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Medicare & Medicaid EHR
Incentive Program Final Rule
    Implementing the American
Recovery & Reinvestment Act of 2009
The Journey to Meaningful Use

Faith is the bird that sings when the dawn is still
  dark. Rabindranath Tagore




                                                  2
Overview
• American Recovery & Reinvestment Act
  (Recovery Act) – February 17, 2009
• Medicare & Medicaid Electronic Health
  Record (EHR) Incentive Program Notice of
  Proposed Rulemaking (NPRM)
  • Display – December 30, 2009
  • Publication – January 13, 2010
• Final Rule on Display – July 13, 2010
• Final Rule Published – July 28, 2010

                                             3
What did not change
   in the final rule
• Adopted statutory provider eligibility and payment
  requirements
• Meaningful Use matrix goals remained the same.
• Hospital definition did not change.
• EPs will still be required to demonstrate MU
  individually
• Clinical quality measures reporting timeline will
  stay the same
• MU reporting period of 90 days for first year and
  one year thereafter.                              4
What Changed from the NPRM
to the Final Rule?
• Meaningful Use Criteria
• Clinical Quality Measures
• Hospital-based EPs
• Medicaid acute care hospitals
• Medicaid patient volume
• Removed reporting period for adopt,
  implement or upgrade (Medicaid)
• All programs will start in 2011
• More clarification throughout
                                        5
Changes to Provider Eligibility
• Due to recent legislation, hospital-based EPs are
  only those who see more than 90% of their
  patients in a hospital in-patient or ER setting
• Medicaid included critical access hospitals in its
  definition of “acute care hospital” (but incentive is
  like other acute care hospitals, not following the
  Medicare CAH formula)




                                                          6
Medicaid Patient Volume
Medicaid EP participation hinges on patient
  volume requirements.
• Medicaid patient volume was significantly
  clarified
  • Expanded definition of “encounter” to include any
    encounter for which Medicaid had any payment
    liability e.g. premiums, co-pays, waivers
  • Allows States to define patient volume as just
    encounters or encounters plus patient panel
    (managed care), both or propose a new
    methodology
                                                        7
Meaningful Use: Process of Defining
• National Committee on Vital and Health Statistics
  (NCVHS) hearings
• HIT Policy Committee (HITPC) recommendations
• Listening Sessions with providers/organizations
• Public comments on HITPC recommendations
• Comments received from the Department and
  the Office of Management and Budget (OMB)
• Revised based on public comments on the
  NPRM


                                                  8
Meaningful Use Stage 1 –
Health Outcome Priorities*
• Improve quality, safety, efficiency, and reduce
  health disparities
• Engage patients and families in their health
  care
• Improve care coordination
• Improve population and public health
• Ensure adequate privacy and security
  protections for personal health information
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform
                    America’s Healthcare. Washington, DC: National Quality Forum; 2008.



                                                                                                                  9
Meaningful Use: Changes from
the NPRM to the Final Rule
NPRM                                        Final Rule
Meet all MU reporting objectives            Must meet “core set”/can defer 5 from
                                            optional “menu set”
25 measures for EPs/23 measures for         25 measures for EPs/24 for eligible
eligible hospitals                          hospitals
Measure thresholds range from 10% to        Measure thresholds range from 10% to
80% of patients or orders (most at higher   80% of patients or orders (most at lower
range)                                      to middle range)
Denominators – To calculate the             Denominators – No measures require
threshold, some measures required           manual chart review to calculate
manual chart review                         threshold
Administrative transactions (claims and     Administrative transactions removed
eligibility) included
Measures for Patient-Specific Education     Measures for Patient-Specific Education
Resources and Advanced Directives           Resources and Advanced Directives (for
discussed but not proposed                  hospitals) included
                                                                                       10
Meaningful Use: Changes from
the NPRM to the Final Rule, cont’d
NPRM                                      Final Rule
States could propose requirements         States’ flexibility with Stage 1 MU is
above/beyond MU floor, but not with       limited to seeking CMS approval to
additional EHR functionality              require 4 public health-related
                                          objectives to be core instead of menu
Core clinical quality measures (CQM)      Modified Core CQM and removed
and specialty measure groups for EPs      specialty measure groups for EPs
90 CQM total for EPs                      44 CQM total for EPs – must report
                                          total of 6
35 CQM total for eligible hospitals and   15 CQM total for eligible hospitals
8 alternate Medicaid CQM
5 CQM overlap with CHIPRA initial core    4 CQM overlap with CHIPRA initial core
set                                       set


                                                                                   11
How were MU Core Objectives
      Selected?
• Overarching considerations
   • Statutory requirements-e.g.- e-prescribing, CQM, health information
     exchange
   • Foundational objectives-e.g. privacy and security and those that
     provide foundational data needed for other measures, like
     demographics, medication lists, etc.
   • Patient-centered
      • Patient access- e.g. clinical summaries
      • Patient safety-e.g.-drug-drug and drug-allergy features)
   • Part of providers’ “normal” practice
• Looked at how the objectives aligned
• Feedback received from HIT Policy Committee and commenters


                                                                      12
Meaningful Use: Denominators
• Two types of percentage based measures are
  included to address the burden of
  demonstrating MU
  1. Denominator is all patients seen or admitted
     during the EHR reporting period
     • The denominator is all patients regardless of whether
       their records are kept using certified EHR technology
  2. Denominator is actions or subsets of patients
     seen or admitted during the EHR reporting period




