Transcript What’s Meaningful U$e Got to Do with HIT?

What’s Meaningful U$e Got to Do with HIT?
Presented by:
Patricia A. Markus, Esq.
Smith Moore Leatherwood LLP
2800 Two Hannover Square
Raleigh, NC 27601
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Introduction
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Overview: What DOES Meaningful Use Have to Do
with HIT?
Meaningful Use Proposed Rule
Eligibility Requirements
Technology
Timelines for Achieving Meaningful Use
Payments
Proposed Pathways
Reporting
Areas of Concern
ARRA/HITECH
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The HITECH Act, enacted within the February 2009
stimulus bill, was intended to improve the health of
Americans and the efficiency and effectiveness of our
health care system through adoption of meaningful use
of electronic health records
Four goals of HITECH:
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Define meaningful use (MU)
Encourage and assist attainment of MU through
incentives and grants
Further public trust in electronic information exchange by
ensuring privacy and security
Foster continued innovation in HIT
HITECH Initiatives That Support MU
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Regional Extension Centers  $643 M
– NC AHEC  $ 13.6 M
– Morehouse SOM  $19.5 M
Beacon Communities  $235 M
Workforce Training  $118 M
Medicare/Medicaid Incentives and Penalties  $34 B
State Grants for HIE  $564 M
– $13 M for GA
– $12.9 M for NC
Standards and Certification Framework  $64.3 M
Privacy and Security
You Can Get Paid To Become an EMU
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Two sections in the HITECH Act of the American
Recovery and Reinvestment Act of 2009 (“ARRA”)
directly address health IT (“HIT”) and health information
exchange (“HIE”):
1. Division A, Title XIII directs the Office of the National
Coordinator for Health Information Technology to establish
certain grant and loan funding programs and established
significant new privacy laws
2. Division B, Title IV established Medicare and Medicaid
reimbursement incentives for eligible professionals (“EP”) and
hospitals that are “meaningful users” of EHR.
CMS Meaningful Use Proposed Rule
• Released as a Notice of Proposed Rule Making for public comment
on December 30, 2009
• 42 C.F.R. Parts 412 et al., published in the Federal Register on
January 13, 2010
• NPRM comment period closing on March 15, 2010
– To comment, go to www.regulations.gov, enter keyword CMS2009-0117-0002
• Final rule anticipated by late spring to allow hospitals to prepare for
the Eligible Hospital Incentive program in October 2010
CMS Meaningful Use Proposed Rule
Proposed Rule specifies:
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Definitions
Eligibility requirements for professionals and hospitals
Medicare and Medicaid EHR incentive programs
Criteria for Stage 1 meaningful use
Reporting methodology and timeframes
Eligibility rules
Payment periods
Payment calculations/procedures for Medicare/Medicaid
CMS Meaningful Use Proposed Rule
EHR incentive payments will be made to:
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Eligible providers
Who meaningfully use
Qualified EHRs
Which have been certified
By a certification organization recognized by the ONC
Meaningful Use Defined and Stages
HHS Secretary will finalize definition, which includes:
• Quality reporting
• Electronic prescribing
• Health information exchange
Three “stages” of MU
• Stage 1  2011
• Stage 2  2013
• Stage 3  2015
Goals of Meaningful Use
Centered around national health outcomes goals
– Improve quality, safety and efficiency of care, and
reduce health disparities
– Engage patients in their care
– Increase care coordination
– Improve the health status of the population
– Ensure privacy and security
Medicare vs Medicaid Incentive
Programs
• Common definition of meaningful use, but several
significant differences in incentive programs:
– Eligibility
– Payment amounts and timing of same
– Governance
Tracking of Participants
• CMS has a goal that all EPs and eligible hospitals
achieve meaningful use by 2015
• CMS proposes to collect the following administrative
data for the Medicare and Medicaid EHR incentive
programs:
– Name, NPI, business address, and business phone of
each EP or eligible hospital
– Taxpayer Identification Number (TIN) to which the EP
or eligible hospital wants the incentive payment made
– For EPs, whether they elect to participate in the
Medicare EHR incentive program or Medicaid EHR
incentive program.
Who Is Eligible For Incentives?
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Eligible Hospital—Eligibility determined by CMS
Certification Number (CCN)
– Medicare Fee-For Service
• Acute Care Subsection (d) Hospitals (IPPS)
• Critical Access Hospitals
• Eligible Professionals (EPs)
• Excludes: psychiatric, rehab, long-term care, children’s and
cancer hospitals and hospitals in US Territories
– Medicaid
• Acute Care Hospitals
• Children’s Hospitals
• EPs
Who Is Eligible For Incentives?
