Health Care IT Advisor Meaningful Use 101 What You Need to Know August 26, 2014 Naomi Levinthal, MA, MS, CPHIMS Consultant, Health Care IT Advisor
Road Map 2 1 2 Legislative and Regulatory Beginnings Attestation, Incentives, and Penalties 3 Meaningful Use Best Practices
3 Legislation Driving Regulation and Incentives 1965 Social Security Act Legislation Created HHS Regulations and Incentives Medicare and Medicaid (definition of a physician) 2003 Medicare Modernization Act Medicare Incentives (who can get incentives) 2005 Deficit Reduction Act 2008 Medicare Improvements for Providers and Patients Act Inpatient Perspective Payment System (Medicare incentives for quality outcomes and NO PAY events) eprescribing Incentives 2009 American Recovery and Reinvestment Act Incentives for Meaningful Use of an EHR 2012 The Affordable Care Act Accountable Care Organizations, Shared Savings Plan and Bundled Payments Source: The Advisory Board research and analysis.
4 Many Moving Parts in Health Care Reform Not a Destination, But a Journey Delivery System Reform Timeline SGR 1 Core Measures Acute Care Episode Demonstration 2010 Coverage Expansion 2010-2014 HAC 2 Medicaid Reimbursement Stops - 2012 Readmissions Program - 2012 ICD-10 Conversion 2014 1997 2016 Never Events Campaigns Physician Group Practice Demonstration 2005 Meaningful Use 2011-??? Shared Savings Program 2012 Bundled Payment Program 2013 1) Sustainable growth rate. 2) Hospital-acquired condition. Source: Health Care IT Advisor research and analysis.
5 Meaningful Use Key Players CMS 1 and ONC 2 Create and Clarify the Requirements EHR 3 Incentive Programs Standards and Certification Program staging Author the attestation regulations Payment adjustments Changes to the Medicaid EHR Incentive Program Identify clinical quality measures available to report on Author the 2014 Edition Test Methods New standards for clinical content, vocabulary, accessibility, data capture and export, transport, and privacy and security Maintain the ONC HIT Certification Program 1) Centers for Medicare & Medicaid Services. 2) Office of the National Coordinator for Health Information Technology. 3) Electronic health record. Sources: Health Care IT Advisor research and analysis.
6 Building the Foundation for New Care Delivery Models Meaningful Use Fosters Organizational Capabilities for Accountable Care 2011 2014 2017 2020? Increasing Maturity of Accountable Payment Models Future Stages Advance real-time evidence-based medicine? Stage 3 Improved Outcomes Drive care coordination and patient engagement Use outcomes-focused clinical quality measures Rely on more mature standards Stage 2 Advanced Clinical Processes Increase information exchange Demonstrate care coordination Engage patients Stage 1 Adopt EHR systems Capture structured data Data Capture and Sharing Source: Health Care IT Advisor research and analysis.
Road Map 7 1 2 Legislative and Regulatory Beginnings Attestation, Incentives, and Penalties 3 Meaningful Use Best Practices
8 First Step in MU: Possess a Certified System In 2014, Must Have a Base EHR 2011 Edition 2014 Edition In order to be able to attest to CMS or States at the end of your EHR reporting period that you possess EHR technology that meets the regulatory definition of Certified EHR Technology adopted by HHS (45 CFR 170.102 and 42 CFR 495.4), the EHR technology in your possession must have been tested and certified to all applicable certification criteria adopted for the setting (ambulatory or inpatient) for which it was designed. Office of the National Coordinator, FAQ 17 2011 vs. 2014 Edition Requirements Base Clinical Decision Support CPOE 1 Demographics Privacy / Security Transitions of Care Core View, Download, and Transmit 2 Vital Signs 3 Capabilities specific to a provider s stage Menu Capabilities specific to the menu set items that a provider has selected 1) CPOE: computerized provider order entry. 2) Moved from Base EHR in the NPRM to Core Set measure in the CMS final rule. 3) Moved from Base EHR in the NPRM to Core Set measure in the CMS final rule. Sources: ONC Regulation FAQ #17, Office of the National Coordinator for Health IT (ONC), available at: http://healthit.hhs.gov/portal/server.pt/community/onc_regulations_faqs/3163; Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition, ONC, available at: http://www.gpo.gov/fdsys/pkg/fr-2012-09-04/pdf/2012-20982.pdf ; The Advisory Board research and analysis.
