Overview of Meaningful Use, Stage One. Presented to Georgetown's Health Information System's class on 4/14//11. Only difference from previous lectures is the addition of slides on adoption sentiment.

1. Jessica Jacobs
Georgetown University
April 14, 2011

2. (Un)fortunately, It‟s more complicated than pie…
Note – I’m not an expert on Meaningful Use – please see http://www.cms.gov/EHRIncentivePrograms for more details!

3. Medicare Clinical
Core
History v.s. Incentives Certification Quality Summary
Objectives
Medicaid Measures
THE BACK STORY
3

4. It all started with ARRA
• The Health Information
Technology for Economic and
Clinical Health (HITECH) Act
of 2009 was a part of ARRA Money Talks …
• HITECH allocated funds to
spur the adoption of
electronic health records -
approximately $20.8 Billion
• While they‟re starting with Graph Source: HIMSS Analytics Survey, September
carrots, there will be sticks 2010, http://www.himss.org/content/files/vantagepoint/vanta
gepoint_201009.asp?pg=1

5. Why “Meaningful Use”?
• ARRA gives out money, with some caveats:
1. Use of certified EHR in a meaningful manner
2. Use of certified EHR technology for electronic
exchange of health information to improve
quality of health care
3. Use of certified EHR technology to submit
clinical quality measures (CQM) and other such
measures selected by the Secretary [of Health]

6. It‟s more than just the money
• Works with other CMS/ONC programs
• Allows for step-wise implementation of EHRs
• Will lead to proper use of Health IT and
better patient care

7. The Five Pillars of Meaningful Use
Ensure Privacy and Security
Improve Population Health
Improve Safety and Quality
Engage Patients and Families
Coordinate Care

8. Basic Timeline
2009 2010 2011 2012 2015 2016 2021
•Feb: •Jan: NPRM •Jan: States •Feb 29th: Last •Payment •Last year to •Last year to
ARRA/HITECH Published can begin to day for EPs to Adjustments receive receive
Become Law •March: launch their register/attest (Penalties) Medicare Medicaid
•Dec: NPRM on Comment programs for FFY 2011 Begin for EPs Incentive Incentive
Display Period Closes •~Jan: and eligible Payment Payment
(2000 Registration hospitals
comments •~March:
received) Attestation
•July: Final •~May:
Rule Payments
•August: •Nov 30th: Last
Certifying day for
Bodies Hospitals/CAH
to register for
FFY 2011

9. Medicare Clinical
Core Quality
History v.s. Incentives Certification Summary
Objectives
Medicaid Measures
DO I QUALIFY?
9

10. Eligible Parties
Medicare Medicaid
Eligible Professionals (EPs) Eligible Professionals (EPs)
• Ambulatory MD/DO • Ambulatory Physicians (Pediatricians
• Doctor of Dental Surgery or Dental have special eligibility & payment rules)
Medicine • Nurse Practitioners (NPs)
• Doctor of Podiatric Medicine • Certified Nurse-Midwives (CNMs)
• Doctor of Optometry • Dentists
• Chiropractors • Physician Assistants (PAs) who lead a
• Medicaid Advantage (20 hours/week of Federally Qualified Health Center (FQHC)
patient-care services for or rural health clinic (RHC)
employees, 80% of time for partners)
Eligible Hospitals* Eligible Hospitals
• Acute Care Hospitals • Acute Care Hospitals
• Critical Access Hospitals (CAHs) • Critical Access Hospitals
*Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC • Children‟s Hospitals
https://questions.cms.hhs.gov/app/answers/detail/a_id/9844/~/[ehr-incentive-program]-are-physicians-who-practice-in-hospital-based
Note: Excludes radiologists, pathologists, anesthesiologists, ER and all other hospital-based physicians

11. Medicaid Eligibility
Entity
Minimum Formula
Threshold
Physicians 30%
Pediatricians 20% Total Medicaid Encounters
Dentists 30% in a 90-Day Period
CNMs 30% _________________________
PAs (at FQHC) 30% Total Encounters
NPs 30% in same 90-Day Period
Acute Care Hospitals 10%
Source: http://www.cms.gov/MLNProducts/downloads/EHR_Final_Rule-
Children's Hospitals -- Medicaid.pdf

12. Expected States with Medicaid Programs
50
45
44
43
42
41
40
35
34
Number of States
30 30
26
25
20
18
16
15
10 8
7
5
5 4 4
2
1 1 1
0
April May June July August September October November December
New State Programs Total State Programs
Source: CMS, MU Program Contacts, Updated March 26, 2011, http://www.cms.gov/apps/files/statecontacts.pdf