                                                               13
Meaningful Use: Applicability of
Objectives and Measures
• 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.
• In these cases, the EP, eligible hospital or
  CAH would be excluded from having to meet
  that measure
  • Ex: Dentists who do not perform immunizations;
    Chiropractors do not e-prescribe
     • The denominator only includes patients, or actions taken
       on behalf of those patients, whose records are kept using
       certified EHR technology
                                                              14
How were the Thresholds Selected
• 80%-Objective part of standard practice-e.g.-
  maintain active medication list
• Others-defined on a case-by-case basis
  based on commenter or clearance feedback
• Example-e-prescribing set at 40% lowered
  from 75% to address concerns by
  commenters regarding non-participation by
  pharmacies and patient preference.



                                                  15
Meaningful Use – Stage 1 Core Set
Health        Stage 1 Objective                                      Stage 1 Measure
Outcomes
Policy
Priority
Improving     Use CPOE for medication orders directly entered by     More than 30% of unique patients with at least one
quality,      any licensed healthcare professional who can enter     medication in their medication list seen by the EP or
safety,       orders into the medical record per state, local, and   admitted to the eligible hospital or CAH have at least
efficiency,   professional guidelines                                one medication entered using CPOE
and
              Implement drug-drug and drug-allergy interaction       The EP/eligible hospital/CAH has enabled this
reducing
              checks                                                 functionality for the entire EHR reporting period
health
disparities   EP Only: Generate and transmit permissible             More than 40% of all permissible prescriptions written
              prescriptions electronically (eRx)                     by the EP are transmitted electronically using certified
                                                                     EHR technology
              Record demographics: preferred language, gender,       More than 50% of all unique patients seen by the EP or
              race, ethnicity, date of birth, and date and           admitted to the eligible hospital or CAH have
              preliminary cause of death in the event of mortality   demographics as recorded structured data
              in the eligible hospital or CAH
              Maintain up-to-date problem list of current and        More than 80% of all unique patients seen by the EP or
              active diagnoses                                       admitted to the eligible hospital or CAH have at least
                                                                     one entry or an indication that no problems are known
                                                                     for the patient recorded as structured data
Meaningful Use – Stage 1 Core Set, cont’d
Health        Stage 1 Objective                                       Stage 1 Measure
Outcomes
Policy
Priority
Improving     Maintain active medication list                         More than 80% of all unique patents seen by the EP or
quality,                                                              admitted to the eligible hospital or CAH have at least
safety,                                                               one entry (or an indication that the patient is not
efficiency,                                                           currently prescribed any medication) recorded as
and                                                                   structured data
reducing
              Maintain active medication allergy list                 More than 80% of all unique patents seen by the EP or
health
                                                                      admitted to the eligible hospital or CAH have at least
disparities
                                                                      one entry (or an indication that the patient has no
                                                                      known medication allergies) recorded as structured
                                                                      data
              Record and chart vital signs: height, weight, blood     For more than 50% of all unique patients age 2 and over
              pressure, calculate and display BMI, plot and display   seen by the EP or admitted to the eligible hospital or
              growth charts for children 2-20 years, including BMI    CAH, height, weight, and blood pressure are recorded as
                                                                      structured data
              Record smoking status for patients 13 years old or      More than 50% of all unique patients 13 years or older
              older                                                   seen by the EP or admitted to the eligible hospital or
                                                                      CAH have smoking status recorded as structured data
              Implement one clinical decision support rule and the    Implement one clinical decision support rule
              ability to track compliance with the rule
              Report clinical quality measures to CMS or the States   For 2011, provide aggregate numerator, denominator,
                                                                      and exclusions through attestation; For 2012,
                                                                      electronically submit clinical quality measures
Meaningful Use – Stage 1 Core Set, cont’d

