What does ARRA, HITECH and Meaningful Use mean to you

What does ARRA, HITECH and “Meaningful Use” Actually Mean to You? Brenda Pawlak – Manatt Health Solutions [email_address]

Meaningful Use Overview Regulatory Definition In HITECH, Congress specified three types of requirements for meaningful use: use of certified EHR technology in a meaningful manner (e.g. Electronic Prescribing); that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary. To be a “meaningful user,” EPs must use a certified EHR to satisfy all Criteria and all Measures .

Meaningful Use Overview Policy Vision & Goals* Vision Enable significant and measurable improvements in population health through a transformed health care delivery system. Goals Improve quality, safety, and efficiency Engage patients and their families Improve care coordination Improve population and public health Ensure privacy and security protections *Source : Health IT Policy Committee Meaningful Use Workgroup’s June 23, 2009 presentation

Meaningful Use Overview Three CMS & ONC Regulations CMS Notice of Proposed Rule Making (NPRM) for EHR Incentive Program Defines the provisions for incentive payments to eligible professionals and hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified EHRs. ONC Interim Final Rule with Comments (IFC) on Standards and Certification Criteria Proposes initial set of standards, implementation specifications, and certification criteria to “enhance the interoperability, functionality, utility, and security of health IT and to support its meaningful use.” ONC Rule on Certification Process Outlines the process by which an organization becomes an official certification entity.

CMS EHR Incentive Program NPRM Brief Overview The NPRM specifies... Eligibility requirements for professionals and hospitals Criteria for Stage 1 Meaningful Use Reporting methodology and timeframes Payment periods Payment calculations/procedures for Medicare & Medicaid Medicare penalties for failing to meaningfully use certified EHRs Medicaid Agencies’ implementation of incentives

Certified EHR : The item of technology that an Eligible Professional (EP) or Eligible Hospital (EH) must meaningfully use in order to qualify for financial incentives ( and avoid reimbursement penalties ). CMS EHR Incentive Program NPRM Key Terms Stages 1- 2 - 3 : Three graduated stages for implementing “meaningful use” and EHR certification requirements.

CMS Vision for Stages Requirements Scaling Up Over Time For Stage 2 , CMS may also consider applying the criteria more broadly to both the inpatient and outpatient hospital settings. CMS expects to propose Stage 2 criteria by the end of 2011. CMS expects to propose Stage 3 criteria by the end of 2013. Stage 1 Stage 2 Stage 3 Capturing health information in a coded format Using the information to track key clinical conditions Communicating captured information for care coordination purposes Reporting of clinical quality measures and public health information Disease management, clinical decision support Medication management Support for patient access to their health information Transitions in care Quality measurement Research Bi-directional communication with public health agencies 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 Improving population health outcomes

Meaningful Use Overview NPRM Definitions To implement these core requirements, CMS proposes several fundamental definitions: Meaningful EHR User . An Eligible Professional (EP) who, for an EHR reporting period for a Payment Year, demonstrates meaningful use of a certified EHR technology in the form and manner consistent with CMS standards. Payment Year . For EPs any calendar year beginning with January 2011. The “first Payment Year” would mean the first calendar year for EP in which they receive an incentive payment. EHR Reporting Period . For the first Payment Year only , CMS proposes to define “EHR Reporting Period” to mean any continuous 90-day period within a Payment Year in which an EP successfully demonstrates meaningful use of certified EHR technology. For the second Payment Year and all subsequent Payment Years, the EHR reporting period would be the entire Payment Year.

Eligibility Framework for EPs EPs must choose Medicare or Medicaid Medicare Medicaid Eligibility Doctor of Medicine or Osteopathy and, for certain limited purposes a Doctor of Dental Surgery or Dental Medicine, a Doctor of Podiatric Medicine, a Doctor of Optometry, or a Chiropractor. Physicians and Osteopaths, Dentists, Certified Nurse Midwives, Nurse Practitioners, Physicians Assistants (in a rural health clinic or FQHC that is led by a physician assistant). Available to physicians paid under the Physician Fee Schedule (PFS). Must meet Meaningful Use in first adoption year. 30% Medicaid volume required for most EPs to qualify. Payment based on a percentage of technology cost. Adopt/Implement/Upgrade option for first adoption year. Total possible funding available per EP: $44,000 Total possible funding available per EP: $63,750

Eligibility Framework for EPs EPs must choose Medicare or Medicaid Medicare Medicaid Payment Timeframe Funds available Calendar Year 2011-2016 Funds available Calendar Years 2011 - 2021 Must adopt by 2014 to receive payments EPs may demonstrate meaningful use as late as 2016 and still qualify for the maximum total incentive but may collect partial incentives thereafter. Lower aggregate payment if adopt in 2013 or later years Aggregate payments not reduced for late adopters Penalties for non-compliant EPs begin in 2015 to receive payments. Reduction in fee schedule: 2015=1%; 2016=2%; 2017 and beyond = 3% No payment penalties proposed by CMS. Up to 5 years of payment Up to 6 years of payment

