RIAHQ Third Annual Quality Education Day October 20, 2010

1. RIAHQ Third Annual Quality Education DayOctober 20, 2010 Meaningful Use Carole M. Cotter Senior Vice President and Chief Information Officer Lifespan

2. Main Objective Demonstrate that �Meaningful Use� is a driver for organizations to improve quality and outcomes �Meaningful Use� requires an electronic clinical documentation process using standard nomenclature and structured data formats real time, enabling sharing of clinical data and use of the data for decision making during the care delivery process �Meaningful Use� requires caregivers to share clinical information electronically with each other and with the patient �Meaningful Use� quality indicators are derived from a certified electronic health record and reported to CMS to measure organizations� ability to use data to improve quality

3. Meeting the Goal of Meaningful Use What is Meaningful Use? Why is it a Quality Initiative? Focus on Quality Measures

4. Meaningful Use American Recovery and Reinvestment Act of 2009 and its Title XIII, Health Information Technology for Economic and Clinical Health (ARRA/HITECH) �February 2009 Leading Edge of Healthcare Reform Meaningful Use Framework and Matrix � June 2009 followed by comment period Proposed Rule containing definition of �meaningful use� of health information technology - December 30, 2009 followed by comment period Final Rule � July 13, 2010

5. Stage 1 - Requirements Stage 1 begins in 2011 Goals for Meaningful Use criteria: ��focuses on electronically capturing health information in a structured format; using that information to track key clinical conditions and communicating that information for care coordination purposes�implementing clinical decision support tools�engage patients and families�and reporting clinical quality measures and public health information.�

6. Stage 2 � Minimal Outline Stage 2 begins in 2013 � to be proposed by end of 2011 � Decision Support Meaningful Use criteria: ��encourage use of health IT for continuous quality improvement at the point of care and the exchange of information�� �Rigorous expectations for health information exchange� �more demanding requirements for e-prescribing and incorporating structured laboratory results� �Electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings and EHR systems� information follows the patient� Anything optional in Stage 1 will likely be required in Stage 2 and thresholds will be reevaluated

7. Stage 3 � Minimal Outline Stage 3 begins in 2015 � to be proposed by end of 2013 � Improved Outcomes Meaningful Use criteria: ��promoting improvements in quality, safety and efficiency leading to improved health outcomes�� �Focusing on decision support for national high priority conditions� �Patient access to self management tools� �Access to comprehensive patient date through robust, patient-centered health information exchange� �Improving population health�

8. Meaningful Use: Incentives and Penalties Hospitals: Payments in years 2011�2016 based on Medicare and Medicaid volume, subject to transition factor Penalties in year 2015 For hospitals 2011 begins October 2010

9. Medicaid Eligible Provider

10. Institute of Medicine � Six Aims for Healthcare Quality Improvement Safe Timely Effective Efficient Equitable Patient Centered Crossing the Quality Chasm, Institute of Medicine, 2001

11. Federal Outcomes Policy Priorities � consistent with those of IOM and the Lifespan Hospitals Improve quality, safety, efficiency, and reduce health disparities Engage patients and families Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information Source: HIT Policy Committee, HITECH Standards Committee Quality Workgroup

12. Meaningful Use Criteria

13. Meaningful Use Criteria for Stage 1 � Hospitals 2011 � Core Set � includes ED Use of CPOE for orders � by licensed healthcare professionals � at least 1 medication order for 30% unique patients Implement drug-drug, drug-allergy interaction checks Record demographics: preferred language, gender, race, ethnicity, DOB, DOD and cause � more than 50% of all unique patients have in structured data Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT � more than 80% of all unique patients have at least one entry or designation of none as structured data Maintain active medication list � more than 80% of all unique patients have at least one entry or designation of none as structured data Maintain active medication allergy list � more than 80% of all unique patients have at least one entry or designation of none as structured data Record and chart changes in vital signs: height, weight, BP, BMI, growth charts 2-20 yrs � more than 50% of all unique patients over 2 as structured data Record smoking status, 13 or older � more than 50% of all unique patients have smoking status recorded as structured data Implement 1 clinical decision support rule related to a high priority hospital condition, along with the ability to track compliance with that rule Report hospital quality measures to CMS or the States � for 2011 aggregate numerator, denominator and exclusions through attestation, 2012 submit electronically Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summaries, procedures) upon request � more than 50% of all patients who request, provide within 3 business days Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request � more than 50% of all discharged patients who request Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically � at least one test of certified EHR technology�s capacity to electronically exchange key clinical information Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities � security risk analysis per 45 CFR 164.308(a)(1) and remediation