Health         Stage 1 Objective                                        Stage 1 Measure
Outcomes
Policy
Priority
Engage         Provide patients with an electronic copy of their        More than 50% of all unique patients of the EP, eligible
patients and   health information (including diagnostic test results,   hospital or CAH who request an electronic copy of their
families in    problem list, medication lists, medication allergies,    health information are provided it within 3 business
their          discharge summary, procedures), upon request             days
healthcare
               Hospitals Only: Provide patients with an electronic      More than 50% of all patients who are discharged from
               copy of their discharge instructions at time of          an eligible hospital or CAH who request an electronic
               discharge, upon request                                  copy of their discharge instructions are provided it
               EPs Only: Provide clinical summaries for each office     Clinical summaries provided to patients for more than
               visit                                                    50% of all office visits within 3 business days
Improve care   Capability to exchange key clinical information (ex:     Performed at least one test of the certified EHR
coordination   problem list, medication list, medication allergies,     technology’s capacity to electronically exchange key
               diagnostic test results), among providers of care and    clinical information
               patient authorized entities electronically
Ensure         Protect electronic health information created or         Conduct or review a security risk analysis per 45 CFR
adequate       maintained by certified EHR technology through the       164.308(a)(1) and implement updates as necessary and
privacy and    implementation of appropriate technical capabilities     correct identified security deficiencies as part of the
security                                                                EP’s, eligible hospital’s or CAH’s risk management
protections                                                             process
for personal
health
information
Meaningful Use – Stage 1 Menu Set
Health         Stage 1 Objective                                          Stage 1 Measure
Outcomes
Policy
Priority
Improving      Implement drug-formulary checks                            The EP/eligible hospital/CAH has enabled this
quality,                                                                  functionality and has access to at least one internal or
safety,                                                                   external drug formulary for the entire EHR reporting
efficiency,                                                               period
and reducing
               Hospitals Only: Record advance directives for              More than 50% of all unique patients 65 years old or
health
               patients 65 years old or older                             older admitted to the eligible hospital or CAH have an
disparities
                                                                          indication of an advance directive status recorded
               Incorporate clinical lab-test results into certified EHR   More than 40% of all clinical lab test results ordered by
               technology as structured data                              the EP, or an authorized provider of the eligible hospital
                                                                          or CAH, for patients admitted during the EHR reporting
                                                                          period whose results are either in a positive/negative or
                                                                          numerical format are incorporated in certified EHR
                                                                          technology as structured data
               Generate lists of patients by specific conditions to       Generate at least one report listing patients of the EP,
               use for quality improvement, reduction of                  eligible hospital or CAH with a specific condition
               disparities, research or outreach
               EPs Only: Send reminders to patients per patient           More than 20% of all unique patients 65 years or older
               preference for preventive/follow-up care                   or 5 years old or younger were sent an appropriate
                                                                          reminder during the EHR reporting period
Meaningful Use – Stage 1 Menu Set, cont’d

Health         Stage 1 Objective                                      Stage 1 Measure
Outcomes
Policy
Priority
Engage         EPs Only: Provide patients with timely electronic      More than 10% of all unique patients seen by the EP are
patients and   access to their health information (including lab      provided timely (available to the patient within 4
families in    results, problem list, medication lists, medication    business days of being updated in the certified EHR
their health   allergies) within 4 business days of the information   technology) electronic access to their health
care           being available to the EP                              information subject to the EP’s discretion to withhold
                                                                      certain information
               Use certified EHR technology to identify patient-      More than 10% of all unique patients seen by the EP or
               specific education resources and provide those         admitted to the eligible hospital or CAH are provided
               resources to the patient, if appropriate               patient-specific education resources
Improve care   The EP, eligible hospital or CAH who receives a        The EP, eligible hospital or CAH performs medication
coordination   patient from another setting of care or provider of    reconciliation for more than 50% of transitions of care
               care or believes an encounter is relevant should       in which the patient is transitioned into the care of the
               perform medication reconciliation                      EP or admitted to the eligible hospital or CAH
               The EP, eligible hospital or CAH who receives a        The EP, eligible hospital or CAH who transitions or refers
               patient from another setting of care or provider of    their patient to another setting of care or provider of
               care or refers their patient to another provider of    care provides a summary of care record for more than
               care should provide a summary of care record for       50% of transitions of care and referrals
               each transition of care or referral
Meaningful Use – Stage 1 Menu Set, cont’d

Health             Stage 1 Objective                                                  Stage 1 Measure
Outcomes
Policy
Priority
Improve            Capability to submit electronic data to immunization               Performed at least one test of the certified EHR
population         registries or Immunization Information Systems and                 technology’s capacity to submit electronic data to
and public         actual submission in accordance with applicable law                immunization registries and follow-up submission if the
health1            and practice                                                       test is successful (unless none of the immunization
                                                                                      registries to which the EP, eligible hospital or CAH
                                                                                      submits such information have the capacity to receive
                                                                                      such information electronically)
                   Hospitals Only: Capability to submit electronic data               Performed at least one test of certified EHR
                   on reportable (as required by state or local law) lab              technology’s capacity to provide submission of
                   results to public health agencies and actual                       reportable lab results to public health agencies and
                   submission in accordance with applicable law and                   follow-up submission if the test is successful (unless
                   practice                                                           none of the public health agencies to which the EP,
                                                                                      eligible hospital or CAH submits such information have
                                                                                      the capacity to receive such information electronically)
                   Capability to submit electronic syndromic                          Performed at least one test of certified EHR
                   surveillance data to public health agencies and                    technology’s capacity to provide electronic syndromic
                   actual submission in accordance with applicable law                surveillance data to public health agencies and follow-
                   and practice                                                       up submission if the test is successful (unless none of
                                                                                      the public health agencies to which the EP, eligible
                                                                                      hospital or CAH submits such information have the
                                                                                      capacity to receive such information electronically)
1Unless
      an EP, eligible hospital or CAH has an exception for all of these objectives and measures they must complete at least one as part of their
demonstration of the menu set in order to be a meaningful EHR user.
Future Stages

• Intend to propose 2 additional Stages
  through future rulemaking. Future Stages will
  expand upon Stage 1 criteria.
• Stage 1 menu set will be transitioned into
  core set for Stage 2
• Administrative transactions will be added
• CPOE measurement will go to 60%
• Will reevaluate other measures – possibly
  higher thresholds
• Stage 3 will be further defined in next
  rulemaking                                    22
States’ Flexibility to Revise
Meaningful Use
• States can seek CMS prior approval to
  require 4 MU objectives be core for their
  Medicaid providers:
  • Generate lists of patients by specific conditions for
    quality improvement, reduction of disparities,
    research or outreach (can specify particular
    conditions)
  • Reporting to immunization registries, reportable
    lab results and syndromic surveillance (can
    specify for their providers how to test the data
    submission and to which specific destination)