9 Going to The CHPL 1 to Decode New Information Action Items Confirm possession: name, version, components Use a Base EHR, subset of required capabilities (Core, Menu) Ensure security capability coverage Match CQMs 2 Related Research Going to the CHPL: Understanding the New 2014 Edition EHR Certification 1) Certified Health IT Product List. 2) Clinical quality measures. Source: ONC CHPL. Available at: http://oncchpl.force.com/ehrcert/chplhome; Product details fictionalized.
10 Crimson Medical Referrals Use CMR as Certified EHR Technology in MU CMR is certified for ONC 2014 Edition Ambulatory Inpatient Use your own primary EHR system in combination with CMR to: o Send a summary of care record for Transitions of Care o Generate the reports necessary for MU attestations
11 Meaningful Use Payment Year and Stage Providers That First Attested in 2011 or 2012 Remain in Stage 2 Longer First Payment Year and Corresponding MU Stage First Payment Year Stage of Meaningful Use 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2011 1 1 1 2 2 2 3 3 TBD TBD TBD 2012 1 1 2 2 2 3 3 TBD TBD TBD 2013 1 1 2 2 3 3 TBD TBD TBD 2014 1 1 2 2 3 3 TBD TBD 2015 1 1 2 2 3 3 TBD 2016 1 1 2 2 3 3 2017 1 1 2 2 3 Source: Health Care IT Advisor research and analysis.
12 No Change to Number of Objectives Major Changes in Measure Complexity Number of Final Stage 2 Core and Menu Objectives Eligible Hospitals 14 16 10 6 19 19 EHs report on 3 of 6 menu set measures Patient Safety CPOE 1 threshold increases from 30% to 60% for medication; expanded to include 30% laboratory and radiology erx 2 core set (EP only) and menu set (EH only) emar 3 using assistive technologies (auto-id) electronically confirming the five rights 4 (EH only) Core Menu Total Eligible Professionals 15 17 20 20 10 6 EPs report on 3 of 6 menu set measures Improve Care Coordination Medication reconciliation moved to core Summary of care record moved to core, and electronic submission is required in 10% of cases Electronic Notes new measure menu set Engage Patients and Families Core Menu Total Stage 1 Stage 2 1) CPOE: computerized provider order entry. 2) erx: electronic prescribing. 3) emar: electronic medication administration record. 4) 5 Rights = right patient, right medication, right dose, right route, and right time, View, download and transmit replaces the e-copy of health information requirement Secure messaging (EP only) Sources: Medicare and Medicaid Programs; Electronic Health Record Incentive Program-- Stage 2, Final Rule at http://www.gpo.gov/fdsys/pkg/fr-2012-09-04/pdf/2012-21050.pdf; The Advisory Board research and analysis.
Eligible Professional Eligible Hospital 13 Important Dates to Remember By Participation Year Meaningful Use Deadlines for Providers in 2014 Program Year Key Meaningful Use Dates Year 2+ Attestation Year 1 Attestation* Hardship Application November 2014 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 July 2014 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 April 2015 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 February 2015 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 October 2014 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 July 2015 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * These are the deadlines to avoid payment adjustment in 2015. First time attesters can still attest by the regular deadlines (i.e., November 30, 2014 for EHs and February 28, 2015 for EPs) to receive incentive payments for the 2014 program year. Source: Health Care IT Advisor research and analysis
14 More Than $24 Billion Paid in Incentives to Date Meaningful Use Payment Status as of May 2014 Number of Eligible Professionals That Have Received Incentive Payments 262,447 Total Incentive Paid $9,811,315,947 Number of Eligible Hospitals That Have Received Incentive Payments Total Incentive Paid $14,604,208,796 123,323 4,222 13,663 238 118 Medicare Medicare Advantage Medicaid Medicare Only Medicaid Only Medicare/Medicaid (Dually Eligible) Average Incentives Received So Far $24,666 $24,240 $29,830 $3.19M Per Medicaid Eligible Professional Per Medicare Eligible Professional Per Medicare Advantage Eligible Professional Per Eligible Hospital Sources: May 2014: EHR Incentive Program Centers for Medicare and Medicaid, available at http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/May2014_SummaryReport.pdf (accessed July 10, 2014); Health Care IT Advisor research and analysis.
