule HITPC – 11 Workgroups – Recommendations on: 9.1.2010 – Privacy & Security Policies & Practices 9.7.2010 – Efficient, transparent enrollment in HHS programs (required under PPACA) 11.29.2010 – Privacy & Security on Provider authentication 12.16.2010 – NHIN governance for HIE within and across states 1.12.2011 – Comment requested on Stage 2 Criteria 1.14.2011 – Entity-Level Provider Directories for HIE 2.8.2011 – Accurately matching patients to health information standards 4.13.2011 – Suggested pathways for HIE; HIE and public trust; Federal data services

Since Stage 1 Final Rule HITSC – 5 Workgroups, 2010: 8.30.2010 – Eligibility checking through web service programs 9.21.2010 – Working to develop a common core focused on HIE called the National Information Exchange Model (NIEM) Health 10.27.2010 – Work on managing intellectual property issues for MU related to vocabularies (e.g. SNOMED CT, RxNORM) and associated costs 11.30.2010 – HIE testimony heard from Verizon, VisionShare, Covisint, Axolotl, Surescripts and Intel 12.17.2010 – Discussed the importance of lab interface cost reduction through a universal compendium of LOINC codes

Since Stage 1 Final Rule HITSC – 5 Workgroups, 2011: 1.12.2011 – Problem noted of 56 HIEs, which will create 56 different directories, formats, security standards that may not allow inter-state transmission. Concise interoperability specs needed now . 2.16.2011 – CQMs focused. 1,100 comments received on Stages 2 & 3 CQMs. ONC wants cross-cutting measures that can take advantage of longitudinal EHR. 3.29.2011 – NPRM on Certification Standards Stage 2 target publish date Q4 2011.

Forecast: Stages 2 & 3 Stage 1 Proposed – Stage 2 Proposed – Stage 3 CPOE for Rx Orders – 30% COPE for Rx and lab/radiology – 60% CPOE for Rx and lab/radiology – 80% Drug-Drug, and Drug-Allergy Interactions Evidence-based interactions: Drug-Drug, and Drug-Allergy Interactions Evidence-based interactions: Drug-Drug, Drug-Allergy, Drug-Age, Drug-Dose, Drug-lab, and Drug-condition ePrescribing – 40% ePrescribing transmission of 50% ePrescribing transmission of 80% Demographics – 50% Demographics on 80% of patients and ability to produce stratified quality reports. Demographics on 90% of patients and ability to produce stratified quality reports. Report CQM electronically Continued and expanded CQM reporting. Continued and expanded CQM reporting. Maintain Problem List – 80% Continue Stage 1 80% problems lists are up-to-date Maintain Active Rx List – 80% Continue Stage 1 80% Active Rx lists are up-to-date Maintain active medication allergy List – 80% Continue Stage 1 80% Rx allergy lists are up-to-date Record vital signs – 50% 80% of unique patients have vital signs recorded 80% of unique patients have vital signs recorded Record Smoking Status – 50% 80% of unique patients have smoking status recorded 90% of unique patients have smoking status recorded Implement 1 CDS Rule Use CDS to improve performance on high-priority conditions and establish CDS attributes for purposes of certification. Use CDS to improve performance on high-priority conditions and establish CDS attributes for purposes of certification. Menu Measure – Implement Drug-Formulary Checks Drug-Formulary Checks becomes a Core Measure 80% of Rx orders are checked against relevant formularies Hospital Menu Measure – Record advance directives – 50% Becomes core measure. Advance directives for 50% of patients age 65+ Advance directives for 90% of patients age 65+ Menu Measure – Incorporate Lab Results – 40% Lab Results becomes a Core Measure, but only where results are available. 90% of lab results are electronically ordered through EHR and reconciled with results, where results and structured orders are available.

Forecast: Stages 2 & 3 Stage 1 Proposed – Stage 2 Proposed – Stage 3 Menu Measure – Generate patient lists for specific conditions Measure becomes Core requirement. Generate lists for multiple patient-specific parameters Use patient lists to manage patients for high-priority health conditions Menu Measure – Reminders to patients age 65+ and/or age 5 and under Measure becomes a Core requirement. 20% of active patients with preference for electronic reminders receive preventive or follow-up reminders Non-existent in Stage 1 At least 1 electronic note for 30% of patient visits. At least 1 electronic note for 90% of patient visits. Menu Measure – Provide electronic copy of health information upon request Continue Stage 1 90% of patients have timely access EHR-enabled patient-specific educational resources – 10% Continue Stage 1 20% offered patient-specific educational resources online in common primary languages. Provide clinical summaries for each office visit – 50% Patient can view and download relevant information about a clinical encounter within 24 hours of visit. Follow-up tests not “ready,” included in future summaries within 4 days Data is available human-readable and structured forms Same as Stage 2 Timely electronic access provided to the patient – 10% Patient can view/download relevant information in the longitudinal record within 4 days of information being available to the practice Patient can filter/organize information by date, encounter, etc. Data is available in human-readable and structured formats Same as Stage 2