                                                        23
MU for Hospitals that Qualify for
Both Medicare & Medicaid Payments
• Applies to sub-section (d) and acute care
  hospitals
• Attest/Report on Meaningful Use to CMS for
  the Medicare EHR Incentive Program
• Will be deemed meaningful users for
  Medicaid (even if the State has CMS approval
  for the MU flexibility around public health
  objectives)



                                             24
Clinical Quality Measures (CQM)
Overview
• 2011 – EPs, eligible hospitals and CAHs
  seeking to demonstrate Meaningful Use are
  required to submit aggregate CQM
  numerator, denominator, and exclusion data
  to CMS or the States by attestation.




                                               25
Meaningful Use for EPs who Work at
Multiple Sites
• An EP who works at multiple locations, but
  does not have certified EHR technology
  available at all of them would:
   • Have to have 50% of their total patient encounters
     at locations where certified EHR technology is
     available
   • Would base all meaningful use measures only on
     encounters that occurred at locations where
     certified EHR technology is available
• 2012 – EPs, eligible hospitals and CAHs seeking to
  demonstrate Meaningful Use are required to electronically
  submit aggregate CQM numerator, denominator, and exclusion
  data to CMS or the States.                                 26
CQM: Eligible Professionals
• Core, Alternate Core, and Additional CQM sets
  for EPs
  • EPs must report on 3 required core CQM, and if the
    denominator of 1or more of the required core
    measures is 0, then EPs are required to report results
    for up to 3 alternate core measures
  • EPs also must select 3 additional CQM from a set of
    38 CQM (other than the core/alternate core measures)
  • In sum, EPs must report on 6 total measures: 3
    required core measures (substituting alternate core
    measures where necessary) and 3 additional
    measures

                                                         27
CQM: Core Set for EPs
NQF Measure Number & PQRI   Clinical Quality Measure Title
Implementation Number
NQF 0013                    Hypertension: Blood Pressure
                            Measurement
NQF 0028                    Preventive Care and Screening Measure
                            Pair: a) Tobacco Use Assessment b)
                            Tobacco Cessation Intervention
NQF 0421                    Adult Weight Screening and Follow-up
PQRI 128




                                                               28
CQM: Alternate Core Set for EPs
NQF Measure Number & PQRI   Clinical Quality Measure Title
Implementation Number
NQF 0024                    Weight Assessment and Counseling for
                            Children and Adolescents
NQF 0041                    Preventive Care and Screening:
PQRI 110                    Influenza Immunization for Patients 50
                            Years Old or Older
NQF 0038                    Childhood Immunization Status




                                                                 29
CQM: Additional Set for EPs
1.    Diabetes: Hemoglobin A1c Poor Control
2.    Diabetes: Low Density Lipoprotein (LDL) Management and Control
3.    Diabetes: Blood Pressure Management
4.    Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker
      (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
5.    Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction
      (MI)
6.    Pneumonia Vaccination Status for Older Adults
7.    Breast Cancer Screening
8.    Colorectal Cancer Screening
9.    Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD
10.   Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
11.   Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation
      Phase Treatment
12.   Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
13.   Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of
      Retinopathy
14.   Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
15.   Asthma Pharmacologic Therapy
16.   Asthma Assessment
17.   Appropriate Testing for Children with Pharyngitis
18.   Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor
      (ER/PR) Positive Breast Cancer
19.   Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients




                                                                                                        30
CQM: Additional Set for EPs, cont’d
20.   Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer
      Patients
21.   Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco
      Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing
      Smoking and Tobacco Use Cessation Strategies
22.   Diabetes: Eye Exam
23.   Diabetes: Urine Screening
24.   Diabetes: Foot Exam
25.   Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol
26.   Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation
27.   Ischemic Vascular Disease (IVD): Blood Pressure Management
28.   Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
29.   Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b)
      Engagement
30.   Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)
31.   Prenatal Care: Anti-D Immune Globulin
32.   Controlling High Blood Pressure
33.   Cervical Cancer Screening
34.   Chlamydia Screening for Women
35.   Use of Appropriate Medications for Asthma
36.   Low Back Pain: Use of Imaging Studies
37.   Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
38.   Diabetes: Hemoglobin A1c Control (<8.0%)


                                                                                                    31
CQM: Eligible Hospitals and CAHs
1.    Emergency Department Throughput – admitted patients Median time from ED
      arrival to ED departure for admitted patients
2.    Emergency Department Throughput – admitted patients – Admission decision time
      to ED departure time for admitted patients
3.    Ischemic stroke – Discharge on anti-thrombotics
4.    Ischemic stroke – Anticoagulation for A-fib/flutter
5.    Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of
      symptom onset
6.    Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2
7.    Ischemic stroke – Discharge on statins
8.    Ischemic or hemorrhagic stroke – Stroke education
9.    Ischemic or hemorrhagic stroke – Rehabilitation assessment
10.   VTE prophylaxis within 24 hours of arrival
11.   Intensive Care Unit VTE prophylaxis
12.   Anticoagulation overlap therapy
13.   Platelet monitoring on unfractionated heparin
14.   VTE discharge instructions
15.   Incidence of potentially preventable VTE




