Transcript Online Clinical Data: A Servant, Not a Master

Impact of the
Healthcare IT Stimulus
Package
Presented by
Mark R. Anderson, FHIMSS, CPHIMS
CEO, AC Group, Inc.
Mark Anderson, FHIMSS, CPHIMSS
Healthcare IT Futurist
CEO of AC Group
– Conducted > 300 Technology Software Searches for
Hospital and Physician Organizations
– National Speaker on EHR > 380 sessions since 2001
– Semi annual report on Vendor product functionality
and company viability
36+ Years In Healthcare IT
– CIO Position at Three Multi Facility Regional IDN’s
– Installed over $1B in technologies since 1972
– Former CIO of a 2,300+ physician (500+ Practices)
IPA
Http://www.acgroup.org
Page No: 2
Disclosure
Speaking at numerous professional associations
and at vendor meetings (over 100/Year)
White Papers on the use of technology
Serve on numerous conference boards
EHR Search and Selections (> 100 Practices)
DOQ-IT and CMS EHR Selection Tool
NO Revenue from any vendor based on any
Sales or increase in Revenues
The Genesis
EHR adoption needs a financial incentive
Health Care Drivers
US health care expenditures now exceed
$2 trillion annually
$6,697 per capita annually (2006)
47 million uninsured and growing
World Health Organization ranked USA
healthcare system at 37th in world (2000)
May, 2008
6
© SFT, 2008
US Health Care Costs Comparison
May, 2008
7
© SFT, ©
2008
SFT, 2008
Burden of Chronic Diseases
Healthcare costs not evenly distributed
–
–
–
–
15% of Americans have no costs annually
10% account for 70% of costs
5% account for 60% of costs
1% account for 35% of costs
75% of total costs are from chronic diseases
–
–
–
–
–
May, 2008
70% of chronic disease costs are from
Diabetes mellitus
Congestive heart failure
Coronary artery disease
Asthma
Depression
8
© SFT, 2008
What about Quality?
Medicare costs versus quality
May, 2008
9
© SFT, 2008
Hospital EMR Adoption Model
Stage
2007
2008
0.0%
0.3%
Stage 6
Physician Documentation using templates,
CDSS (variance and compliance, full PACS
0.3%
0.5%
Stage 5
Closed Loop Medication
1.9%
2.5%
Stage 4
CPOE, CDSS with Clinicals protocols
2.2%
2.5%
Stage 3
Clinical Documentation, Flow sheets, CDSS
error checking
25.1%
35.7%
Stage 2
CDR, Controlled Clinical Vocabulary, CDS,
DIM
37.2%
31.4%
Stage 1
Lab, Radiology and Pharmacy Installed
14.0%
11.5%
Stage 0
Lab, Radiology and Pharmacy not Installed
19.3%
15.6%
Stage 7
Functionality
Full e-chart, Creation of CCD record, Data
warehousing, outcomes reporting
Estimated EHR Penetration in
Physician Offices
Source: AC Group Annual Survey, February 2009
Why are Practices not using what
they Purchased?
Source: AC Group Annual Survey of buying patterns
New England Journal of Medicine
EHR Failure rate
Through 2007, the EHR failure rate continues
to increase.
When asked, “1 year of EHR installation, are
you seeing 80% of your patients using the EHR
for charting, ROS, HPI, Evaluation, coding,
orders and results reporting”.
– 73% of the physicians (3,245) indicated that no, they
were NOT using the EHR for 80% of their patients.
– Why, are 73% of the physicians NOT fully utilizing
the EHR after 1 year?
Page No: 14
Stimulus Act
On February 17, 2009, President Barack Obama signed into law the
American Recovery & Reinvestment Act to stimulate the lagging
U.S. economy.
Total funds allocated = $29.6B
The health IT component of the Bill is called the Health Information
Technology for Economic and Clinical Health (HITECH) Act
– $19.2 billion dollars allocated between 2009 and 2016
– Encourage healthcare organizations to adopt and effectively
utilize Electronic Health Records (EHR)
– Establish health information exchange networks at a regional
level, all while ensuring that the systems deployed protect and
safeguard the critical patient data at the core of the system.
