EHR vs. EMR EHR Incentives Company Profit by using LOGO a certified EHR EMR - Electronic records of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization A real time record of health -related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization Incentives available PQRI Incentives PQRI E-prescribing Medicare EHR Medicaid EHR * * Doctors of Optometry are not eligible for Medicaid EHR incentives PQRI Background Tax Relief and Health Care Act of 2006 (TRHCA) TRHCA required the establishment of a physician quality reporting system, Including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures CMS named this program the Physician Quality Reporting Initiative (PQRI). PQRI Incentive for 2011 Individual EPs may choose to report PQRI quality measures or measures groups to: CMS on their Medicare Part B claims, or A qualified PQRI registry, or CMS via a qualified EHR product. Can earn PQRI incentive payment equal to 1.0% of their total Medicare Part B charges There is a Penalty of 1% for 2012 1
PQRI Registration Individual EPs do not need to sign-up or pre-register To qualify must meet the criteria for satisfactory reporting specified by CMS PQRI Reporting modifiers Each measure has a Quality Data Code (QDC - a CPT II code or G-code) associated with it. Several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and the 8P reporting modifier. Modifiers are only used when the reported measure was not performed The 8P modifier (reason not specified) may not be used indiscriminately PQRI Codes for Reporting PQRI Eligible Claims Correct QDC must be reported on at least 80 percent of the claims that are eligible for each selected measure. A claim is "eligible" in PQRI when the ICD- 9 diagnosis and the CPT Category I service codes on the claim match the diagnosis and encounter codes listed in the denominator criteria of the measure specification. PQRI reporting frequency E-Prescribing Incentive Each measure has a reporting frequency i.e.: report each visit, once during the reporting period, each episode, etc. The reporting frequency is found in the Instructions section of each measure specification. 2
E-Prescribing Background Authorized by Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) It is a new and separate incentive program for eligible professionals (EPs) who are successful electronic prescribers Eligible Professionals The following professionals are eligible to participate in E-Prescribing Incentive Program: Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Eligible professionals must have prescribing authority in order to participate in this incentive program. E-Prescribing Registration There is no sign-up or pre-registration May begin reporting at any time throughout the 2011 program Simply begin submitting the G-code on your claims appropriately Can potentially receive an incentive payment of 1.0% E-Prescribing Requirements First, must have and use a qualified erx system and report adoption and use of the erx system. Second, eligible professionals must report the erx measure at least 25 times (for eligible patient encounters) and Finally, at least 10% of a successful electronic prescriber's Medicare Part B covered services must be made up of codes that appear in the denominator of the erx measure. Qualified E-Prescribing Systems Qualified E-Prescribing Systems Capable of ALL of the following: 1. Generates a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs), if available. 2. Selects medications, prints prescriptions, electronically transmits prescriptions, and conducts all alerts (defined below). 3. Provides information related to lower cost, therapeutically appropriate alternatives, if any (the availability of an erx system to receive tiered formulary information would meet this requirement for 2010). 4. Provides information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available. Two types of systems: 1. A system for erx only (stand-alone) 2. An electronic health record (EHR system) with erx functionality. CMS maintains a list of "qualified registries/ehr vendors Are qualified to report e-prescribing information to CMS (but have not been checked for e-prescribing functionality) 3
Qualified E-Prescribing Example Numerator / Denominator? Numerator: erx Quality-Data Code for Successful Reporting: G8553:At least one prescription created during the encounter was generated and transmitted electronically using a qualified erx system Denominator one (or more) of the following codes applies and is included on the claim 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109 E-Prescribing Reporting EHR Incentives EPs may choose to report on their adoption and use of a qualified erx system by submitting information to: 1. CMS on their Medicare part B claims, 2. A qualified registry, or 3. CMS via a qualified electronic health record (EHR) product. EHR Incentives Overview Incentive amounts based on Fee-for- Service allowable charges 75% of EP s allowed charges for CY 2011 About 1 exam per day to get maximum Maximum incentives are $44,000 over 5 years Incentives decrease if starting after 2012 Must begin by 2014 to receive incentive payments (at all) Penalties begin in 2015 HITECH Act EHR Incentives Background Established programs in Medicare and Medicaid Programs Provide incentive payments for the "meaningful use" of certified EHR technology. Programs begin in 2011. Designed to help providers transition to the use of EHRs in meaningful ways 4
A Medicare EP is a: Medicare Eligible Professionals doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, who is legally authorized to practice under state law. A qualifying EP is one who successfully demonstrates meaningful use for the EHR reporting period. Medicare EHR - Requirements NPI, NPPES User Account and PECOS Enrollment All EPs must have a National Provider Identifier (NPI). All Medicare EPs must also be enrolled in the CMS Provider Enrollment, Chain and Ownership System (PECOS) Most will also need an active user account in the National Plan and Provider Enumeration System (NPPES). Certified EHR Technology Standards can be found on HHS HIT website Do not need to have certified EHR in place in order to register Medicare Registration The Medicare and Medicaid EHR Incentive programs began in early 2011. Registration is now open. EHR Certification Certification criteria for HIT were established by the Office of the National Coordinator (ONC.) ONC Final rule Released on July 13, 2010 Specifies minimal criteria for Stage 1 meaningful use ONC maintains a list http://onc-chpl.force.com/ehrcert/ehrproductsearch?setting=ambulatory Meaningful Use The Recovery Act specifies the following 3 components of Meaningful Use: Use of certified EHR in a meaningful manner (e.g., e-prescribing) Use of certified EHR technology for electronic exchange of health information to improve quality of health care Use of certified EHR technology to submit clinical quality measures(cqm) and other such measures selected by the Secretary Meaningful Use - Stage 1 For stage 1, which began in 2011, CMS proposes 25 objectives for physicians Stages 2 & 3 will expand the list in 2013 & 2015 Added requirements will be proposed through future rulemaking Physicians failing to adopt EMRs and meet the objectives by 2015 will face Medicare penalties. 5