Forecast: Stages 2 & 3 Stage 1 Proposed – Stage 2 Proposed – Stage 3 Timely electronic access and clinical summaries for each office visit. 20% of patients use a web-based portal to access information at least once. Exclusions : Patients with no Internet access. 30% of patients use a web-based portal to access information at least once. Exclusions : Patients with no Internet access. Non-existent in Stage 1 Online secure patient messaging in use. Same as Stage 2 Non-existent in Stage 1 Patient preferences for communication medium recorded – 20% Patient preferences for communication medium recorded – 80% TBD Exchange data between EHRs and PHRs using standards-based HIE. TBD Patients have ability to report experience of care measures online TBD Ability to upload and incorporate patient-generated data Perform 1 test of HIE Connect to at least 3 external providers in “primary referral network” (but outside delivery system that uses same EHR), or Establish ongoing bidirectional connection to at least 1 HIE. Connect to at least 30% of external providers in “primary referral network,” or Establish ongoing bidirectional connection to at least 1 HIE. Menu Measure – Medication reconciliation during transitions in care – 50% Medication reconciliation at 80% of care transitions by receiving provider Medication reconciliation at 90% of care transitions by receiving provider Menu Measure – Provide summary of care record during transitions in care- 50% Measure becomes Core. Summary of care record provided electronically for 80% of transitions and referrals Non-existent in Stage 1 List of care team members (including PCP) available for 10% of patients in EHR List of care team members (including PCP) available for 50% of patients in EHR Non-existent in Stage 1 Record a longitudinal care plan for 20% of patients with high-priority conditions Record a longitudinal care plan for 50% of patients with high-priority conditions

Forecast: Stages 2 & 3 Stage 1 Proposed – Stage 2 Proposed – Stage 3 Menu Measure – Submit immunization data Mandatory test. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law. During well child/adult visits, providers review IIS via the EHR. Menu Measure – Submit reportable lab data Lab reporting menu option. Ensure lab results and conditions are submitted to public health agencies either directly or through performing labs Mandatory Test. Lab reporting menu. Ensure lab results and conditions are submitted to public health agencies either directly or through performing labs Menu Measure – Submit syndromic surveillance data Measure becomes a core requirement. Mandatory test; Submit if accepted. TBD “ Public Health Button”: Mandatory test and submit if accepted. Submit notifiable conditions using a reportable public-health submission button. EHR can receive and present public health alerts or follow-up requests. TBD Patient-generated data submitted to public health agencies Conduct security review analysis and correct deficiencies. TBD TBD

Assessment – “You Are Here” Clinic Culture Prep Think about Users and Roles Create a Vision Statement Identify Leadership (Formal / Informal) Communicate Plans

Assessment – “You Are Here” Workflow Self-Assessment – I dentify sources of: Assessment Worksheet Inefficiency / Delay / Duplication Risk / Liability / Non-Compliance (e.g. HIPAA) Quality concerns High costs

Leadership: Administration Remember – this is a Provider Program Remember – the Providers are part of a Clinic / Group Practice Plan for Administration Ease Consistency in measures Evaluate Technology and Workflows

Provider Assessment Identify potential barriers before reengineering Low comfort level with technology (Provider / Support Staff) Gaps in Hardware Impact on productivity What additional problems can be solved? Workflows MUST BE CONSISTENT for data capture and reporting

Practice Redesign Compliant and certified for MU EHR Software Senior Leadership and Staff – Awareness and Understanding Identified Champions – Formal and Informal Key Partner Collaboration Lab Interfaces – (ORM/ORU) Results to Patient Chart Immunization Interface – (VXU) Single entry / upload to Registry HIE Interface HIPAA Security Analysis Implementing New Technologies Patient Portal IT Needs

Practice Redesign Data Collection Considerations Must be consistent Like CDS - Identifying the “5 Rights” in Workflow Right Information Right Person Collecting Right Format Right Channel (e.g. EHR, Portal, PM) Right Time in Workflow Data Needed: Vitals, Smoking Status, Rx Reconciliation, Refills, Health Disparities

Practice Redesign Set-up / Configuration – e.g. CEM for patient reminders, alerts Training MU Dashboard, Reporting, Ongoing Quality Improvement

To learn more about the CMS EHR Incentive Programs, visit: http://www.successehs.com/item/hitech-meaningful-use-certified-systems/erx-and-meaningful-use-incentive-programs.htm .

Understanding the CMS EHR Incentive Programs

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