HITECH Finances
$2B for HIT infrastructure, especially HIE
$17.2B Medicare/Medicaid incentives to doctors and
hospitals for “meaningful” use of certified HIT (net after
government projected savings)
$4.7B for the National Telecommunications and
Information Administration's Broadband Technology
Opportunities Program
$2.5B for the U.S. Department of Agriculture's Distance
Learning, Telemedicine, and Broadband Program
$1.1B for comparative effectiveness grants from AHRQ,
NIH, and HHS- does automation improve care
HITECH Finances
$1.5B for the community health centers through the Health
Resources and Services Administration;
$500M for the Social Security Administration;
$85M for the Indian Health Service; and
$50M for the Veterans Benefits Administration
Assorted “pockets” of HIT funding in state and community funding
allotments.
$29.6B IN TOTAL (not counting local funding)
Note
There is actually another $20B for Medicare Incentives
The real total for Health IT is about $50 B
High Level Allocation of Funds
HITECH includes $19.2B in Funding
– $2 billion immediately to the Department of Health &
Human Services (HHS)
The Office of the National Coordinator for Health IT (ONC)
Directs creation of standards and policy committees
– $17.2 billion that will eventually be paid to healthcare
providers who can demonstrate their use of Electronic
Health Records.
High Level Allocation of Funds
Incentives actually total ~$34B
CBO calculation
The $17.2 B figure is the net expenditure
after including expected savings in health
care costs
The Office of the National
Coordinator for Health
Information Technology
(ONC)
Office of National Coordinator
$2 billion immediately to the Department of Health & Human Services
(HHS)
David Blumenthal, MD will head ONC
Charged with developing a nationwide HIT infrastructure to improve quality,
reduce costs, and protect privacy
Chief Privacy Officer to be appointed by ONC within 12 months
Federal Health IT Strategic Plan to be updated on published on a website.
Must include a plan for implementation of EHRs for every patient in the US
by 2014
Privacy and Interoperatability standards to be set by 12/2009
$2 billion to HHS / ONC
$300 million to establish more health information
exchange (HIE) initiatives in regions and towns across
the country, as well as helping existing HIEs to progress
in connecting providers.
$20 million allocated to ensure that standards are
consistent across products and care settings.
Beyond those guidelines, the Bill does not assign
specific dollar amounts to specific programs.
The incoming Secretary will announce how the
remaining funds will be allocated by November 2009.
$2 billion to HHS / ONC
Areas called out for investment include:
– clarifying and further developing standards related to
interoperability and privacy
– building infrastructure for the advances of telemedicine
– expanding health IT in public health departments
– establishing a Health IT Research Center and regional Health IT
Extension Centers to provide information to healthcare providers
on best practices, vendor selection, implementation, training, etc.
– Funding through Federal grants via AHRQ, HRSA, CMS and the
CDC, as well as grants to states and state-designees to be
passed on to healthcare organizations needing assistance with
upfront funding for EHRs
Standards and Certification
Qualified EHR technology means:
– EHR is certified to meet standards and
includes:
patient demographic and clinical health
information,
medical history and problem lists,
provides decision support for physician order entry,
capture and query healthcare quality information,
exchange electronic health information with other
sources.
Standards and Certification
The Secretary of HHS is required by the Bill
– Review all existing standards,
– Determine the initial set of standards
– Define “Meaningful Use” criteria
– Establish implementation specifications.
– All of this must be completed by the HIT Policy
Committee and HIT Standards Committee before the
end of 2009.
Standards and Certification
Adopt initial set of standards by December 31, 2009
Does this mean CCHIT 2009 Certification?
Does not specifically state CCHIT
National Coordinator may recognize an entity – but
which one?
NIST shall support the establishment of conformance
testing infrastructure, in collaboration with the
Certification program and coordination with HIT
Standards Committee
Will CCHIT Survive?
CCHIT has been Federally recognized since 2006
The organization met all contractual goals, on time/on
budget
Operationally successful and sustainable with high levels
of market acceptance – large number of EHR products
currently certified and ‘adoption-ready’
It is not practical to design, bid, and develop a credible
new certification body in 20 months
ONC has many other challenging new programs to
develop
CCHIT Certified EHR Vendors
Certification is good for 3 years – but!!!!!