                                                                                   32
Participation in HITECH and other
Medicare Incentive Programs for EPs
Other Medicare Incentive       Eligible for HITECH EHR Incentive Program?
Program
Medicare Physician Quality     Yes, if the EP is eligible.
Reporting Initiative (PQRI)
Medicare Electronic Health     Yes, if the EP is eligible.
Record Demonstration (EHR
Demo)
Medicare Care Management       Yes, if the practice is eligible. The MCMP demo will end
Performance Demonstration      before EHR incentive payments are available.
(MCMP)
Electronic Prescribing (eRx)   If the EP chooses to practice in the Medicare EHR Incentive
Incentive Program              Program, they cannot participate in the Medicare eRx
                               Incentive Program simultaneously in the same program
                               year. If the EP chooses to participate in the Medicaid EHR
                               Incentive Program, they can participate in the Medicare
                               eRx Incentive Program simultaneously.


                                                                                          33
EHR Incentive Program Timeline
•   Registration for the EHR Incentive Programs will begin in January 2011
•   For Medicare providers, attestation for the EHR Incentive Programs will
    begin in April 2011
•   EHR incentive payments will be made 11 months after the rule is
    published*
•   For Medicaid providers, States may launch their programs in January 2011
    and thereafter
•   November 30, 2011 – Last day for eligible hospitals and CAHs to register
    and attest to receive an incentive payment for FFY 2011 (Medicare
    providers)
•   February 29, 2012 – Last day for EPs to register and attest to receive an
    incentive payment for CY 2011 (Medicare providers)
•   2015 – Medicare payment adjustments begin for EPs and eligible hospitals
    that are not meaningful users of EHR technology**
•   2016 – Last year to receive a Medicare EHR incentive payment; Last year
    to initiate participation in Medicaid EHR Incentive Program**
•   2021 – Last year to receive Medicaid EHR incentive payment**
                                      **Statutory