15 Longer Payment Schedule for Medicaid Incentives 2016 Last Year to Earn Maximum Incentives Medicaid Incentive Payments Schedule for Eligible Professionals Calendar Year Medicaid EPs who begin adoption in 2011 2012 2013 2014 2015 2016 2011 $ 21,250 2012 $8,500 $ 21,250 2013 $8,500 $8,500 $ 21,250 2014 $8,500 $8,500 $8,500 $ 21,250 2015 $8,500 $8,500 $8,500 $8,500 $ 21,250 2016 $8,500 $8,500 $8,500 $8,500 $8,500 $ 21,250 2017 $8,500 $8,500 $8,500 $8,500 $8,500 2018 $8,500 $8,500 $8,500 $8,500 2019 $8,500 $8,500 $8,500 2020 $8,500 $8,500 2021 $8,500 TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750 Note: Assumes EPs will collect Medicaid incentive for six consecutive years; EPs are allowed to skip years until 2016 and EPs must start in the Medicaid program no later than 2016. Source: Medicare and Medicaid EHR Incentive Program Basics, at http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Basics.html
16 Hospital Incentives and Penalties Annual Incentive and Payment Adjustment Estimate, Typical Hospital 1 2011 First Year of MU Demonstration, in Millions of Dollars Eligible for $12.98M across 4 years of Medicare and Medicaid EHR incentive payments 3 years of Medicare payment adjustments ($10.6M) would erode almost the entire incentive collection 4.14 2.35 1.05 (2.30) (3.50) (4.80) 5.44 2011 2012 2013 2014 2015 2016 2017 Medicare and Medicaid EHR Incentives Medicare Payment Adjustments 1) Assumes ~34,000 discharges, 66% Medicare share, 15% Medicaid, and 3% annual market basket update. Sources: American Recovery and Reinvestment Act, 2009; Health Care IT Advisor research and analysis.
17 Late Starters Lose Out on Medicare Incentives Medicare Incentive Payment Schedule for Eligible Professionals Calendar Year First Payment Year 2011 2012 2013 2014 2015 and Later 2011 $18,000 1 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 $2,000 $4,000 $4,000 $0 TOTAL $44,000 $44,000 $39,000 $24,000 $0 1) Medicare incentive payment capped at $18,000, calculated as 75% of $24,000 in Medicare allowable charges. Source: Medicare and Medicaid EHR Incentive Program Basics, at http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Basics.html
18 Medicare Payment Adjustments Payment Adjustments Apply to EP s Entire Medicare population Potential Payment Adjustments for Eligible Professionals by Specialty Payment Adjustment Year Specialty Median Compensation 2015 2016 2017 Payment adjustment to Medicare physician fee schedule 1% 2% 3% Internal medicine $219,500 $2,195 $4,390 $6,585 Pediatrician and adolescent Orthopedics (surgery) $213,379 $2,134 $4,268 $6,401 $501,808 $5,018 $10,036 $15,054 Cardiology $422,921 $4,229 $8,458 $12,688 Oncology (surgical) Orthopedics (medical) $313,046 $3,130 $6,261 $9,391 $293,873 $2,939 $5,877 $8,816 Source: Health Care IT Advisor research and analysis
19 Hardships vs. Just Hard Hardship Exceptions Not for Everyone Potential Scenarios Qualify for Exception Do Not Qualify Insufficient Internet connection No face-to-face interactions or no follow up care with patients 2014 Software upgrade to 2014 Edition (exceptions to this rule) A new physician or hospital No control over CERHT decisions at multiple locations A B Changing EHR vendors! Unforeseen circumstances/ Natural disasters Anesthesiology, Pathology, and Radiology in the PECOS system Merger or acquisition Notes Hardship exceptions are considered on a case-by-case basis; EHR vendor hardships considered Eligible professionals must apply for the hardship exception by July 1st (EPs) of the year prior to the payment adjustment year (i.e., July 1, 2014 to avoid payment adjustments in CY 2015) Source: Medicare and Medicaid Programs; Electronic Health Record Incentive Program-- Stage 2, Final Rule at http://www.gpo.gov/fdsys/pkg/fr-2012-09-04/pdf/2012-21050.pdf; Health Care IT Advisor research and analysis.