Renew
100
80
New Vendors
60
Pass 2008
40
Pass 2007
20
Pass 2006
0
2006 2007 2008 2009 2010
As of March 20, 2009 only 50 products have passed the 2007 CCHIT
and 24 have passed the 2008 CCHIT Requirements
Page No: 30
Many Vendors Pretend to be part of the
Marketplace
Privacy Expansion
Defining which actions constitute a breach (including
some inadvertent disclosures) by 12/09
Imposing restrictions on certain disclosures, sales, and
marketing of protected health information
Requiring an accounting of disclosures to a patient upon
request
Authorizing increased civil monetary penalties for
HIPAA violations
Granting authority to state attorneys general to enforce
HIPAA
Breach Notification
Establishes a federal security breach notification
requirement for breach of protected health information
Requires each individual be notified if their “unsecured”
PHI is accessed, acquired or disclosed as a result of the
breach
Requires notification to Sec HHS and prominent media
outlets if more than 500 individuals impacted
Applies to PHR vendors
Accounting of Disclosures
Gives patients the right to request an accounting of
disclosures of their health information made through an
EHR
– Does not state how the EHR will provide information
Secretary of HHS to promulgate regulations that take
into account the “interests of individuals” in learning
– when and to whom their information is disclosed,
– the “usefulness” of the information to the individual, and
– the “cost burden” for such accounting
Business Associates
Ensures that new entities that were not contemplated
when HIPAA was written
– PHR vendors,
– RHIOs,
– HIEs, etc.
Requires Business Associate contracts, and treating
these entities as Business Associates under HIPAA
Marketing and Sale of PHI
Provides new restrictions on marketing using PHI
Marketing Communications are not Health Care
Operations
Provides new restrictions on payment for PHI
Prohibits a CE/BA from receiving remuneration in
exchange for any PHI without a valid authorization from
the individual.
Enforcement/Penalties
Allows criminal penalties to apply to individuals
Provides new system of civil monetary penalties
Modifies distribution of certain civil monetary penalties
collected
Requires the Secretary to provide for periodic audits of
covered entities and business associates
Allows State Attorneys General to bring a civil action in
federal court on behalf of the residents of their state
Additional Items
Development and Routine Updating of a
Qualified EHR Technology
Study Concerning Open Source
Technology
$17.2 billion in incentive payments
to physicians and hospitals
The government is focused on two primary goals in this legislation:
–
moving physicians who have been slow to adopt Electronic Health Records to a
computerized environment, and
– ensuring that patient data no longer sits in silos within individual provider
organizations but instead of actively exchanged between healthcare
professionals to ensure that patients are receiving informed care.
Therefore, the vast majority of the funds within the HITECH Act are
assigned to payments that will reward physicians and hospitals for
effectively using a robust, connected EHR system.
There is a program designed for those that see large volumes of
Medicaid patients, and another for those that accept Medicare
$17.2 B to Physicians and Hospitals
In order to qualify for the incentive payments,
both physicians and hospitals have to prove
three things:
– 1. Use of a certified EHR product with ePrescribing capability
that meets current HHS standards.
– 2. Connectivity to other providers to improve access to the full
view of a patient’s health history.
– 3. Ability to report on their use of the technology to HHS.
Connecting Physicians
Delivers the Connected Community
Ancillary
Departments
Hospitals
Employers
Physicians
Providers areIn-patient
best positioned
to lead the
Clinicals &
Physician Portal
way to a connected
care community
Physician Office
Solutions
Homecare
Providers
Patients
Http://www.acgroup.org
Broad Community
Connectivity
Retail
Pharmacy
Payers & PBMs
Page No: 43
Connecting the Community
Patient
Health Care Insurer
Pharmacy
Laboratory
Access
Consent
Radiology
Security and Access Control
Hospital
Enterprise Master Patient Index
Patient Event Information
Patient Demographics, Social & Family, Clinical Information
Medication Details, Laboratory Results, Insurance Details
Scanned Documents
Specialist Transcription
Providers
Physician Medicaid Incentives
Physicians who see more than 30% of patients
paying with Medicaid (20% for pediatricians) are
eligible for payments of up to $64,000 over five
years.
The incentives will be calculated through a
formula that factors in the exact Medicaid mix
seen by the provider.
