Meaningful Use Final Rule:

Meaningful Use Final Rule: Safety and Quality of Care Jonathan Teich, FACMI, FHIMSS, MD, PhD CMIO, Elsevier Health Sciences August 4, 2010 Today s webinar is sponsored by

History HITECH Feb. 2009 Initial proposals Jul. 2009 Notice of Proposed Rule Making Jan. 2010 > 2000 comments All or nothing Inflexible Few would pass Final rule on display July 13, 2010

Final MU rule Eligible professionals (EPs), eligible hospitals, critical access hospitals Core and menu set philosophy p Rollback of thresholds for tasks Reduced # of quality measures Emphasis on this as first of three stages

Meaningful Use categories 1. Improve quality, safety, efficiency, and reduce health disparities 2. Engage Patients and Families 3. Improve Care Coordination 4. Protect Privacy and security of Personal Health Info 5. Improve Population and Public Health

Quality philosophy of Final Rule Balance between improving quality as much as possible and encouraging widespread adoption / avoiding excessive work burden Ensures that you have the functional capability, and get your feet wet Many criteria will reappear in phase 2 & 3 (2013+)

Tasks

Task changes from proposed rule 25 objectives divided into 15 core objectives and menu set (fulfill 5 out of 10) 24 objectives (14 core + 5/10) for hospitals Exclusions as well, where objective doesn t apply Lowered thresholds for most objectives New adds: providing patient resources, advance directivesi Calculations simplified in some cases (e.g., patients, not encounters); no chart review Claims & eligibility transactions removed

Threshold changes (examples) E prescribing: 75% 40% of prescriptions transmitted CPOE: reduced from: 80% of all orders of all kinds done via CPOE, to: 30% of patients (who have meds at all) with at least one medication order in CPOE CDS rules: 5 1

Things not changed Some thresholds (e.g., 80% of patients to have problems/allergies/meds documented) Clinical quality measures reporting timeline will stay the same MU reporting period of 90 days for first year and one year thereafter.

Core tasks (sample) Task Criterion 1. Record patient demographics (sex, Morethan 50% of patients demographic race, ethnicity, date of birth, data recorded as structured preferred language, and in the case of data hospitals, date and preliminary cause of death in the event of mortality) 2. Record vital signs and chart changes More than 50% of patients 2 years of age (height, weight, blood pressure, or older have height, body mass index, growth charts for weight, ihtand blood pressure recorded ddas children) structured data 3. Record smoking status for patients 13 More than 50% of patients 13 years of years of age or older age or older have smoking status recorded as structured data

Core tasks Demographics Vital signs, BMI, growth Problem List Medication List Allergy List Smoking Status Givepts clinical encounter summaries Givepts health summary Transmit prescriptions (EP) CPOE for med orders Drug drug and drug allergy checks Test ability to exchange clinical information One clinical decision support rule & track it Security risk analysis Report quality measures

Formulary checking Clinical lab test results Lists of pts with specific conditions UseEHR to identify educational resources specific to the pt Pts get summaries for use in referrals (Test) Send data to immunization registry Menu Set (pick 5) Med reconciliation Send syndromic surveillance data (test) Advance directives for pts > 65 (H) Reportable labs to public health (H) Send preventive care reminders (EP) Give pts access to problems/meds/labs (EP)

Clinical Decision Rule Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule

Quality Measures

Quality Measure changes NPRM: report on 90 core and specialtyrelated quality measures Final: EPs: 3 core quality measures (3 alternatives) + 3 others from menu of 38 Hospitals: 15 core measures (report all, even if zero), down from 35

Selection of Quality Measures Designed to favor well established and endorsed measures, but not to duplicate measures from other Federal programs Measures for which electronic specifications are available Focus on CAD, CHF, diabetes, asthma, obesity, hypertension, prenatal care, cancer screening, cancer treatment

Core Measures for EPs Hypertension and Blood Pressure Management Tobacco Use Assessment and Tobacco Cessation Intervention Adult Weight Screening and Follow Up Alternatives: Weight assessment for pts <21 Flu shots for pts >50 Childhood immunization status

Menu set Measures (pick 3) Diabetes: A1C, LDL, BP, eye/foot exam, UA CHF: ACE/ARB, betablocker CAD: Beta blockers, Plavix, statins, BP check, Aspirin, Pneumovax Mammography Colon ca. screening Antidepressants Smoking counseling Glaucoma: reevaluation Diabetic retinopathy reexam Asthma med treatment Asthma assessment Antibiotics for pharyngitis Many more..