                                                                            34
More Information


• http://www.cms.gov/EHRIncentivePrograms




                                            35

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Meaningful use stage-1

  • 1. Medicare & Medicaid EHR Incentive Program Final Rule Implementing the American Recovery & Reinvestment Act of 2009
  • 2. The Journey to Meaningful Use Faith is the bird that sings when the dawn is still dark. Rabindranath Tagore 2
  • 3. Overview • American Recovery & Reinvestment Act (Recovery Act) – February 17, 2009 • Medicare & Medicaid Electronic Health Record (EHR) Incentive Program Notice of Proposed Rulemaking (NPRM) • Display – December 30, 2009 • Publication – January 13, 2010 • Final Rule on Display – July 13, 2010 • Final Rule Published – July 28, 2010 3
  • 4. What did not change in the final rule • Adopted statutory provider eligibility and payment requirements • Meaningful Use matrix goals remained the same. • Hospital definition did not change. • EPs will still be required to demonstrate MU individually • Clinical quality measures reporting timeline will stay the same • MU reporting period of 90 days for first year and one year thereafter. 4
  • 5. What Changed from the NPRM to the Final Rule? • Meaningful Use Criteria • Clinical Quality Measures • Hospital-based EPs • Medicaid acute care hospitals • Medicaid patient volume • Removed reporting period for adopt, implement or upgrade (Medicaid) • All programs will start in 2011 • More clarification throughout 5
  • 6. Changes to Provider Eligibility • Due to recent legislation, hospital-based EPs are only those who see more than 90% of their patients in a hospital in-patient or ER setting • Medicaid included critical access hospitals in its definition of “acute care hospital” (but incentive is like other acute care hospitals, not following the Medicare CAH formula) 6
  • 7. Medicaid Patient Volume Medicaid EP participation hinges on patient volume requirements. • Medicaid patient volume was significantly clarified • Expanded definition of “encounter” to include any encounter for which Medicaid had any payment liability e.g. premiums, co-pays, waivers • Allows States to define patient volume as just encounters or encounters plus patient panel (managed care), both or propose a new methodology 7
  • 8. Meaningful Use: Process of Defining • National Committee on Vital and Health Statistics (NCVHS) hearings • HIT Policy Committee (HITPC) recommendations • Listening Sessions with providers/organizations • Public comments on HITPC recommendations • Comments received from the Department and the Office of Management and Budget (OMB) • Revised based on public comments on the NPRM 8
  • 9. Meaningful Use Stage 1 – Health Outcome Priorities* • Improve quality, safety, efficiency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health • Ensure adequate privacy and security protections for personal health information *Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008. 9
  • 10. Meaningful Use: Changes from the NPRM to the Final Rule NPRM Final Rule Meet all MU reporting objectives Must meet “core set”/can defer 5 from optional “menu set” 25 measures for EPs/23 measures for 25 measures for EPs/24 for eligible eligible hospitals hospitals Measure thresholds range from 10% to Measure thresholds range from 10% to 80% of patients or orders (most at higher 80% of patients or orders (most at lower range) to middle range) Denominators – To calculate the Denominators – No measures require threshold, some measures required manual chart review to calculate manual chart review threshold Administrative transactions (claims and Administrative transactions removed eligibility) included Measures for Patient-Specific Education Measures for Patient-Specific Education Resources and Advanced Directives Resources and Advanced Directives (for discussed but not proposed hospitals) included 10
  • 11. Meaningful Use: Changes from the NPRM to the Final Rule, cont’d NPRM Final Rule States could propose requirements States’ flexibility with Stage 1 MU is above/beyond MU floor, but not with limited to seeking CMS approval to additional EHR functionality require 4 public health-related objectives to be core instead of menu Core clinical quality measures (CQM) Modified Core CQM and removed and specialty measure groups for EPs specialty measure groups for EPs 90 CQM total for EPs 44 CQM total for EPs – must report total of 6 35 CQM total for eligible hospitals and 15 CQM total for eligible hospitals 8 alternate Medicaid CQM 5 CQM overlap with CHIPRA initial core 4 CQM overlap with CHIPRA initial core set set 11
  • 12. How were MU Core Objectives Selected? • Overarching considerations • Statutory requirements-e.g.- e-prescribing, CQM, health information exchange • Foundational objectives-e.g. privacy and security and those that provide foundational data needed for other measures, like demographics, medication lists, etc. • Patient-centered • Patient access- e.g. clinical summaries • Patient safety-e.g.-drug-drug and drug-allergy features) • Part of providers’ “normal” practice • Looked at how the objectives aligned • Feedback received from HIT Policy Committee and commenters 12
  • 13. Meaningful Use: Denominators • Two types of percentage based measures are included to address the burden of demonstrating MU 1. Denominator is all patients seen or admitted during the EHR reporting period • The denominator is all patients regardless of whether their records are kept using certified EHR technology 2. Denominator is actions or subsets of patients seen or admitted during the EHR reporting period 13
  • 14. Meaningful Use: Applicability of Objectives and Measures • 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. • In these cases, the EP, eligible hospital or CAH would be excluded from having to meet that measure • Ex: Dentists who do not perform immunizations; Chiropractors do not e-prescribe • The denominator only includes patients, or actions taken on behalf of those patients, whose records are kept using certified EHR technology 14
  • 15. How were the Thresholds Selected • 80%-Objective part of standard practice-e.g.- maintain active medication list • Others-defined on a case-by-case basis based on commenter or clearance feedback • Example-e-prescribing set at 40% lowered from 75% to address concerns by commenters regarding non-participation by pharmacies and patient preference. 15
  • 16. Meaningful Use – Stage 1 Core Set Health Stage 1 Objective Stage 1 Measure Outcomes Policy Priority Improving Use CPOE for medication orders directly entered by More than 30% of unique patients with at least one quality, any licensed healthcare professional who can enter medication in their medication list seen by the EP or safety, orders into the medical record per state, local, and admitted to the eligible hospital or CAH have at least efficiency, professional guidelines one medication entered using CPOE and Implement drug-drug and drug-allergy interaction The EP/eligible hospital/CAH has enabled this reducing checks functionality for the entire EHR reporting period health disparities EP Only: Generate and transmit permissible More than 40% of all permissible prescriptions written prescriptions electronically (eRx) by the EP are transmitted electronically using certified EHR technology Record demographics: preferred language, gender, More than 50% of all unique patients seen by the EP or race, ethnicity, date of birth, and date and admitted to the eligible hospital or CAH have preliminary cause of death in the event of mortality demographics as recorded structured data in the eligible hospital or CAH Maintain up-to-date problem list of current and More than 80% of all unique patients seen by the EP or active diagnoses admitted to the eligible hospital or CAH have at least one entry or an indication that no problems are known for the patient recorded as structured data
