HIT Incentives: Issues of Concern to Hospitals in the CMS Proposed Meaningful Use Stage 2 Rule Lori Mihalich-Levin, J.D. lmlevin@aamc.org; 202-828-0599 Jennifer Faerberg jfaerberg@aamc.org; 202-862-6221
Understanding Meaningful Use AAMC Teleconferences: 2-3:30 ET April 19: Hospital Issues April 24: Physician Issues Comments on both the CMS and ONC Stage 2 rules are due May 7, 2010 COMMENTS ARE IMPORTANT!! 2
Agenda for Today s Call 1. Meaningful use functionality measures 2. Quality measures 3. Penalty timing 4. Anything else? 3
Have you met IT functionality? CMS proposes Stage 2 requirements Earliest required = 2014 Hospitals must meet: All 16 core measures 2 of 4 menu measures 24 clinical quality measures 4
Hospital Stage 2 Measures Big change re: denominators: Stage 1 patients w/ records maintained using Certified EHR Stage 2 ALL patients Still have option between Observation services method (inpatient + observation) Emergency department method (inpatient + ED) Thoughts? 5
Meaningful Use Functionality - Core Objective Use of CPOE for medication, laboratory, and radiology orders directly entered by any HC professional who can enter orders Measure CPOE is used for > 60% of medication, laboratory, and radiology orders Stage 1? -Was only medication orders expanded to include labs + radiology -CMS asks: should lab + radiology have a different threshold? -If yes, should it be a lower percentage or a yes/no attestation? -Was 30% of patients with at least one medication in medication list 6
Meaningful Use Functionality - Core Objective Record demographics (preferred language, gender, race, ethnicity, date of birth, date and preliminary cause of death in the event of mortality) Measure > 80% of all unique patients admitted to the eligible hospital have demographics recorded as structured data Stage 1? Was 50% Seeking comments on whether to require inclusion of (1) disability status; and (2) gender identity/sexual orientation 7
Meaningful Use Functionality - Core Objective Record and chart changes in vital signs Height/length Weight Blood Pressure (age 3+) Calculate & Display BMI Plot & display growth charts for patients 20 years, including BMI Measure For > 80% of all unique patients admitted to the eligible hospital, record blood pressure (age 3+ only), height/length and weight (for all ages) recorded as structured data 8 Stage 1? Was 50% Height/length & weight was 2 20; now everyone BP was 2+, now 3+
Meaningful Use Functionality - Core Objective Record smoking status for patients 13 years old or older Measure > 80% percent of all unique patients 13 years old or older admitted to the eligible hospital have smoking status recorded as structured data Stage 1? Was 50% 9
Meaningful Use Functionality - Core Objective Use clinical decision support to improve performance on highpriority health conditions Measure 1. Implement 5 clinical decision support interventions relevant to the clinical quality metrics the eligible hospital reports for entire EHR reporting period 2. Enable & implement functionality for drug-drug & drug-allergy interaction checks for entire reporting period Stage 1? Was 1 measure Combined several measures into 1 10
Meaningful Use Functionality - Core Objective Incorporate clinical lab-test results into EHR as structured data Measure > 55% of all clinical lab tests results ordered by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data 11 Stage 1? Was in menu set, now core Was 40%
Meaningful Use Functionality - Core Objective Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach Measure Generate at least one report listing patients of the eligible hospital with a specific condition Stage 1? Was in menu set, now core 12
Meaningful Use Functionality - Core Objective Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (emar) Measure >10% of medication orders created by authorized providers of the hospital s inpatient or emergency dept. during EHR reporting period are tracked using emar Brand new to MU was not in Stage 1 Placed directly into core (not menu first) 13
Meaningful Use Functionality - Core Objective Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies, discharge summary, and procedures), upon request Measure 1. >50% of all patients discharged from hospital have their info available online w/in 36 hours 2. >10% of all patients discharged from hospital download or transmit to a 3 rd party their info during the reporting period 14 Stage 1? >80% of all patients who request an electronic copy of their health info are provided it w/in 48 hours Was in menu now in core Was in hands of hospital now #2 is dependent on patient action
Meaningful Use Functionality - Core Objective Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient Measure >10% of all unique patients admitted to the hospital s inpatient department or ED are provided patient-specific education resources identified by the Certified EHR Technology Stage 1? Was in menu set, now core 15
Meaningful Use Functionality - Core Objective Perform medication reconciliation at relevant encounters and each transition of care Measure Perform medication reconciliation for at least 65 percent of relevant encounters and transitions of care Stage 1? Was required for >50% of relevant encounters and transitions of care Was in menu now in core 16