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Eligible Professional—EPs identified by National
Provider Identifier (NPI)
– Medicare
• MD, DO, DDS, OD, DPM, DC
– Medicaid
• MD, DO, DDS, NP, CNM, and PA in FQHC or RHC led by
PA
– Hospital based professional is not eligible
• EPs who provide 90%+ of their professional services in
inpatient or outpatient hospital setting or emergency room
• Site of service code determinative (21, 22, 23 are hospitalbased)
• BUT: EPs ineligible for incentives also ineligible for
“adjustments”
Which Incentive Program to
Choose?
• Hospitals
– May participate in both programs if eligible
– Hospital serving patients in more than one state can
only participate in one state’s Medicaid incentive
program in any given year
• EPs
– May participate in Medicare or Medicaid, not both
– May switch between programs once before 2015
Certified EHR Technology
• HHS issued an interim final rule on December 30, 2009:
Initial Set of Standards, Implementation Specifications,
and Certification Criteria for Electronic Health Record
Technology (45 C.F.R. Part 170)
• The rule establishes EHR certification criteria tied to
meaningful use objectives and includes 60-day comment
period
• A final rule is expected in late spring 2010
Which EHR to Choose?
• Must use “certified EHR technology” to get incentives
– Complete EHR  all-in-one solution certified to meet
all criteria
– EHR Module  any service, component, or
combination that is certified to meet at least one
criterion (such as SaaS, interface, specific
functionality)
• “Buyer beware” with multiple modules
– Each component must be certified
– Know which module meets which certification criteria
– Together, modules must address all certification
criteria
Certification and Standards
• Certification criteria exist for hospitals and EPs
– General criteria apply to all complete EHRs or EHR modules
– Ambulatory criteria apply to complete or modules designed for
ambulatory setting
– Inpatient criteria apply to complete or modules designed for
inpatient setting
• Standards for
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Content (sharing clinical info—HL7, ASTM, messaging)
Vocabulary (terminologies—SNO-MED, CPT)
Transport (communication protocol between systems)
Privacy and Security (authentication, encryption)
Don’t Ignore HIPAA Compliance
• Use of certified EHR does not mean you are in
compliance with HIPAA privacy and security
rules
• Privacy advocates have charged that MU and
Standards rules do not address privacy and
security issues (e.g., how practically to ensure
that PHI of patient who pays in full for care is not
sent to insurer)
Meaningful Use Proposed Pathway
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Three-stage approach with increasingly rigorous requirements:
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Stage I – Electronic capture of health information in coded format; track
key clinical conditions and communicate outcomes for care coordination;
implement clinical decision support tools to facilitate disease and medication
management; and report outcomes for public health purposes.
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Stage II – Stage I plus: exchange data to accomplish computerized provider
order entry; transitions in care; electronic transmission of diagnostic test
results; and research.
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Stage III – Stage II plus: improvements to health care quality and safety;
focuses on clinical decision support at a national level by encouraging patient
access and involvement; and, improved population health data.
Progression Through MU Stages
First
payment
year
2011
2012
2013
2014
2015
2011
Stage 1
Stage 1
Stage 2
Stage 2
Stage 3
Stage 1
Stage 1
Stage 2
Stage 3
Stage 1
Stage 2
Stage 3
Stage 1
Stage 3
2012
2013
2014
2015
Stage 3
Progression Through Stages
• The earlier you become an EMU, the more time you
have to develop compliance with various criteria to move
through the stages
• Can begin as late as 2104 and still receive incentives for
stage 1 compliance
Medicare Payment to EPs
• Get an additional 75% of charges for Medicare-covered
services for year, capped at the annual maximum (next
slide).