CMS EHR Incentive Program NPRM Medicare Incentives for Eligible Professionals For each year under the incentive program, an EP will receive 75 percent of the EP’s total “allowed charges” (that is, the amounts Medicare pays under the PFS) during the Payment Year, subject to a cap. Adoption Year Maximum Payment PFS Penalty 2011 2012 2013 2014 2015 2016 Total 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000 2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 2013 $15,000 $12,000 $8,000 $4,000 $39,000 2014 $12,000 $8,000 $4,000 $24,000 2015 $0 1% 2016 $0 2% 2017+ $0 3%

CMS EHR Incentive Program NPRM Medicaid Incentives for Eligible Professionals EPs can receive a total of six years of payments totaling $63,750; the first incentive payment year at $21,250, plus five years at $8,500. EPs can start collecting incentives in January 2011. Medicaid incentives run through 2021. EPs may demonstrate meaningful use as late as FY 2016 and still qualify for the maximum total incentive. Eligible Professional Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Total Physician – 30% $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 Certified Nurse Mid-Wife – 30% $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 Dentist – 30% $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 RN Practitioner- 30% $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 Physician Assistant $21,250 $ 8,500 $8,500 $8,500 $8,500 $8,500 $63,750 Pediatrician (at 20% Medicaid) $14,167 $5,667 $5,667 $5,667 $5,667 $5,667 $42,502

Eligibility Framework for EPs Reporting In order to draw down incentive payments, EPs will need to attest to meeting meaningful use requirements: 25 Objectives and Measures for EPs for Stage 1 Meaningful Use 8 measures will require ‘Yes’ or ‘No’ as structured data 17 measures will require a Numerator and Denominator

Meaningful Use Measures Measures are grouped into two categories: Each measure is linked to a related Meaningful Use Objective Electronic Health Record Technology Functionality Measures Clinical Quality Measures

Meaningful Use Measures Related to Medication Objective Measure Generate and transmit permissible prescriptions electronically (eRx) 75% of all permissible prescriptions Implement drug-drug, drug-allergy, drug-formulary checks Functionality Enabled Maintain active medication list 80% Maintain active medication allergy list 80% Record demographics 80%

Meaningful Use Measures Related to Documentation & Orders Objective Measure Use CPOE – Computerized Provider Order Entry 80% Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT 80% Record smoking status for patients 13 years or older 80% Record demographics 80% Vital signs 80% Incorporate clinical lab test results into EHR as structured data 50%

Meaningful Use Measures Related to Clinical Decision Support Related to Administrative Transactions Objective Measure Implement five clinical decision support rules relevant to specialty or high clinical priority along with the ability to track compliance 5 rules Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach 1 list Objective Measure Check insurance eligibility electronically from public and private payers 80% Submit claims electronically to public and private payers 80%

Meaningful Use Measures Related to Patient & Family Engagement Objective Measure Send reminders to patients, per patient preference, for preventive/follow-up care 50% of all patients aged 50 or over Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies), upon request 80% of requests - within 48 hours Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP 10% of all unique patients seen Provide clinical summaries for patients for each office visit 80%

Meaningful Use Measures Related to Care Coordination Objective Measure Provide summary-of-care record for each transition of care and referral 80% Perform medication reconciliation at relevant encounters and each transition of care 80% Capability to exchange key clinical information (for example, problem list, medication list, allergies, diagnostic test results), among providers of care and patient-authorized entities electronically 1 test

Meaningful Use Measures Related to Public Health & Data Security Objective Measure Capability to submit electronic data to immunization registries and actual submission where required and accepted 1 test Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice 1 test Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Conduct risk assessment & fix problems as required

EPs are required to submit clinical data on 2 measure groups. Example: A primary care physician would submit information on core measures, and on measures in the set for “primary care.” Once an EP selects a specialty-specific measure group for 2011, cannot alter choice for 2012. Report Core Measures + Report on At Least One Group of Specialty Measures Clinical Quality Measures Core Measures to be reported by all EPs PQRI 114 NQF 0028 Preventive Care & Screening: Inquiry Regarding Tobacco Use NQF 0013 Blood pressure measurement NQF 0022 Drugs to be avoided in the elderly Measure Group for 15 specialties Cardiology Pulmonology Endocrinology Oncology Proceduralist/ Surgery Primary Care Pediatrics Ob/Gyn Neurology Psychiatry Ophthalmology Podiatry Radiology Gastroenterology Nephrology

Examples: Clinical Quality Measures Preventative Care & Screening: Inquiry Regarding Tobacco Use Description: Percentage of patients aged 13 years or older who were queried about tobacco use one or more times within 24 months Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Description: Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy

How are Clinical Quality Measures Reported? 2011: self-attestation methodology will be utilized 2012 & beyond: intent to receive electronic information via a web portal local HIE specialty registries

What Happens Next? Public comment period for stakeholders closed March 15, 2010 CMS is reviewing all public comments (3,000+) and will issue the final rule Final rule is expected around June 2010 CMS is concurrently reviewing and approving individual state plans around distribution of Medicaid funds Incentives come on line for EPs Jan 2011

What does ARRA, HITECH and Meaningful Use mean to you

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