Meaningful Use Functionality - Core Objective Provide summary care record for each transition of care and referral Measure 1. Provide summary of care record for at least 65 percent of transitions of care and referrals 2. Electronic submission of summary of care record using Certified EHR Technology to recipient w/no organizational affiliation and using a different Certified EHR Technology vendor than sender for >10% of all transitions of care and referrals 17 Stage 1? >Was 50% of transitions of care and referrals Was in menu now in core #2 is completely new to MU
Meaningful Use Functionality - Core Objective Measure 18 Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and accordance with applicable law and practice Successful ongoing submission of electronic immunization data from Certified EHR Technology to immunization registry or immunization information system for the entire EHR reporting period Stage 1? Addition of except where prohibited Was performed at least one test of capacity to submit data to registries now continuous and ongoing throughout reporting period Was in menu now in core
Meaningful Use Functionality - Core Objective Measure Capability to submit electronic reportable lab results to public health agencies, except where prohibited, and in accordance with applicable law and practice Successful ongoing submission of electronic reportable lab results from Certified EHR Technology to public health for the entire EHR reporting period as authorized 19 Stage 1 Added except where prohibited Was perform at least 1 test now continuous and ongoing during entire reporting period Was in menu now in core
Meaningful Use Functionality - Core Objective Capability to provide electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice Measure Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period Stage 1 Added except where prohibited Was perform at least 1 test now continuous and ongoing during entire reporting period Was in menu now in core 20
Meaningful Use Functionality - Core Objective Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities Measure Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1), including addressing the encryption/security of data at rest and implement security updates as necessary and correct deficiencies Stage 1? Expanded to include data at rest (b/c of lost/stolen devices) 21
Meaningful Use Functionality - MENU Objective Record whether a patient 65 years old or older has an advance directive Measure >50% of all patients 65+ admitted to inpatient department have indication of advance directive status recorded as structured data Stage 1 No change from Stage 1 22
Meaningful Use Functionality MENU Objective Imaging results and information are accessible through Certified EHR Technology Measure > 40% of all scans and tests whose result is an image ordered by an authorized provider of the hospital for patients admitted to inpatient department or ED during EHR reporting period are accessible through Certified EHR Technology Brand new to MU 23
Meaningful Use Functionality - MENU Objective Record patient family health history as structured data Measure > 20% of all patients admitted to hospital s inpatient department or ED during EHR reporting period have a structured data entry for one or more first-degree relatives Brand new to MU 24
Meaningful Use Functionality - MENU Objective Generate and transmit permissible discharge prescriptions electronically (erx) Measure >10% of hospital discharge medication orders for permissible prescriptions (for new or changed prescriptions) are compared to at least one drug formulary and transmitted electronically using Certified EHR Technology Brand new to MU 25
26 Stage 2 MU Clinical Quality Measures (CQMs) for Eligible Hospitals and Critical Access Hospitals (CAHs)
Major CQM Changes Through 2013 Continue to report 15 CQMs finalized in Stage 1 Changes for 2014 - CHOICE Hospitals would report 24 out of 49 (proposed) CQMs Must have at least one measure in each of the six quality domains Hospitals can pick the measures most relevant to their patient population or services offered 27
Proposed Measures by Domain Patient and Family Engagement ED-1 Emergency Department Throughput Median time from ED arrival to ED departure for admitted ED patients. ED-2 Emergency Department Throughput admitted patients Admit decision time to ED departure time for admitted patients. Stroke-8 Ischemic or hemorrhagic stroke Stroke education VTE-5 VTE discharge instructions HF-1 Heart Failure (HF): Detailed Discharge Instructions Home Management Plan of Care Document Given to Patient/Caregiver. PICU Pain Assessment on Admission PICU Periodic Pain Assessment Patient Safety Venous Thromboembolism (VTE)-1 VTE prophylaxis VTE-2 Intensive Care Unit (ICU) VTE prophylaxis VTE-6 Incidence of potentially preventable VTE SCIP-INF-1 Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision. SCIP-INF-6-Surgery patients with appropriate hair removal SCIP-INF-9-Urinary catheter removed on Postoperative Day 1(POD1) or Postoperative Day 2 (POD2) with day of surgery being day zero. Stroke-1 Venous Thromboembolism (VTE) Prophylaxis SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism (VTE) Prophylaxis Within 24 hours Prior to Surgery to 24 Hours After Surgery End Time. Healthy Term Newborn 28