• Cap determined by year of first qualification and number
of years provider has earned incentive
• EPs providing services in HPSAs eligible for an
additional 10% in incentive payments
Maximum Total Medicare Incentives for EPs
Calendar
year
Payment
year--2011
Payment
year--2012
Payment
year--2013
Payment
year--2014
Payment
year—2015+
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
$0
$2,000
$4,000
$4,000
$0
TOTAL
$44,000
$44,000
$39,000
$24,000
$0
Payment Timing
• For EPs in Medicare incentive program, CY beginning on
January 1, 2011
• For hospitals, federal fiscal year, beginning on October
1, 2010
• Some state Medicaid programs may be ready to
commence payments in October 2010
Medicaid Incentives
• Based on Medicaid patient volumes
– For EPs, at least 30% Medicaid patient encounters
over 90 consecutive days
– Pediatricians must have at least 20% Medicaid
patient encounters over same time period
– EPs in FQHC/RHC must have at least 30% of “needy
individual” patients
• For hospitals, at least 10% Medicaid patients
– Incentives based on EHR amount multiplied by
Medicaid share
Medicaid Payments
• For EPs, 85% of “net average allowable costs” for EHR
• These costs can’t exceed $25,000 in year 1 and $10,000
in years 2 through 6
• Pediatricians may get less if under 30% Medicaid patient
volume
• Maximum incentive: $63,750 (85% of $75,000) over 6
years
Medicare vs Medicaid Incentive Programs
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Medicare
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Implemented by feds
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Payment “adjustments” kick in after incentives expire
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Must be an EMU in year 1
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MU definition
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Physicians, subsection (d) hospitals, CAHs
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Last year EP can start is 2014
Medicaid
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States implement
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No payment “adjustments”
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Can adopt, implement, or upgrade in year 1
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States can adopt stricter definition (like HIPAA preemption)
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Several types of EPs and hospitals
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Last year EP may start is 2016
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EPs may receive more $
Meaningful Use Proposed Pathway
• For each of the three stages, there are:
• Objectives
– For Hospitals
• E.g., 10% of all orders via CPOE, implement once clinical
decision rule, report quality data to CMS, etc.
– For Providers
• E.g., same as hospitals but add electronic prescribing,
generate lists of patients with specific conditions, etc.
• Measures
– E.g. the percent of patients with hypertension under control, etc.
Complete matrix is available on ONC website: http://healthit.hhs.gov
Proposed Pathway, Stage 1
This table outlines a few of the Stage 1 objectives defining meaningful use
and what criteria the government will use to measure meaningful use.
Meaningful Use Objectives
Meaningful Use Measures
Use Computer Provider Order Entry
(CPOE)
CPOE is used for at least 80% for all
orders; 10% for hospitals
Implement drug/allergy checks
EHR software function is enabled
Maintain up-to-date problem list of
current and active diagnoses based
on ICD-9-CM or SNOMED CT
At least 80% of all unique patients have
at least one entry or an indication of
none recorded
E-prescribing (EP only)
At least 75% of all permissible
prescriptions written by the EP are
transmitted electronically
Proposed Pathway, Stage 1
Meaningful Use Objectives
Meaningful Use Measures
Maintain active medication/allergy list
At least 80% of all unique patients have at
least one entry or an indication of none
recorded
Record demographics
At least 80% of all unique patients have
demographics recorded
Record and chart changes in vital signs
For at least 80% of all unique patients age 2
and over, record blood pressure and BMI,
and plot growth chart for children age 2-20
Incorporate clinical lab-test results into
EHR as structured data
At least 50% of all clinical lab tests are
incorporated as structured data
Reporting
• Hospitals and EPs are able to use an attestation
methodology to submit summary quality information to
CMS (Medicare) or states (Medicaid) in 2011. Expect a
more formalized process from HHS by 2012.
• Hospitals and EPs have a 90-day minimum reporting
period in the first year to qualify as a meaningful user.
Subsequent years require full year reporting.
• Hospitals can participate in both Medicare and Medicaid
incentives, if eligible by volume.
Areas of Concern
• Funds are all or nothing, depending on whether you achieve/report
on all measures
• Objectives and Measures are numerous (23 for hospitals, 25 for
EPs) and very high – can EPs and hospitals meet these standards?
• American Hospital Association concerned with the stringent
definition of “meaningful use” that doesn’t recognize existing health
IT efforts and may unfairly penalize many hospitals
• Payment incentives exclude physicians who practice in outpatient
centers and clinics owned by a hospital
Next Steps
• If you currently use successful EHR technology that
likely will not meet the new certification requirements,
submit comments to CMS (consider grandfathering
request?)
• Learn about your state’s plans for Medicaid incentive
program and, if you are an EP, determine which program
likely will benefit you more
• If you’re in the market for an EHR, negotiate with
vendors and be sure you have language in the contract
requiring certification and compliance with MU
requirements and, in the event of noncertification or
noncompliance, termination and indemnification rights
for your organization
Questions?
Patricia A. Markus
[email protected]
(919) 755-8850