If your practice doesn t see this then your denominator is zero Must try to find 3 core measures and 3 menu measures with nonzero denominators If not, then report six measures anyway and attest that all theotherswould be zeroes 2011 only

Quality measures for hospitals ED throughput for admitted patients (2) Stroke: thrombolysis, antithrombotic meds by day 2 and for A Fib (3) Stroke: discharge on antithrombotic med and statin, stroke education, rehab assessment (4) VTE prophylaxis after admission and ICU (2) VTE: overlap of heparin and warfarin, platelet monitoring for UFH, discharge instructions, preventable in hospital VTE (4) *VTE=venous thromboembolism

Attestation and timelines

Eligible Provider definition changes Hospital based ambulatory practice is ok (just not inpatient or ED practice) Multiple locations requirements and measurements apply only at sites where certified technology is available (must be >50% of total encounters) Select any 90 day period in year 1

Claiming MU Tasks are scored by: # patients, # actions, yes/no (drug checks), tests (exchange) 2011 Manual attestation including clinical quality measure numerator, denominator, exclusions to CMS or to State

Claiming MU 2012 Electronic submission through certified EHR technology Upload files through CMS portal Submit files through a registry or HIE (later) Rules to be posted by 4/1/2011 /

Timelines Register for program in January 2011 Only 90 days reporting needed in year 1 (goes to full year) Attestation begins in April (format TBD)

The present and the future (to stage 2 and beyond)

Returning for stage 2 CMS states that many measures and tasks removed from stage 1 (e.g., specialty measures) will return in stage 2 Minimum performance criteria may replace some report only measures Menu set likely to all become core tasks CPOE usage requirement goes to 60%; CDS rules and thresholds likely to increase

Stage 2 goals (2013) Disease management Clinical decision support Medication management Patient access to health information Transitions in care Quality measurement and research Communication to/from public health

Stage 3 goals (2015) Improvements in quality/safety/efficiency Clinical decision support for national highpriority conditions Patient self management tools Access to comprehensive patient data (HIE) Population health outcomes

What does it all mean? Significant rollback in the level of quality monitoring and quality related tasks from proposed rule Emphasis was placed d(ft (after feedback) on ensuring adoption first QI provisions essentially deferred for 2 years, in expectation that more providers will be comfortable with their new EHRs by then ( make the computer your friend first )

What does it all mean? Rolled back provisions still ensure that all claimants get their feet wet in: adopting technology suitable for QM / QI / CDS Measuring and reporting quality metrics Using CPOE, e prescribing, drug checks, decision rules, HIE

Enablers HITRC / Regional Extension Centers Mission to bring providers into MU and keep them there as it progresses Learning communities Beacon communities ONC and AHRQ contracts regarding better implementation, dissemination, simplification, and sharing of clinical decision support

For further information

http://www.cms.gov/ehrincentiveprograms/

http://healthit.hhs.gov

Other references Blumenthal summary in NEJM HIMSS page contains updated fact and commentary www.himss.org/economicstimulus Nice collection of presentations at http://news.avancehealth.com/2010/07/finalrule on meaningful use.html use.html

Meaningful Use Final Rules Webinar Series August 11 12:00 1:00PM Central Implication of Meaningful Use for Eligible Professionals August 18 12:00 1:00 PM Central Regulatory Impact for Business Associates August 25 12:00 1:00 PM Central Overview of Standards, Implementation Specifications and Certification Criteria Available On Demand in HIMSS elearning Academy (www.himss.org/education) Overview of Meaningful Use Implication of Meaningful Use for Hospitals

Contact info: Jonathan Teich j.teich@elsevier.com or jteich@harvard.edu

Meaningful Use Final Rule: Safety and Quality of Care Today s webinar was sponsored by