Up to 85% of certain costs for certified EHR
technology, subject to caps
Physician Medicaid Incentives
1st year of payment capped at $25,000
Costs for purchase and implementation or upgrade of EHR
technology and support and training services,
Engaging in efforts to adopt, implement or upgrade a certified EHR
technology, or
Investment was made prior to beginning of funding period with
demonstration of “meaningful use” of certified EHR technology
Subsequent years of payment, capped at $10,000 per year, for
costs relating to the operation, maintenance and use of certified
EHR technology
Physician Medicaid Incentives
First year costs must not be later than 2016
No payments made after 2021 or for more than
5 years (Maximum incentive will be $65,000)
Medicaid Pediatricians are eligible for 2/3 the
amount otherwise specified
Physician Medicare Incentives
Physicians who do not have a large Medicaid
volume but do accept Medicare can receive up
to $44,000 over the five years.
Additionally, physicians operating in a "provider
shortage area" will be eligible for an incremental
increase of 10%,
and those delivering care entirely in a hospital
environment, such as anesthesiologists,
pathologists and ED physicians, are ineligible.
Medicare Incentives for Physicians
Money is available commencing in 2011
Compensate “meaningful EHR users” in an amount equal to an
additional 75% of the allowed charge for professional services
furnished by physicians
Incentives are for 5 years, with a decreasing schedule each year
Phase down for physicians adopting after 2013
Physicians whose first payment year is after 2014 receive no
incentives
No incentives after 2016
Beginning 2015, reduction in Medicare reimbursements by 1 to 3
percent each year for physicians who are not meaningful EHR users
Medicare Incentives in $1,000’s
YR
c11
c12
c13
c14
c15
c16
Tot
1-4
$18
$12
$8
$4
$2
$0
$44
$18
$12
$8
$4
$2
$44
$15
$12
$8
$4
$42
$12
$8
$4
$24
$0
$0
$0
$0
$0
1-4
1-4
2-4
No
Pay
No
Pay
Medicare Penalties
1% of your Medicare fee schedule - 2015
2% of your Medicare fee schedule - 2016
3% of your Medicare fee schedule – 2017
For 2018 and beyond, if proportion of eligible
professionals who are meaningful users is less than
75%, percentage shall increase by 1% from percent
in previous year but not be greater than 5%
Meaningful Use of Certified EHR
Technology for Physicians
That the CCHIT-certified EHR should have
robust functionality;
The EHR enables the physician to electronically
exchange standardized patient summary data
with clinical & administrative stakeholders; and,
The EHR equips the physician to quantify and
report improved patient safety, quality outcomes,
and cost reductions.
Meaningful Use of Certified EHR
Technology for Physicians
Must include a clinical data repository and CPOE supported by
CDS.
ePrescribing technology to electronically transmit prescriptions to
pharmacies.
Exchange health information electronically with external entities.
E-submission of claims complying with HIPAA Claims Attachment
regulations
Quality reporting metrics.
Meaningful Use of Certified EHR
Quality Reporting Metrics
Baseline reporting of percentage of medical orders entered
electronically into the EHR by physicians
Baseline electronic reporting of Joint Commission core measures
Baseline reporting of AHRQ quality outcomes
Baseline reporting of National Priorities Partnership goals, convened
by National Quality Forum
Baseline reporting of all adverse (drug) events
Baseline reporting of percentage of prescriptions sent to the
pharmacy electronically upon a patient’s visit
Hospital Medicaid Incentives:
Category
Eligibility Criteria
Non-hospitals based pediatricians
(“Medicaid Pediatricians”)
At least 20% of patient volume is
attributable to individuals receiving medical
assistance
Other non-hospital based providers
At least 30% of patient volume is
attributable to individuals receiving medical
assistance
Non-hospital based providers that practice
predominantly in federally qualified health
center or rural health clinic
At least 30% of patient volume is
attributable to needy individuals (medical
assistance, SCHIP assistance,
uncompensated care and those charged
based on a sliding scale per ability to pay)
Children’s hospitals
No requirement
Acute-Care hospitals
At least 10% of patient volume attributable
to individuals receiving medical assistance
Hospital Medicaid Incentives
Start of incentive payments not specified in legislative language;
probably 2011
Must demonstrate “meaningful use” of certified EHR technology in
second and subsequent years of incentives.