Road Map 20 1 2 Legislative and Regulatory Beginnings Attestation, Incentives, and Penalties 3 Meaningful Use Best Practices
21 Key Principles Underpin Ongoing Success in MU Adaptation Audit Preparation Organizations must devote resources to react to the ever-changing nature of meaningful use requirements. Monitor newly released CMS 1 and ONC 2 meaningful use content for any clarifications and/or modifications (e.g., Stage 3 delay to 2017 3 ) Assess the impact of the changes and revise meaningful use work plan Meaningful Use Alignment Organizations must prepare for meaningful use audits from the when not if perspective. Build a robust book of evidence Conduct a mock audit and address business continuity gaps in documentation and response processes Forward thinking organizations view meaningful use as an enabling agent to health care transformation. Seize an opportunity to align meaningful use with population health management and other quality reporting programs (e.g., IQR 4 and PQRS 5 ) Align tactical approach to meaningful use with the national health priority goals: Improving quality of care and safety Engage patients and families in their health care Improve care coordination Improve population and public health Affordable Care Reduce Health Disparities 1) The Centers for Medicare and Medicaid Services 2) The Office of National Coordinator for Health Information Technology 3) Hospitals Federal Fiscal Year 2017 (October 1, 2016 September 30, 2017) and Ambulatory Providers Calendar Year 2017 4) The Hospital Inpatient Quality Reporting Program 5) The Physician Quality Reporting System Source: Health Care IT Advisor research and analysis
22 Can You Put Together the Puzzle Pieces? Constantly Monitor and Assess for MU Changes 1) Health IT Policy Committee Sources: Health Care IT Advisor research and analysis.
# of Patients 23 Numerator Not Bound by Reporting Period Several Measures Provide Extra Time to Increase Numerators Progress Toward Demographics Threshold Across Attestation Period 3000 2500 2000 End of Reporting Period 60% 71% 70% 73% 89% 80% 86% 77% 93% 100% 95% 100% 80% - Stage 2 Threshold Numerator may increase after the end of the reporting period, but denominator remains constant 1500 1000 500 Related Research 0 Denominator Numerator "Extra" Time to Succeed in Meaningful Use, A New CMS FAQ Confirms Your Guide to More Time for Meaningful Use Source: CMS Frequently Asked Questions (FAQ). Available at:: https://questions.cms.gov/faq.php?faqid=8231.
24 Stage 3 HITPC 1 Recommendations A Lighter Lift Between Stages 2 to 3 Improving Quality of Care and Safety Multiple CDS interventions Order tracking (Menu EPs) Demographic information to reduce disparities Care plans, electronic notes, hospital labs, unique device identifiers Engaging Patients and their Families in their Care Enable VDT within 24 hours Patient education (Per patient s preferred language) Patient-generated health information (Menu) Secure messaging Clinical Summary Improving Care Coordination Care notifications from EH to known patient care team members for significant event (Menu) Transitions of care Medication reconciliation Improving Population and Public Health Immunization history Registry reporting Reportable Labs Syndromic Surveillance 1) Health IT Policy Committee Sources: http://www.healthit.gov/facas/sites/faca/files/hitpc_muwg_stage3_recs_2014_03_11.pdf; Health Care IT Advisor research and analysis.
