1. Medicare & Medicaid EHR Incentive NPRM Implementing the American Reinvestment & Recovery Act of 2009 Office of E-Health Standards and Services Centers for Medicare & Medicaid Services

3. Electronic Health Record (EHR) Incentive Notice of Proposed Rulemaking (NPRM) on Display – December 30, 2009; published January 13, 2010

4. NPRM Comment Period Closes – March 15, 20102 Overview

6. Definition of Eligible Professional (EP) and Eligible Hospital/Critical Access Hospital (CAH)

7. Definition of Hospital-Based Eligible Professional

8. Medicare Fee-for-service (FFS) EHR Incentive Program

9. Medicare Advantage (MA) EHR Incentive Program

10. Medicaid EHR Incentive Program

11. Collection of Information Analysis (Paperwork Reduction Act)

12. Regulatory Impact Analysis3 What is in the CMS EHR Incentive program NPRM?

14. Changes to HIPAA

15. Office of the National Coordinator (ONC) Interim Final Rule (IFR) – Health Information Technology (HIT): Initial Set of Standards, Implementation Specifications, and Certification Criteria for EHR Technology

16. EHR certification requirements

17. ONC NPRM - Establishment of Certification Programs for Health Information Technology

18. Procedures to become a certifying body4 What is not in the CMS NPRM?

20. Closely links with the ONC certification and standards IFR

21. Builds on the recommendations of the HIT Policy Committee

22. Coordinates with the existing CMS quality initiatives

23. Provides a platform that allows for a staged implementation over time5 What the NPRM Does

25. 7 Who is a Medicare Eligible Provider? *Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC (including Maryland hospitals)

26. 8 Who is a Medicare Advantage Eligible Provider?

27. 9 Who is a Medicaid Eligible Provider?

29. Most hospital-based EPs will not qualify for Medicaid EHR incentive payments

30. Defined as an EP who furnishes 90% or more of their services in a hospital setting (inpatient, outpatient, or emergency room)10 Hospital-based EPs

33. To be determined by Secretary

34. Must include quality reporting, electronic prescribing, information exchange

35. Process of defining

36. NCVHS hearings

37. HIT Policy Committee (HITPC) recommendations

38. Listening Sessions with providers/organizations

39. Public comments on HITPC recommendations

40. Comments received from the Department and the Office of Management and Budget (OMB)12 Defining Meaningful Use

41. 13 Conceptual Approach toMeaningful Use

44. Engage patients and families in their health care

45. Improve care coordination

46. Improve population and public health

47. Ensure adequate privacy and security protections for personal health information15 Stage 1 – Health Outcome Priorities* *Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.

48. 16 Proposed Stages of Meaningful Use Timeline *Avoids payment adjustments only for EPs in Medicare EHR Incentive Program **Stage 3 criteria of meaningful use or a subsequent update to criteria if one is established

50. Use CPOE Implement drug-drug, drug-allergy, drug-formulary checks Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT® Maintain active medication list Maintain active medication allergy list Record demographics Record and chart changes in vital signs 18 Meaningful Use Objectives for EPs & Eligible Hospitals/CAHs

51. Record smoking status for patients 13 years and older Incorporate clinical lab-test results into EHR as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach Report ambulatory quality measures to CMS or the States Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules Check insurance eligibility electronically from public and private payers Submit claims electronically to public and private payers 19 Meaningful Use Objectives for EPs & Eligible Hospitals/CAHs

52. Provide patients with an electronic copy of their health information upon request Capability to electronically exchange key clinical information among providers of care and patient-authorized entities Perform medication reconciliation at relevant encounters and each transition of care Provide summary care record for each transition of care and referral Capability to submit electronic data to immunization registries and actual submission where required and accepted Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities 20 Meaningful Use Objectives for EPs & Eligible Hospitals/CAHs

53. Generate and transmit permissible prescriptions electronically Send reminders to patients per patient preference for preventive/follow-up care Provide patients with timely electronic access to their health information within 96 hours of information being available to the EP Provide clinical summaries for patients for each office visit 21 Additional Meaningful Use Objectives for EPs Only

54. Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request Capability to provide electronic submission of reportable lab results, as required by state or local law, to public health agencies and actual submission where it can be received. 22 Additional Meaningful Use Objectives for Eligible Hospitals/CAHs Only

55. NPRM changes from HITPC Recommendations 23

57. Added a % threshold to measures recommended as “% of …”

58. Calculated some % based on “unique patients seen” as not every action would be taken for every office visit

59. Narrowed lab results to those “whose results are in a positive/negative or numeric format”

60. For exchange of information changed “implemented ability” to “Performed at least one test”

61. Clinical quality measures were greatly expanded to accommodate the diversity of specialists meeting the definition of an eligible professional24