14. Meaningful Use Criteria for Stage 1 � Hospitals 2011 � Menu Set � Choose 5 , 1 of which Addresses Population and Public Health Implement drug-formulary checks Record advance directives for patients 65 years old or older-more than 50% of all unique patients 65yrs or older have indication of advance directive recorded Incorporate clinical lab-test results into EHR as structured data � more than 40% of clinical lab results Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach � at least one report Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate-more than 10% of unique patients Perform medication reconciliation at relevant encounters and each transition of care � more than 50% of patients Provide summary care record for each transition of care and referral � more than 50% of transitions of care and referrals Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice � at least one test of certified EHR technology�s capacity to submit electronic date to immunization registries Capability to submit electronic submission of reportable lab results (as required by state or local law) to public health agencies and actual submission in accordance with applicable law and practice � at least one test of certified EHR technology�s capacity to submit electronic reportable lab results Capability to submit electronic syndromic surveillance data to public health agencies and actual transmission in accordance with applicable law and practice - at least one test of certified EHR technology�s capacity to provide , unless it cannot be received

15. Meaningful Use Criteria for Stage 1 � Eligible Providers 2011 � Core Set Use of CPOE for orders � by licensed healthcare professionals � at least 1 medication order for 30% unique patients Implement drug-drug, drug-allergy interaction checks Generate and transmit permissible prescriptions electronically (eRX) � more than 40% of all permissible prescriptions Record demographics: preferred language, gender, race, ethnicity, DOB � more than 50% of all unique patients have in structured data Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT � more than 80% of all unique patients have at least one entry or designation of none as structured data Maintain active medication list � more than 80% of all unique patients have at least one entry or designation of none as structured data Maintain active medication allergy list � more than 80% of all unique patients have at least one entry or designation of none as structured data Record and chart changes in vital signs: height, weight, BP, BMI, growth charts 2-20 yrs � more than 50% of all unique patients over 2 as structured data Record smoking status, 13 or older � more than 50% of all unique patients have smoking status recorded as structured data Implement 1 clinical decision support rule relevant to specialty or high clinical priority, along with the ability to track compliance with that rule Report ambulatory quality measures to CMS or the States � for 2011 aggregate numerator, denominator and exclusions through attestation, 2012 submit electronically Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request � more than 50% of all patients who request, provide within 3 business days Provide clinical summaries for patients for each office visit � more than 50% of all office visits within 3 business days Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically � at least one test of certified EHR technology�s capacity to electronically exchange key clinical information Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities � security risk analysis per 45 CFR 164.308(a)(1) and remediation

16. Meaningful Use Criteria for Stage 1 �Eligible Providers 2011 � Menu Set � Choose 5, 1 of which Addresses Population and Public Health Implement drug-formulary checks Incorporate clinical lab-test results into EHR as structured data � more than 40% of clinical lab results Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach � at least one report Send reminders to patients per patient preference for preventive/follow-up care � more than 20% of all unique patients 65 years or older or 5 years old or younger Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within 4 business days of the information being available to the EP � more than 10% of all unique patients seen subject to discretion of EP to withhold certain information Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate-more than 10% of all unique patients Perform medication reconciliation at relevant encounters and each transition of care � more than 50% of patients Provide summary care record for each transition of care and referral � more than 50% of transitions of care and referrals Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice � at least one test of certified EHR technology�s capacity to submit electronic date to immunization registries Capability to submit electronic syndromic surveillance data to public health agencies and actual transmission in accordance with applicable law and practice - at least one test of certified EHR technology�s capacity to provide , unless it cannot be received

17. Meaningful Use Criteria for Stage 1Measures with a Denominator of Unique Patients Regardless of Whether the Patient�s Records are Maintained Using Certified EHR Technology Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT � more than 80% of all unique patients have at least one entry or designation of none as structured data Maintain active medication list � more than 80% of all unique patients have at least one entry or designation of none as structured data Maintain active medication allergy list � more than 80% of all unique patients have at least one entry or designation of none as structured data Record demographics: preferred language, gender, race, ethnicity, DOB � more than 50% of all unique patients have in structured data. Add DOD and Cause for Eligible Hospitals. Optional: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within 4 business days of the information being available to the EP � more than 10% of all unique patients seen subject to discretion of EP to withhold certain information Optional: Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate-more than 10% of all unique patients