13. Medicare Clinical
Core
History v.s. Incentives Certification Quality Summary
Objectives
Medicaid Measures
THE MONEY
13

14. Ambulatory Incentive Structure
– Medicare: $44k/physician
• Bonuses for EPs in Health Provider Shortage Areas
(HPSAs)
– Medicaid: up to $63,750k/physician
– Incentives will be paid 2011- 2016, then
penalties will begin
• Switching between programs:
– Allowed, but only once

15. Medicare EPs
Year MUer  2011 2012 2013 2014
2011 $18,000 - - -
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
2016 - $2,000 $4,000 $4,000
TOTAL $44,000 $44,000 $39,000 $24,000
Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

16. Medicare HPSA EP Bonuses
Year MUer  2011 2012 2013 2014
2011 $1,800 - - -
2012 $1,200 $1,800 - -
2013 $800 $1,200 $1,500 -
2014 $400 $800 $1,200 $12,000
2015 $200 $400 $800 $8,000
2016 - $200 $400 $4,000
TOTAL $4,400 $4,400 $3,900 $2,400
Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

17. Medicaid EPs
Year MUer  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
Source: https://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

18. Hospital Incentive Structure
• The Money:
• Two Million Dollar Base + Variable Based on Discharges
(Medicare/Medicaid Share)
• Hospitals meeting Medicare MU requirements may be
eligible for Medicaid payments
• The Timeline:
• Medicare: no payments after 2016, Sticks start in 2015
• Medicaid: can’t initiate payments after 2016
• The Caveats:
– All Medicare Hospitals qualify as Medicaid Hospitals
– Hospitals eligible for Medicare dollars may be eligible for
Medicaid dollars
18

19. Medicare Clinical
Core
History v.s. Incentives Certification Quality Summary
Objectives
Medicaid Measures
ARE YOU LEGAL?
19

20. Certification
• Temporary Certification Program will expire
December 31, 2011, Permanent program Vendors Planning to Achieve
starts January 1, 2012. „
Certification
• National Institute of Standards and Technology
(NIST) will help accredit testing bodies through
its National Voluntary Laboratory Accreditation
Program (NVLAP)
• Handled by external bodies
• Currently there are five certifying agencies:
– CCHIT – Chicago, IL. (8/30/10)
– Drummond Group – Austin, TX.
(8/30/10)
– InfoGard – San Luis Obispo, CA.
(9/17/10) Graph Source: HIMSS Analytics Survey, September
– ICSA - Mechanicsburg, PA. (12/10/10) 2010, http://www.himss.org/content/files/vantagepoint/vanta
gepoint_201009.asp?pg=1
– Surescripts, LLC – Arlington, VA.
(12/23/10)

21. Certification: Current Stats
Product Type
Complete EHR Modular EHR
• There are 575 Current Certifications
– 393 Ambulatory
– 182 Acute
43%
• This is up from 136 Certifications last
57%
December
Type of Certification
Complete EHR Modular EHR SLI Certifying Body
Global
1%
ICSA
Labs
Ambulatory 70% 30% 1% InfoGard
14%
Drummo CCHIT
nd 50%
Acute 30% 70%
Group
Inc.
34%

22. Medicare Clinical
Core
History v.s. Incentives Certification Quality Summary
Objectives
Medicaid Measures
THE HEART OF IT
22

23. The Core Objectives
• You Gotta Have:
– Ambulatory Providers = 15
– Hospitals = 14
– All Hospital Criteria Overlap with Ambulatory
• the only addition to the ambulatory provider list is e-
Prescribing
– Most measures must be reported as structured
data

24. Core Objectives – Gotta Do „em All
Maintain/Record Do/Implement Provide/Report
• Maintain an up-to-date • Computerized physician • Report clinical quality
problem list of current and order entry (CPOE) (30%) measures to CMS or States
active diagnoses (50%) • E-Prescribing (Ambulatory (2011 Attestation, 2012
• Maintain active medication Only, 40%) Electronically)
list (80%) • Drug-drug and drug-allergy • Provide Patients with an
• Maintain active medication interaction checks (enabled electronic copy of their
allergy list (80%) whole period) health information, upon
• Record and chart changes • Clinical decision support (1 request (50% within 3 days)
in vital signs (50%) rule) • Provide clinical summaries
• Record smoking status for • Protect electronic health for patients for each office
patients 13 years or older information (whole period) visit/at each discharge
(50%) (50% within 3 days)
• Record demographics • Capability to exchange key
(50%) clinical information among
providers of care and
patient-authorized entities
electronically (perform at
least one test)
Source: http://healthpolicyandreform.nejm.org/?attachment_id=3742