– But standards are not set yet
Must be established by a means approved by the state and
acceptable to HHS
Consistent with the definition used for Medicare incentives
No reductions in Medicaid payments for failure to demonstrate
“meaningful use”
Hospital Medicaid Incentives
Hospitals that adopt in 2017 or later are not eligible for
any incentives
Incentives limited to 6 years
Incentives equal the product of the overall Hospital EHR
Amount and the Medicaid Share for such provider
(“Medicaid Incentive”)
– What in the world does that mean?
In any year, the total amount shall not exceed 50% of the
Medicaid Incentive and in any 2 year period, the total
amount shall not exceed 90% of the Medicaid Incentive
Hospital Medicare Incentives
Hospitals stand to make up to $11 million from incentive
$2 million base payment, plus
$0 for first 1,149 discharges and $0 for each discharge after 23,000
$200 for each discharge between the 1,150th and the 23,000th
discharge annually
Note that Critical Care Hospitals are not eligible for the incentives
described above;
instead, they will be allowed to expense the acquisition cost of
health IT in a single year up to $1.5 million.
Hospital Incentives
Fee Reductions:
– Eligible hospitals not demonstrating meaningful EHR use by
2015
– Fee schedules will not increased as planned
– Fee schedules will be adjusted increasingly to the disadvantage
of the hospital.
– This reduction only applies to the individual fiscal year;
– if the hospital begins demonstrating use of an EHR the following
year, their fee schedule increase will normalize.
Hospital Medicare Incentives
Medicare Share is a fraction:
– Numerator equals: Inpatient-bed days attributable to Part A plus
inpatient-bed days attributable to Part C
– Denominator equals: Total number of inpatient-bed days times
((a) non-charity care charges divided by (b) total amount of
charges)
Critical Access Hospitals increase the Medicare Share
by 20 percentage points, as long as Medicare Share
does not exceed 100%.
Hospital Medicare Incentives
“Meaningful EHR users”
– Hospitals that demonstrate to HHS that they are using
certified EHR technology in a meaningful manner
– Certified EHR technology is connected in a manner that
provides for electronic exchange of health information to
improve quality of health care
– Submit information to HHS on clinical quality measures
– No e-prescribing requirement
– CCHIT for Inpatient Systems? Which year?
The Problem!!
Which vendor sells a hospital EMR product?
–
–
–
–
Cerner Corporation
Epic Systems Corporation
McKesson
Siemens Medical Solutions
- CPSI
- GE Healthcare,
- MEDITECH
But no one list an EMR product
They list CIS, Nursing Documentation, CPOE, Lab,
Pharmacy, Surgery, Radiology, etc.
Hospital Medicare Incentives
FY 11
FY 12
FY 13
FY 14
FY 15
FY 16
FY 11
1.00
FY 12
0.75
1.00
FY 13
0.50
0.75
1.00
FY 14
0.25
0.50
0.75
0.75
FY 15
0.00
0.25
0.50
0.50
0.50
FY 16
0.00
0.00
0.25
0.25
0.25
0.00
FY 17
0.00
0.00
0.00
0.00
0.00
0.00
Meaningful Use of Certified EHR
Technology for Hospitals
That the CCHIT-certified EHR should have
robust functionality;
The EHR enables the physician to electronically
exchange standardized patient summary data
with clinical & administrative stakeholders; and,
The EHR equips the hospital to quantify and
report improved patient safety, quality outcomes,
and cost reductions.
Meaningful Use of Certified EHR
Technology for Hospitals
A hospital’s EMR infrastructure ought to include the
major ancillary department information systems
– lab, pharmacy, radiology, as well as a clinical data
repository.
Clinical documentation by nurses and other clinicians
such as pharmacists, but optional for physicians.
Such documentation is a prerequisite for effective
computerized practitioner order entry (CPOE).
– For example, to make effective patient care decisions,
clinicians must have a patient’s allergies, problem list,
vital signs, I&Os, flow sheets, and medication list.
Meaningful Use of Certified EHR
Technology for Hospitals
A majority of physicians electronically entering orders, followed in another
two years by requiring all physicians to enter orders and provide clinical
documentation electronically.
ePrescribing beyond the bounds of the hospital.