  • 17. Meaningful Use – Stage 1 Core Set, cont’d Health Stage 1 Objective Stage 1 Measure Outcomes Policy Priority Improving Maintain active medication list More than 80% of all unique patents seen by the EP or quality, admitted to the eligible hospital or CAH have at least safety, one entry (or an indication that the patient is not efficiency, currently prescribed any medication) recorded as and structured data reducing Maintain active medication allergy list More than 80% of all unique patents seen by the EP or health admitted to the eligible hospital or CAH have at least disparities one entry (or an indication that the patient has no known medication allergies) recorded as structured data Record and chart vital signs: height, weight, blood For more than 50% of all unique patients age 2 and over pressure, calculate and display BMI, plot and display seen by the EP or admitted to the eligible hospital or growth charts for children 2-20 years, including BMI CAH, height, weight, and blood pressure are recorded as structured data Record smoking status for patients 13 years old or More than 50% of all unique patients 13 years or older older seen by the EP or admitted to the eligible hospital or CAH have smoking status recorded as structured data Implement one clinical decision support rule and the Implement one clinical decision support rule ability to track compliance with the rule Report clinical quality measures to CMS or the States For 2011, provide aggregate numerator, denominator, and exclusions through attestation; For 2012, electronically submit clinical quality measures
  • 18. Meaningful Use – Stage 1 Core Set, cont’d Health Stage 1 Objective Stage 1 Measure Outcomes Policy Priority Engage Provide patients with an electronic copy of their More than 50% of all unique patients of the EP, eligible patients and health information (including diagnostic test results, hospital or CAH who request an electronic copy of their families in problem list, medication lists, medication allergies, health information are provided it within 3 business their discharge summary, procedures), upon request days healthcare Hospitals Only: Provide patients with an electronic More than 50% of all patients who are discharged from copy of their discharge instructions at time of an eligible hospital or CAH who request an electronic discharge, upon request copy of their discharge instructions are provided it EPs Only: Provide clinical summaries for each office Clinical summaries provided to patients for more than visit 50% of all office visits within 3 business days Improve care Capability to exchange key clinical information (ex: Performed at least one test of the certified EHR coordination problem list, medication list, medication allergies, technology’s capacity to electronically exchange key diagnostic test results), among providers of care and clinical information patient authorized entities electronically Ensure Protect electronic health information created or Conduct or review a security risk analysis per 45 CFR adequate maintained by certified EHR technology through the 164.308(a)(1) and implement updates as necessary and privacy and implementation of appropriate technical capabilities correct identified security deficiencies as part of the security EP’s, eligible hospital’s or CAH’s risk management protections process for personal health information
  • 19. Meaningful Use – Stage 1 Menu Set Health Stage 1 Objective Stage 1 Measure Outcomes Policy Priority Improving Implement drug-formulary checks The EP/eligible hospital/CAH has enabled this quality, functionality and has access to at least one internal or safety, external drug formulary for the entire EHR reporting efficiency, period and reducing Hospitals Only: Record advance directives for More than 50% of all unique patients 65 years old or health patients 65 years old or older older admitted to the eligible hospital or CAH have an disparities indication of an advance directive status recorded Incorporate clinical lab-test results into certified EHR More than 40% of all clinical lab test results ordered by technology as structured data the EP, or an authorized provider of the eligible hospital or CAH, for patients admitted during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data Generate lists of patients by specific conditions to Generate at least one report listing patients of the EP, use for quality improvement, reduction of eligible hospital or CAH with a specific condition disparities, research or outreach EPs Only: Send reminders to patients per patient More than 20% of all unique patients 65 years or older preference for preventive/follow-up care or 5 years old or younger were sent an appropriate reminder during the EHR reporting period
  • 20. Meaningful Use – Stage 1 Menu Set, cont’d Health Stage 1 Objective Stage 1 Measure Outcomes Policy Priority Engage EPs Only: Provide patients with timely electronic More than 10% of all unique patients seen by the EP are patients and access to their health information (including lab provided timely (available to the patient within 4 families in results, problem list, medication lists, medication business days of being updated in the certified EHR their health allergies) within 4 business days of the information technology) electronic access to their health care being available to the EP information subject to the EP’s discretion to withhold certain information Use certified EHR technology to identify patient- More than 10% of all unique patients seen by the EP or specific education resources and provide those admitted to the eligible hospital or CAH are provided resources to the patient, if appropriate patient-specific education resources Improve care The EP, eligible hospital or CAH who receives a The EP, eligible hospital or CAH performs medication coordination patient from another setting of care or provider of reconciliation for more than 50% of transitions of care care or believes an encounter is relevant should in which the patient is transitioned into the care of the perform medication reconciliation EP or admitted to the eligible hospital or CAH The EP, eligible hospital or CAH who receives a The EP, eligible hospital or CAH who transitions or refers patient from another setting of care or provider of their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary of care record for more than care should provide a summary of care record for 50% of transitions of care and referrals each transition of care or referral
  • 21. Meaningful Use – Stage 1 Menu Set, cont’d Health Stage 1 Objective Stage 1 Measure Outcomes Policy Priority Improve Capability to submit electronic data to immunization Performed at least one test of the certified EHR population registries or Immunization Information Systems and technology’s capacity to submit electronic data to and public actual submission in accordance with applicable law immunization registries and follow-up submission if the health1 and practice test is successful (unless none of the immunization registries to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) Hospitals Only: Capability to submit electronic data Performed at least one test of certified EHR on reportable (as required by state or local law) lab technology’s capacity to provide submission of results to public health agencies and actual reportable lab results to public health agencies and submission in accordance with applicable law and follow-up submission if the test is successful (unless practice none of the public health agencies to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) Capability to submit electronic syndromic Performed at least one test of certified EHR surveillance data to public health agencies and technology’s capacity to provide electronic syndromic actual submission in accordance with applicable law surveillance data to public health agencies and follow- and practice up submission if the test is successful (unless none of the public health agencies to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) 1Unless an EP, eligible hospital or CAH has an exception for all of these objectives and measures they must complete at least one as part of their demonstration of the menu set in order to be a meaningful EHR user.