25. Menu Sets – Pick Five
Maintain/Record Do/Implement Provide/Report
• Drug-formulary checks (whole
• Incorporate clinical lab test results period) • Generate lists of patients by
(50%) specific conditions (at least 1 list)
• Medication reconciliation (50%)
• Record advanced directives for • Summary of care record for each
patients 65 years or older (Acute transition of care/referrals (50%)
Only, 50%) • Capability to provide electronic
syndromic surveillance data to
public health agencies (1 test)
• Capability to submit electronic
data to immunization
registries/systems (1 test)
• Provide patient-specific education
resources and provide to patient
(10%)
• Send reminders to patients per
patient preference for
preventive/follow up care
(Ambulatory Only, 20%, in the 65<
& <5 age groups)
• Provide patients with timely
electronic access to their health
information (Ambulatory
Only, 10% within 4 days)

26. Medicare Clinical
Core
History v.s. Incentives Certification Quality Summary
Objectives
Medicaid Measures
CLINICAL QUALITY MEASURES
(CQM)
26

27. Clinical Reporting Measures
• Many selected from the Physician Quality Reporting Initiative (PQRI) and Pay-for-Performance Initiatives
(P4P)*
– CMS intends to create an added incentive for EPs to adopt EHRs by leveraging the PQRI
measures and eventually integrate both programs.
– CMS envisions a single reporting infrastructure for electronic submission in the
future, eliminating redundant or duplicative reporting.
• The HITECH Act required that in selecting clinical quality measures CMS give preference to those
endorsed by the National Quality Forum.*
– NQF is a nonprofit organization that ensures clinical quality measures are developed and
maintained through a consistent and collaborative process.
– All clinical quality measures selected in the final rule are endorsed by NQF.
• Number of Measures
– EPs – 3 core, 3 pick
• If your practice doesn‟t have the 3 core to report on (pediatricians don‟t have adult weight
screenings), then you pick an “alternate” measure to report
– Hospitals – 15, all required
*Source: http://journal.ahima.org/2010/09/15/clinical-quality-measures-for-providers-3/

28. EP CQM
• CORE SET: • Hemoglobin A1c Poor Control • Heart Failure (HF): Angiotensin- • Breast Cancer Screening
Converting Enzyme (ACE) Inhibitor or
•Preventive Care and Screening • Low Density Lipoprotein (LDL) Angiotensin Receptor Blocker (ARB) • Colorectal Cancer Screening
Measure Pair: a) Tobacco Use Management and Control Therapy for Left Ventricular Systolic • Oncology Breast Cancer:
Assessment b) Tobacco • Blood Pressure Management Dysfunction (LVSD) Hormonal Therapy for Stage
Cessation Intervention (NQF • Diabetic Retinopathy:
• Coronary Artery Disease (CAD): IC-IIIC Estrogen
0028) Documentation of Presence
Beta-Blocker Therapy for CAD
Patients with Prior Myocardial Receptor/Progesterone
•Hypertension: Blood Pressure or Absence of Macular Edema Infarction (MI) Receptor (ER/PR) Positive
Measurement (NQF 0013) and Level of Severity of • Coronary Artery Disease (CAD): Oral Breast Cancer
•Adult Weight Screening and Retinopathy Antiplatelet Therapy Prescribed for
• Oncology Colon Cancer:
Patients with CAD
Follow-up (NQF 0421, PQRI • Diabetic Retinopathy: • Heart Failure (HF): Beta-Blocker Chemotherapy for Stage III
128) Communication with the Therapy for Left Ventricular Systolic Colon Cancer Patients
•ALTERNATE SET: Physician Managing Ongoing Dysfunction (LVSD) • Prostate Cancer: Avoidance
•Preventive Care and Screening: Diabetes Care • Heart Failure (HF): Warfarin Therapy of Overuse of Bone Scan for
Patients with Atrial Fibrillation
Influenza Immunization for • Eye Exam • Ischemic Vascular Disease (IVD):
Staging Low Risk Prostate
Patients > 50 Years old (NQF • Urine Screening Blood Pressure Management Cancer Patients
0041, PQRI 110) • Ischemic Vascular Disease (IVD):
• Foot Exam
•Childhood Immunization Status Use of Aspirin or Another
(NQF 0038) • Hemoglobin A1c Control Antithrombotic
(<8.0%) • Coronary Artery Disease (CAD): Drug
•Weight Assessment and Therapy for Lowering LDL-
Counseling for Children and Cholesterol
Adolescents (NQF 0024) • Ischemic Vascular Disease (IVD):
• Pneumonia Vaccination Complete Lipid Panel and LDL
Control
Status for Older Adults
Prevention Diabetics Cardiology Oncology