Meaningful Use - Exclusions Some MU objectives are not applicable to every provider s clinical practice, thus they would not have any eligible patients or actions for the measure denominator. Exclusions do not count against the 5 deferred measures In these cases, the EPs excluded from having to meet that measure Examples cited by CMS Dentists who do not perform immunizations Chiropractors who do not e-prescribe Meaningful Use - Stage 1 Meaningful use includes both a core set and a menu set of objectives that are specific for eligible professionals For Eligible Professionals, there are a total of 25 meaningful use objectives. 20 of the objectives must be completed 15 are core objectives that are required, and the remaining 5 objectives may be chosen from the list of 10 menu set objectives. The definition of meaningful use includes reporting of clinical quality measures. Meaningful Use - Stages 2 & 3 Help w/ Meaningful Use The criteria for meaningful use will be staged in three steps over the course of the next five years. Stage 1 sets the baseline for electronic data capture and information sharing. Stage 2 (est. 2013) and Stage 3 (est. 2015) will continue to expand on this baseline and be developed through future rule making. 15 Core Objectives MU- Core Objectives 1. Computerized physician order entry (CPOE) 2. E-Prescribing (erx) 3. Report ambulatory clinical quality measures to CMS/States 4. Implement one clinical decision support rule 5. Provide patients with an electronic copy of their health information, upon request 6. Provide clinical summaries for patients for each office visit 7. Drug-drug and drug-allergy interaction checks 8. Record demographics MU- Core objectives cont. 9. Maintain an up-to-date problem list of current and active diagnoses 10. Maintain active medication list 11. Maintain active medication allergy list 12. Record and chart changes in vital signs 13. Record smoking status for patients 13 years or older 14. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 15. Protect electronic health information 6
MU- Menu Objectives Menu objectives must complete 5 of 10 1. Drug-formulary checks 2. Incorporate clinical lab test results as structured data 3. Generate lists of patients by specific conditions 4. Send reminders to patients per patient preference for preventive/follow up care 5. Provide patients with timely electronic access to their health information MU- Menu Objectives cont. 6. Identify patient-specific education resources and provide to patient, if appropriate 7. Medication reconciliation 8. Summary of care record for each transition of care/referrals 9. Capability to submit electronic data to immunization registries/systems* 10. Capability to provide electronic syndromic surveillance data to public health agencies* Meaningful Use CQM Must complete 3 core and 3 additional In 2011, required to submit aggregate clinical quality measure numerator, denominator, and exclusion data to CMS In 2012, must electronically submit clinical quality measures selected by CMS directly to CMS through certified EHR technology. Certified EHRs will make this much easier Complete EHR Systems ONC-ATCB Approved Crystal Practice Management (V 3) Compulink Advantage (V 10) Eyefinity/OfficeMate s ExamWriter (V 10) MaximEyes SQL EHR (V 1.1.0) EHR modules Revolution EHR (V 5.1.0) EHR Reporting Period Incentive Payment Calculation For 2011, the EHR Reporting Period is 90 days for any continuous period beginning and ending within the year For every year after, the EHR reporting period is the entire year. Under FFS Medicare, payment incentive amount, is up to 75% of Medicare allowed charges Annual limit in year 1 is $18,000 Would need to bill $24,000 to get full amount Would equal 200 exams at $120 per exam Would equal about 1 Medicare exam per day 7
Medicare Incentive payments Incentives For 2011-2016, meaningful EHR users can receive up to $44,000 over 5 years To get the maximum incentive payment, Medicare eligible professionals must begin participation by 2012. Medicare Extra incentives The amount of the annual EHR incentive payment limit for each payments year will be increased by 10% for Medicare eligible professionals who predominantly furnish services in an area that is designated as a Health Professional Shortage Area (HPSA.) For 2015 and later, EPs who do not demonstrate MU will have a payment reduction Payment reduction starts at 1% and increases up to 5% for every year that a Medicare EP does not demonstrate MU Medicare Penalties EHR vs. E-prescribing vs. PQRI Medicare vs. Medicaid Cannot participate in both EHR incentive program AND e-prescribing incentive For most, the EHR incentive program will provide the greater monetary value. If you register for EHR incentive program, you will no longer be able to participate in the e-prescribing program. Physicians can participate in the Physicians Quality Reporting Initiative (PQRI) at the same time 8
Medicaid EHR incentives Medicaid will provide incentive payments for EHR use, but optometrist are not eligible providers under ARRA Even if we were listed as EPs under ARRA you would have to have 30% of your patients be Medicaid patients. EHR incentives are theoretically higher for Medicaid : maximum cumulative amount over 6 year period $63,750 EHR Incentives in TX Medicaid Data (presented at THSA) 1600+ providers registered at federal level 155 hospitals 1500+ eligible professionals First payments were mailed on May 12 4 hospitals paid = $7 million 244 professionals paid = $5 million Technology Adaptation Curve 92% 100% 90% The Chasm 84% Late Majority Conservatives Laggards Skeptics 80% 50% 70% 60% 50% 40% 30% 20% 2.5% Innovators Enthusiasts 16% Early Adopters Visionaries Early Majority Pragmatists 10% 0% 2008 2011 2014 2017 Consumer seeks technology and performance Consumer seeks solutions and convenience 9