Hospitals electronically exchanging patient summary (CCD) information with
external entities such as, but not limited to, other hospitals, payers,
transitional/long-term care, physician practices, patients’ personal health
record, and health information exchanges.
Such summary information should include demographics, allergies,
medication summaries, problem list, reporting of diagnostic tests, the
patient’s primary spoken language, race, and ethnicity.
Grant the hospital the latitude to electronically exchange information as
discrete data elements or in a text document.
Meaningful Use of Certified EHR
Technology for Hospitals
Demonstration of a hospital’s active process of
implementing EMR applications, working
towards true interoperability.
– Note that this requires no actual operational, external exchange
of health information with another entity.
E-submission of claims complying with HIPAA
Claims Attachment regulations.
Quality reporting metrics.
Meaningful Use of Certified EHR
Technology for Hospitals
Baseline reporting of percentage of medical orders entered electronically
into the EMR by physicians
Baseline electronic reporting of Joint Commission core measures
Baseline reporting of AHRQ quality outcomes
Baseline reporting of re-admissions within 24 hours of discharge
Baseline reporting of duplicate diagnostic test orders
Baseline reporting of present-on-admission tests compliance (i.e. MRSA,
pneumonia)
Baseline reporting of medication errors
Baseline reporting of percentage of diagnostic test results and medical
images that are electronically available to clinician’s via CDR access
Hospital EMR Adoption Model
Stage
2007
2008
0.0%
0.3%
Stage 6
Physician Documentation using templates,
CDSS (variance and compliance, full PACS
0.3%
0.5%
Stage 5
Closed Loop Medication
1.9%
2.5%
Stage 4
CPOE, CDSS with Clinicals protocols
2.2%
2.5%
Stage 3
Clinical Documentation, Flow sheets, CDSS
error checking
25.1%
35.7%
Stage 2
CDR, Controlled Clinical Vocabulary, CDS,
DIM
37.2%
31.4%
Stage 1
Lab, Radiology and Pharmacy Installed
14.0%
11.5%
Stage 0
Lab, Radiology and Pharmacy not Installed
19.3%
15.6%
Stage 7
Functionality
Full e-chart, Creation of CCD record, Data
warehousing, outcomes reporting
Community Health
Center Programs
$1.5 billion to be distributed by HRSA
Plan is to be ready by May 2009
Only Federally Qualified Health Centers or groups of these
centers are eligible
Primary Care Associations cannot apply for the money but
Health Center Controlled Networks (HCCN's) are beneficial
recipients
FQHC providers- identified as physicians, physician assistants,
nurse midwives, nurse practitioners and dentists- are eligible
for the Medicaid incentives outlined in previous slides as long
that they are treating a minimum 30% Medicaid base.
When Is The Right Time To Start
Your HIT Planning?
NOW!
It will take you 12-18 months to prepare
appropriately
If you don’t have a “certified” EHR, you need to get
one.
If you have no EHR, conduct your site analysis and
start your solution search
Review 2008 certified products ~24 and the 2007
Inpatient CCHIT products
Will the Stimulus Package Help?
Physicians
As of August 2008, only 4% of providers are using full EHR
An additional 13% are using a partial EHR product.
Traditional EHRs require 7X more time to capture information
Requires provider to change the way they provide care
Allows documentation of 1,000’s of data elements, although less
than 30 are used today.
Does not reduce duplicate data entry – Silos of Info
Will the Stimulus Package Help?
Hospitals
As of August 2008, only 1% of hospitals are using full Inpatient
EMRs
An additional 34% are using a partial EMR product.
Traditional EMRs require 7X more time to capture information
Requires Physicians to change the way they provide care
Allows documentation of 1,000’s of data elements, although less
than 30 are used today.
Does not reduce duplicate data entry – Silos of Info
Need direct interface with Physicians EHR’s
Need fully functional HIE communities
Take Home Message
There is NO Stimulus in the Stimulus plan
Hospitals and Physicians have not seen the benefits or
“value” in changing
Clinical studies have show no outcomes improve by using
EHRs
EHRs Can Improve Patient Service and Provide Financial
Benefits.
EHR Products Are Available in 5 Types. Each Type Can
Impact What the Product Will Do for Your Organization.
EHR Implementation is a “Bet the Organization”
Proposition That Requires Adequate Resources and
Investments to Achieve Success.