29. EP CQM
• Prenatal Care: Screening for • Smoking and Tobacco Use • Asthma Pharmacologic • Primary Open Angle
Human Immunodeficiency Cessation, Medical Therapy Glaucoma (POAG): Optic
Virus (HIV) assistance: a) Advising • Asthma Assessment Nerve Evaluation
• Prenatal Care: Anti-D Smokers and Tobacco • Use of Appropriate • Low Back Pain: Use of
Immune Globulin Users to Quit, b) Discussing Medications for Asthma Imaging Studies
• Prenatal Care: Controlling Smoking and Tobacco Use
• Appropriate Testing for
High Blood Pressure Cessation Medications, c)
Children with Pharyngitis
Discussing Smoking and
• Cervical Cancer Screening
Tobacco Use Cessation
• Chlamydia Screening for Strategies
Women
• Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment: a)
Initiation, b) Engagement
• Anti-depressant medication
management: (a) Effective
Acute Phase
Treatment,(b)Effective
Continuation Phase
Treatment
OBGYN Psychology Respiratory Other

30. Hospital CQM Requirements
• Ischemic stroke – Discharge on anti-thrombotics • Emergency Department Throughput – admitted • VTE prophylaxis within 24 hours of arrival
• Ischemic stroke – Anticoagulation for A-fib/flutter patients Median time from ED arrival to ED • Intensive Care Unit VTE prophylaxis
• Ischemic stroke – Thrombolytic therapy for departure for admitted patients • Anticoagulation overlap therapy
patients arriving within 2 hours of symptom onset • Emergency Department Throughput – admitted • Platelet monitoring on unfractionated heparin
• Ischemic or hemorrhagic stroke – Antithrombotic patients – Admission decision time to ED
• VTE discharge instructions
therapy by day 2 departure time for admitted patients
• Incidence of potentially preventable VTE
• Ischemic stroke – Discharge on statins
• Ischemic or hemorrhagic stroke – Stroke
education
• Ischemic or hemorrhagic stroke – Rehabilitation
assessment
Stroke Throughput Surgery

31. Medicare Clinical
Core
History v.s. Incentives Certification Reporting Summary
Measures
Medicaid Measures
SO WHAT WAS THE POINT?
31

32. Overview
Medicare Medicaid
Implementers Federal Level (CMS) States (Voluntary)
Initiate By 2014 2016
Carrots 2011-2016 2011-2021
Sticks 2015 (1%), 2016 and on (2%) None Federally Mandated
By year one… Demonstrate MU 90 days A/I/U (Adopt, Implement, Upgrade)
Maximum EP Incentive $44,000 (HPSA Bonus) $63,750
Rule Variance None State Specific
Eligible Providers physicians, subsection (d) 5 types of EPs, acute care hospitals,
hospitals and CAHs CAHs, and children‟s hospitals
32

33. Overview - Requirements
EPs
80% of 15 Core + 3 Core + 3
Certified Alternative Meaningful
Patient 5 Menu
EHR Use
Records Objectives CQM
Hospitals
80% of 14 Core + 5 15
Certified Meaningful
Patient Menu
EHR CQM Use
Records Objectives

34. Overview - Pursuit and Achievement
Providers Planning to Pursue Providers who will Achieve
Graph Source: HIMSS Analytics Survey, September
2010, http://www.himss.org/content/files/vantagepoint/vanta
gepoint_201009.asp?pg=1

35. Overview
Current Sentiments on Adoption
Satisfied Neutral Unsatisfied
will achieve MU
could achieve if systems
14%
23% 22% asdfasdfasdf are fully utilized.
31%
15%
34% 36%
30%
72%
40% 42% 39%
Overall Satisfaction Decreases Costs Increase Revenue Increase Productivity
Source: MGMA Study, April 6, 2011, http://www.mgma.com/press/default.aspx?id=1248514, n= 4588, representing
practices/organizations with 120,000 physicians, online survey

36. The Point…
• This was only the first stage
– Stages Two: expected 2011, menu set becomes core, new
parameters, more HIE, device guidelines
– Stage Three: expected 2013, likely more patient access
• Using Electronic Health Records Meaningfully will (hopefully) lead
to:
– better clinical outcomes for patients
– Less waste
– Less fraud and abuse
– Better ROI
– Reduce health disparities and improve public health
– Engage patients and family

37. Why we need Meaningful Use
RCM eRX
RCM mHealth
PHR EHR #2 CDS
CDS EHR #1 PHR Health
Labs
Information
Lab Exchange
eRX
Lab
PHR
Community
Health
Record