63. 2012 – Providers required to electronically submit summary quality measure data to CMS or States

64. EPs are required to submit clinical data on the 2 measure groups: core measures and a subset of clinical measures most appropriate to the EP’s specialty

65. Eligible hospitals are required to report summary quality measures for applicable cases25 Clinical Quality Measures Overview

67. Blood pressure management

68. Drugs to be avoided by the elderly:

69. Patients who receive at least one drug to be avoided

70. Patients who receive at least two different drugs to be avoided26 Core Quality Measures for EPs

71. 27 Specialty Quality Measures for EPs

73. For Medicaid, hospitals have the option to select 8 alternative Medicaid clinical quality measures if the 35 measures do not apply to their patient population

74. Hospitals only eligible for Medicaid will report directly to the States

75. For hospitals in which the measures don’t apply, they will have the option of selecting an alternative set of Medicaid clinical quality measures28 Clinical Quality Measures for Eligible Hospitals

78. Calendar Year

79. 2011-2016 (Medicare) – Up to $44,000 over 5 years if “meaningful EHR user”

80. 2011-2021 (Medicaid) – Up to $63,750 over 6 years – Adopt/Implement/Upgrade or meaningful use in Year 1, MU Years 2-6

81. 2015 and later – If not “meaningful EHR user” up to 3% payment adjustment in Medicare reimbursement

82. We propose that after the initial designation, EPs be allowed to change their program selection only once during payment years 2012 through 201430 Incentive Payments for EPs

83. 31 Incentive Payments for Medicare EPs

84. 32 Additional Incentives for Medicare EPs Practicing in HPSAs

85. 33 Incentive Payments for Medicaid EPs

88. Medicare can pay eligible hospitals and CAHs no sooner than October 2010

89. Medicaid EPs can potentially receive payments as early as 2010 for adopting, implementing or upgrading35 Incentive Payment Timeline

91. Providers must be enrolled in Medicare FFS, MA or Medicaid to qualify for incentive payments

92. Medicare incentive is based on 75% of Medicare allowable charges subject to maximum payments

93. All providers must have a National Provider Identifier

94. For Medicare – Must be using an EHR that is certified for the EHR Incentive Program36 Registration Requirements

95. Name of the EP, eligible hospital or qualifying CAH National Provider Identifier (NPI) Business address and business phone Taxpayer Identification Number (TIN) to which the provider would like their incentive payment made Eligible Hospitals – CMS Certification Number (CCN) Eligible Professionals – Medicare or Medicaid program selection (may only switch once over the course of the program) 37 To register, the following are required:

96. 38 Participation in HITECH and other Medicare Incentive Programs for EPs

97. 39 Notable Differences Between the Medicare & Medicaid EHR Programs

99. Public comment period ends March 15, 2010

100. CMS review of comments

101. Draft final regulation

102. CMS/HHS/OMB clearance

103. Final rule publication - Spring 201040 Next Steps

105. Document type: Proposed Rule

106. Keyword or ID: CMS-2009-0117-0002

107. Comments are due March 15, 2010 at 5 p.m. 41 How to Comment on the NPRM

109. CAH – Critical Access Hospital

110. CCN – CMS Certification Number

111. CDS – Clinical Decision Support

112. CMS – Centers for Medicare & Medicaid Services

113. CY – Calendar Year

114. EHR – Electronic Health Record

115. EP – Eligible Professional

116. eRx – E-Prescribing

117. FFS – Fee-for-service

118. FY – Federal Fiscal Year

119. HHS – U.S. Department of Health and Human Services

120. HIT – Health Information Technology

121. HITECH Act – Health Information Technology for Electronic and Clinical Health Act

122. HITPC – Health Information Technology Policy Committee

123. HIPAA – Health Insurance Portability and Accountability Act of 1996

124. HPSA – Health Professional Shortage Area

125. IFR – Interim Final Rule

126. MA – Medicare Advantage

127. MCMP – Medicare Care Management Performance Demonstration

128. MU – Meaningful Use

129. NPI – National Provider Identifier

130. NPRM – Notice of Proposed Rulemaking

131. OMB – Office of Management and Budget

132. ONC – Office of the National Coordinator of Health Information Technology

133. PQRI – Medicare Physician Quality Reporting Initiative

134. Recovery Act – American Reinvestment & Recovery Act of 2009

135. TIN – Taxpayer Identification Number42 Acronyms