18. Meaningful Use Criteria for Stage 1Measures with a Denominator Based on Counting Actions for Patients whose Records are Maintained Using Certified EHR Technology Use of CPOE for orders � at least 1 medication order for 30% unique patients Generate and transmit permissible prescriptions electronically (eRX) � more than 40% of all permissible prescriptions Record and chart changes in vital signs: height, weight, BP, BMI, growth charts 2-20 yrs � more than 50% of all unique patients over 2 as structured data Record smoking status, 13 or older � more than 50% of all unique patients have smoking status recorded as structured data Optional: Record advance directives for patients 65 years old or older-more than 50% of all unique patients 65yrs or older have indication of advance directive recorded Optional: Incorporate clinical lab-test results into EHR as structured data � more than 40% of clinical lab results Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request � more than 50% of all patients who request, provide within 3 business days Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request � more than 50% of all discharged patients who request Provide clinical summaries for patients for each office visit � more than 50% of all office visits within 3 business days Optional: Send reminders to patients per patient preference for preventive/follow-up care � more than 20% of all unique patients 65 years or older or 5 years old or younger Optional: Perform medication reconciliation at relevant encounters and each transition of care � more than 50% of patients Optional: Provide summary care record for each transition of care and referral � more than 50% of transitions of care and referrals

19. Meaningful Use Criteria for Stage 1Measures Requiring Only a Yes/No Attestation Implement drug-drug, drug-allergy interaction checks Optional: Implement drug-formulary checks Optional: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach � at least one report Implement 1 clinical decision support rule relevant to specialty or high clinical priority, along with the ability to track compliance with that rule Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically � at least one test of certified EHR technology�s capacity to electronically exchange key clinical information Optional: Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice � at least one test of certified EHR technology�s capacity to submit electronic date to immunization registries Optional: Capability to submit electronic submission of reportable lab results (as required by state or local law) to public health agencies and actual submission in accordance with applicable law and practice � at least one test of certified EHR technology�s capacity to submit electronic reportable lab results Optional: Capability to submit electronic syndromic surveillance data to public health agencies and actual transmission in accordance with applicable law and practice - at least one test of certified EHR technology�s capacity to provide , unless it cannot be received Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities � security risk analysis per 45 CFR 164.308(a)(1) and remediation

20. CPOE An Example of the Quality Effect

21. CPOE In Context Responsive to external drivers in healthcare environment Institute of Medicine Reports � CPOE prevents errors Health Care Reform Meaningful Use � Improve quality, safety and efficiency Declining Hospital Reimbursement � Errors are costly Directly supports organization�s strategic plan Align physicians� interests Improve health status of community Financial viability CPOE reduces �Slips��of the pen and the tongue Use of pick lists (drug, dose, frequency) Decimal points Units Misspelled sound alike / look alike drugs Avoids transcription errors Eliminates confusion due to spelling Entry from home or office reduces verbal orders CPOE reduces �Lapses� � failure to perform a process that is normally performed Drug-allergy checking Drug-drug interaction checking Checking lab results against given drug Check dosage against age/size Discharge orders based on diagnosis / age CPOE reduces �Mistakes� � apply wrong process (treat patient for heartburn when they have heart attack) Physicians have most accurate and complete clinical information available - more likely to have the right diagnosis to pick the right process Alerts based on emerging clinical findings - quickly change course Rules engine prompts physician based on diagnosis or other problems Situation/disease based �order sets� for lab, radiology, pharmacy CPOE reduces �System failures� � compensates for communication failures Smoothly transmits order to appropriate place and insures that the order is responded to - the appropriate process takes place Bar coding and automated medication administration record assures �five rights� (patient, drug, dose, route, time) CPOE reduces �Slips��of the pen and the tongue Use of pick lists (drug, dose, frequency) Decimal points Units Misspelled sound alike / look alike drugs Avoids transcription errors Eliminates confusion due to spelling Entry from home or office reduces verbal orders CPOE reduces �Lapses� � failure to perform a process that is normally performed Drug-allergy checking Drug-drug interaction checking Checking lab results against given drug Check dosage against age/size Discharge orders based on diagnosis / age CPOE reduces �Mistakes� � apply wrong process (treat patient for heartburn when they have heart attack) Physicians have most accurate and complete clinical information available - more likely to have the right diagnosis to pick the right process Alerts based on emerging clinical findings - quickly change course Rules engine prompts physician based on diagnosis or other problems Situation/disease based �order sets� for lab, radiology, pharmacy CPOE reduces �System failures� � compensates for communication failures Smoothly transmits order to appropriate place and insures that the order is responded to - the appropriate process takes place Bar coding and automated medication administration record assures �five rights� (patient, drug, dose, route, time)

22. Provide and Explain the Evidence

23. Traditional Medication Administration Looking at this diagram we can see all the places where handoffs typically occur. Each is an opportunity for error.Looking at this diagram we can see all the places where handoffs typically occur. Each is an opportunity for error.