  • 22. Future Stages • Intend to propose 2 additional Stages through future rulemaking. Future Stages will expand upon Stage 1 criteria. • Stage 1 menu set will be transitioned into core set for Stage 2 • Administrative transactions will be added • CPOE measurement will go to 60% • Will reevaluate other measures – possibly higher thresholds • Stage 3 will be further defined in next rulemaking 22
  • 23. States’ Flexibility to Revise Meaningful Use • States can seek CMS prior approval to require 4 MU objectives be core for their Medicaid providers: • Generate lists of patients by specific conditions for quality improvement, reduction of disparities, research or outreach (can specify particular conditions) • Reporting to immunization registries, reportable lab results and syndromic surveillance (can specify for their providers how to test the data submission and to which specific destination) 23
  • 24. MU for Hospitals that Qualify for Both Medicare & Medicaid Payments • Applies to sub-section (d) and acute care hospitals • Attest/Report on Meaningful Use to CMS for the Medicare EHR Incentive Program • Will be deemed meaningful users for Medicaid (even if the State has CMS approval for the MU flexibility around public health objectives) 24
  • 25. Clinical Quality Measures (CQM) Overview • 2011 – EPs, eligible hospitals and CAHs seeking to demonstrate Meaningful Use are required to submit aggregate CQM numerator, denominator, and exclusion data to CMS or the States by attestation. 25
  • 26. Meaningful Use for EPs who Work at Multiple Sites • An EP who works at multiple locations, but does not have certified EHR technology available at all of them would: • Have to have 50% of their total patient encounters at locations where certified EHR technology is available • Would base all meaningful use measures only on encounters that occurred at locations where certified EHR technology is available • 2012 – EPs, eligible hospitals and CAHs seeking to demonstrate Meaningful Use are required to electronically submit aggregate CQM numerator, denominator, and exclusion data to CMS or the States. 26
  • 27. CQM: Eligible Professionals • Core, Alternate Core, and Additional CQM sets for EPs • EPs must report on 3 required core CQM, and if the denominator of 1or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures • EPs also must select 3 additional CQM from a set of 38 CQM (other than the core/alternate core measures) • In sum, EPs must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures 27
  • 28. CQM: Core Set for EPs NQF Measure Number & PQRI Clinical Quality Measure Title Implementation Number NQF 0013 Hypertension: Blood Pressure Measurement NQF 0028 Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention NQF 0421 Adult Weight Screening and Follow-up PQRI 128 28
  • 29. CQM: Alternate Core Set for EPs NQF Measure Number & PQRI Clinical Quality Measure Title Implementation Number NQF 0024 Weight Assessment and Counseling for Children and Adolescents NQF 0041 Preventive Care and Screening: PQRI 110 Influenza Immunization for Patients 50 Years Old or Older NQF 0038 Childhood Immunization Status 29
  • 30. CQM: Additional Set for EPs 1. Diabetes: Hemoglobin A1c Poor Control 2. Diabetes: Low Density Lipoprotein (LDL) Management and Control 3. Diabetes: Blood Pressure Management 4. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) 6. Pneumonia Vaccination Status for Older Adults 7. Breast Cancer Screening 8. Colorectal Cancer Screening 9. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD 10. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 11. Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment 12. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 13. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 15. Asthma Pharmacologic Therapy 16. Asthma Assessment 17. Appropriate Testing for Children with Pharyngitis 18. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients 30
  • 31. CQM: Additional Set for EPs, cont’d 20. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 21. Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies 22. Diabetes: Eye Exam 23. Diabetes: Urine Screening 24. Diabetes: Foot Exam 25. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol 26. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation 27. Ischemic Vascular Disease (IVD): Blood Pressure Management 28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 29. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement 30. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) 31. Prenatal Care: Anti-D Immune Globulin 32. Controlling High Blood Pressure 33. Cervical Cancer Screening 34. Chlamydia Screening for Women 35. Use of Appropriate Medications for Asthma 36. Low Back Pain: Use of Imaging Studies 37. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control 38. Diabetes: Hemoglobin A1c Control (<8.0%) 31
  • 32. CQM: Eligible Hospitals and CAHs 1. Emergency Department Throughput – admitted patients Median time from ED arrival to ED departure for admitted patients 2. Emergency Department Throughput – admitted patients – Admission decision time to ED departure time for admitted patients 3. Ischemic stroke – Discharge on anti-thrombotics 4. Ischemic stroke – Anticoagulation for A-fib/flutter 5. Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset 6. Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 7. Ischemic stroke – Discharge on statins 8. Ischemic or hemorrhagic stroke – Stroke education 9. Ischemic or hemorrhagic stroke – Rehabilitation assessment 10. VTE prophylaxis within 24 hours of arrival 11. Intensive Care Unit VTE prophylaxis 12. Anticoagulation overlap therapy 13. Platelet monitoring on unfractionated heparin 14. VTE discharge instructions 15. Incidence of potentially preventable VTE 32
  • 33. Participation in HITECH and other Medicare Incentive Programs for EPs Other Medicare Incentive Eligible for HITECH EHR Incentive Program? Program Medicare Physician Quality Yes, if the EP is eligible. Reporting Initiative (PQRI) Medicare Electronic Health Yes, if the EP is eligible. Record Demonstration (EHR Demo) Medicare Care Management Yes, if the practice is eligible. The MCMP demo will end Performance Demonstration before EHR incentive payments are available. (MCMP) Electronic Prescribing (eRx) If the EP chooses to practice in the Medicare EHR Incentive Incentive Program Program, they cannot participate in the Medicare eRx Incentive Program simultaneously in the same program year. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously. 33
  • 34. EHR Incentive Program Timeline • Registration for the EHR Incentive Programs will begin in January 2011 • For Medicare providers, attestation for the EHR Incentive Programs will begin in April 2011 • EHR incentive payments will be made 11 months after the rule is published* • For Medicaid providers, States may launch their programs in January 2011 and thereafter • November 30, 2011 – Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011 (Medicare providers) • February 29, 2012 – Last day for EPs to register and attest to receive an incentive payment for CY 2011 (Medicare providers) • 2015 – Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology** • 2016 – Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program** • 2021 – Last year to receive Medicaid EHR incentive payment** **Statutory 34