Proposed Measures by Domain, Cont. Care Coordination Stroke-10 Ischemic or hemorrhagic stroke Assessed for Rehabilitation. ED-3 Description: Median time from ED arrival to ED departure for discharged ED patients. Population and Public Health IMM-1 Pneumococcal Immunization (PPV23) IMM-2 Influenza Immunization Efficient Use of Healthcare Resources PN-3b-Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital. PN-6-Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients. SCIP-INF-2-Prophylactic Antibiotic Selection for Surgical Patients. SCIP-INF-3-Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time. 29
Proposed Measures by Domain, Cont. Clinical Processes/ Effectiveness Stroke-2 Ischemic stroke Discharged on anti-thrombotic therapy. Stroke-3 Ischemic stroke Anticoagulation Therapy for Atrial Fibrillation/ Flutter. Stroke-4 Ischemic stroke Thrombolytic Therapy Stroke-5 Ischemic stroke Antithrombotic therapy by end of hospital day two. Stroke-6 Ischemic stroke Discharged on Statin Medication VTE-3 VTE Patients with Overlap of Anticoagulation Therapy VTE -4 Patients Unfractionated Heparin (UFH) Dosages/Platelet Count Monitoring by Protocol (or Nomogram) Receiving Unfractionated Heparin (UFH) with Dosages/Platelet Count Monitored by Protocol (or Nomogram). AMI-1-Aspirin at arrival for acute myocardial infarction (AMI) (also in the IQR program) AMI-2-Aspirin Prescribed at Discharge for AMI Elective delivery prior to 39 completed weeks gestation AMI-3-ACEI or ARB for Left Ventricular Systolic Dysfunction Acute Myocardial Infarction (AMI) Patients. AMI-5-Beta Blocker Prescribed at Discharge for AMI AMI-7a-Fibrinolytic Therapy received within 30 minutes of hospital arrival. AMI-8a-Primary Percutaneous Coronary Intervention (PCI) AMI-10 Statin Prescribed at Discharge SCIP-INF-4-Cardiac Patients with Controlled 6 AM Postoperative Serum Glucose. SCIP-Card-2 Surgery Patients on a Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period. Exclusive Breastfeeding at Hospital Discharge First temperature measured within one hour of admission to the NICU. First NICU Temperature < 36 degrees C Use of relievers for inpatient asthma Use of systemic corticosteroids for inpatient asthma Proportion of infants 22 to 29 weeks gestation treated with surfactant who are treated within 2 hours of birth. Hearing screening prior to hospital discharge (EHDI-1a) 30
Review of CQMs by the MAP Of the 49 measures in the proposed rule, 8 were not supported by the MAP: Aspirin at arrival for acute myocardial infarction (AMI) Heart failure discharge instructions ACEI or ARB for Left Ventricular Systolic Dysfunction- Acute Myocardial Infarction (AMI) Patients. Beta Blocker Prescribed at Discharge for AMI Surgery patients with appropriate hair removal Exclusive Breastfeeding at Hospital Discharge First temperature measured within one hour of admission to the NICU First NICU Temperature < 36 degrees C The MAP s final report on performance measures is located here: http://www.qualityforum.org/map/ 31
Proposed Measures by Reporting Program Meaningful Use 49 CQMs Inpatient Quality Reporting 36 CQMs Outpatient Quality Reporting 1 CQM Value Based Purchasing 11 CQMs 32
Meaningful Use and Inputs to Value-Based Purchasing Meaningful Use? Inpatient Quality Reporting Hospital Outpatient Reporting Value Based Purchasing 33
CQM Reporting Concerns To choose or not to choose? Number of measures Many of the proposed CQM specifications are not yet available Not all measures are NQF endorsed or Measure Application Partnership (MAP) approved. 34
Submission of Hospital CQMs Two different options for submitting CQMs: CMS Designated Portal o CQMs submitted using XML-based format on an aggregate basis, without regard to payer. Electronic Reporting Program o Similar format to the 2012 EHR Incentive Program Electronic Reporting Pilot, specified in the FY 2012 OPPS final rule. 35
CQM Submission Time Period for Hospitals No Change from Stage 1 to Stage 2 Reporting Period for 1st year of MU (Stage 1) Submission Period for 1st year of MU (Stage 1) Reporting Period for Subsequent years of MU (2nd year and beyond) Submission Period for Subsequent years of MU (2nd year and beyond) 90 consecutive days within the fiscal year Anytime immediately following the end of the 90-day reporting period, but no later than November 30 of the following fiscal year 1 fiscal year (October 1 September 30) 2 months following the end of the EHR reporting period (October 1 November 30) 36
Patient Population CMS is proposing to use 1 of the following 4 options in collecting patient population data: All patients- Medicare only, All patients- all payer, Sampling- Medicare only, or Sampling- all payer In the IQR program, CMS utilizes the all-payer sampling methodology. For consistency, the AAMC recommends that CMS apply this methodology for MU Stage 2. Do you agree? 37
38 Timing of Hospital Penalties
Key points on hospital penalties MU Stage 1 (AIU for Medicaid isn t enough!) by required date General rule: 2 year lag Exception: NEW meaningful users MU in FY 2011 and FY 2012 but skip 2013? YES, you will be penalized in FY 2015! 39
To avoid penalties, do what by when? To Avoid Penalties in FY: 2015 Existing Meaningful User: MU for All of FY 2013 Attest by November 30, 2013 New Meaningful User: MU for April 3, - June 2, 2014 Attest by July 1, 2014 2016 Existing Meaningful User: MU for All of FY 2014 Attest by November 30, 2014 40 Existing Meaningful User: MU for April 3, - June 2, 2015 Attest by July 1, 2015
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