25 Audits Are the Norm Rather than the Exception It is When, Not If 12 10 Audit Timing Audit Status 11.0 2 8 6 4 2 0 2.0 3.0 1 No Audit Pre-Payment Post-Payment Two years in a row. I was under the impression they were random. So it seemed odd to me to get the notification again, the second year after the filing. Ralph Johnson, CIO Franklin Community Health Network, Farmington, Maine 15% 85% Audit No Audit Study cohort for interviews conducted October and November 2013 13 Health Systems 102 Eligible Hospitals 6 EHR Vendors 1) At the conclusion of the study period one of the interviewees self-reported that an audit request letter was received 2) Three interviewees experienced both pre and post payment audits Source: The Advisory Board Company Health Care IT Advisor research and analysis; http://www.healthcareitnews.com/news/muaudits-one-cios-recurring-bad-dream?topic=01,08,29
26 Validate Measures with Identical Denominators Avoid a Major Reporting Pitfall Percentage-based Measures with Identical Denominators Number of unique patients admitted to the EHs or CAH s IP or ED during the EHR reporting period Stage 2 Performance Scorecard April 1 June 30, 2014 Measure Numerator Denominator Performance Demographics 5,236 5,338 98% Vital signs 5,300 5,338 99% Patient-specific Education 3,281 4,999 65% Know your numbers: How to avoid a major Meaningful Use pitfall Five Meaningful Use Tips That May Keep You out of an Auditor s Crosshairs Source: Health Care IT Advisor research and analysis.
27 Best Practices in Audit Preparation Share Accountability Generate executive support Establish dedicated MU audit preparation team Maximize Audit Response Efficiency Utilize a centralized MU audit notification email Leverage MU audit response process or other audits Ensure data accuracy of detailed and summary reports Build Audit Documentation as you Prepare Identify additional ways to document rationales behind decisions and policies Develop stricter methodology to validate accuracy of report logic Collect targeted information Source: Health Care IT Advisor research and analysis.
28 Aligning MU with Population Health Management Population Health Management Identify Populations Map and Track Care Deliver Care Coordinate Cross Continuum Care Engage Patients Meaningful Use Clinical data (e.g., Problem List, Medication List, Medication Allergy List, Demographics, Vital Signs) collected and normalized in CEHRT for subsequent use to identify high utilizers, high-risks patients, and patients with chronic diseases Patient List, Public Health objectives, and Clinical Quality Measures contribute to map and track care of patient population, as well as the health of the community and public CDS, CPOE, e-prescribing are gearing towards evidence-based care delivery at the point of care and beyond; ensure the right care is delivered correctly Transitions of Care with care plans and future requirements to Follow Through the Orders and Referral focus on care coordination across different settings View, Download, and Transmit, Patient-Specific Education Resources, Patient-Generated Health Data engage patients into their own care; allow patients to be proactive in their own health. Related Research Is Your MU Game Plan Solid A Framework for IT-Enabled Population Health Management Source: Kilbridge, P. A Framework for IT-Enabled Population Health Management, Health Care IT Suite, February 2013. Available at: http://www.advisory.com/research/it-strategy- Council/Research-Notes/2013/A-Framework-for-IT-Enabled-Population-Management.
29 Download Useful Tools and Educate Yourself Publicly Available Tools Meaningful Use The Whiteboard Story www.advisory.com/muwhiteboard Quick Guide Comparison Stage 1 to Stage 2 Objectives and Measures www.advisory.com/mupocketguide Bookmark Versions of the Final Rules www.advisory.com/mubookmarkcms www.advisory.com/mubookmarkonc Additional resources o Detailed Analysis of the Final Rule on Stage 2 of Meaningful Use Changes to Stage 1 Measures Detailed List Comparison of NPRM to Stage 2 Final Rules Core and Menu Set Measures o Five Meaningful Use Tips That May Keep You out of an Auditor s Crosshairs o MU Audits: Lessons Learned from the Front Line Source: The Advisory Board research and analysis.
30 Meaningful Use Services One-Time Assessment We are about to attest and need assurance everything is right Not certain where to start or what should be on our audit radar We have outside support but want additional validation Long-Term Support We need daily support We require assistance to stay on top of all the clarifications We cannot hire an additional FTE to support MU We have a fairly complex IT environment Meaningful Use Scorecard Meaningful Use Navigator Extensive detail Provide regulatory references with each question answered for your audit documentation Rapid return of detailed and customized analysis. For more information, contact: RYAN MILLER Assess current Regulatory monitoring environment and Networking identify gaps, and opportunities between monitor your progress members Experts on-call Proactive alerts Senior Manager, Health Care IT Advisor P =202.266.5850 I millerr@advisory.com Provide regulatory references for audit documentation
31 Q&A and Next MU Webconference Be sure to register for our next webconference September 30 1:00pm ET More advanced content