24. Computerized Physician Order Management Eliminated several handoffs. But we have significantly changed the nursing process, not improved it. They react. They need to know when a physician places an order and when a pharmacist dispenses. Pharmacy interface helps the pharmacy workflow. So they finally get on board.Eliminated several handoffs. But we have significantly changed the nursing process, not improved it. They react. They need to know when a physician places an order and when a pharmacist dispenses. Pharmacy interface helps the pharmacy workflow. So they finally get on board.

25. Closed Loop of Medication Safety We further change the nursing process. No real benefit for nursing until we do this step. Hopefully this is when they will be on board.We further change the nursing process. No real benefit for nursing until we do this step. Hopefully this is when they will be on board.

26. Results

27. Direct Benefits With CPOE, cycle time to first administration reduced from 90 minutes to 11 minutes With rules and alerts, preventing 4 high severity errors per day With Closed Loop in Place, preventing six identifications of wrong patient and twelve identifications of wrong drug, route, dose each day Reduction in rate of automatic dispensing overrides from 7.2% to 2.9% (formerly missing doses?)

28. Examples of Leveraged Benefits Use MAK in diagnostic procedure areas to document contrast media and do clinical checking Use CPOE and Data Warehouse to warn physicians ordering CT scans if patient has had excessive radiation Use electronic order data and MAK data for Meaningful Use indicators

29. CPOE � Foundation for Quality Improvement �Human beings, in all lines of work, make errors. Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.� . . . �It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives and meet the challenges ahead.� Source: IOM Report To Err Is Human-Building a Safer Health System Clinicians, vendors, IT working together. We can do it. We can improve the quality of care we provide to patients. But we must work together. Clinicians, vendors, IT working together. We can do it. We can improve the quality of care we provide to patients. But we must work together.

30. Quality Measures

31. Measure Process Workflow

32. Proposed Rule Affirmed Require electronic clinical quality reporting directly to CMS and States using certified Electronic Health Record in 2012 Report through attestation in 2011

33. What is the Requirement for Reporting to CMS Electronically?

34. What is the Mechanism for Reporting to CMS Electronically? Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Interim Final Rule, December 30, 2009, p.76-77.

35. 2011 � Clinical Quality Reporting through Attestation

36. Sample Health IT Functionality Measure Objective: #8 Incorporate clinical lab-test results into EHR as structured data Applies to: Eligible Hospital/Inpatient Facility Measure: At least 50 percent of all clinical lab tests results ordered by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data. Numerator: The numerator for this objective is the number of lab tests ordered during the EHR reporting period by authorized providers of the eligible hospital for patients admitted to an inpatient facility/department whose results are expressed in a positive or negative affirmation or as a number and are incorporated as structured data into certified EHR technology. Denominator: The denominator for this objective is the number of lab tests ordered during the EHR reporting period by authorized providers of the eligible hospital for patients admitted to an inpatient facility/department whose results are expressed in a positive or negative affirmation or as a number.

37. Sample Health IT Functionality Measure

38. Clinical Quality Measures for Electronic Submission� Hospitals 2011-2012 ED-1 NQF 0495 ED throughput � admitted patients Median time from ED arrival to ED departure for admitted patients ED-2 NQF 0497 ED throughput � admitted patients Admission decision time to ED departure for admitted patients Stroke-2 NQF 0435 Ischemic stroke � Discharge on anti-thrombotics Stroke-3 NQF 0436 Ischemic stroke � Anticoagulation for A-fib flutter Stroke-4 NQF 0437 Ischemic stroke � Thrombolytic therapy for patients arriving within 2 hours of symptom onset Stroke-5 NQF 0438 Ischemic or hemorrhagic stroke � Antithrombotic therapy by day 2 Stroke-6 NQF 0439 Ischemic stroke � Discharge on statins Stroke-8 NQF 0440 Ischemic or hemorrhagic stroke � Stroke Education Stroke-10 NQF 0441 Ischemic or hemorrhagic stroke � Rehabilitation Assessment VTE-1 NQF 0371 VTE prophylaxis within 24 hours of arrival VTE-2 NQF 0372 Intensive Care Unit VTE prophylaxis VTE-3 NQF 0373 VTE Anticoagulation overlap therapy VTE-4 NQF 0374 VTE Platelet monitoring on unfractionated heparin VTE-5 NQF 0375 VTE discharge instructions VTE-6 NQF 0376 VTE Incidence of potentially preventable VTE

39. Clinical Quality Measures for Electronic Submission� Eligible Providers 2011-2012

40. TABLE 6:Clinical Quality Measures for Submission by Medicare or Medicaid EPs for the 2011 and 2012 Payment Year � choose three PQRI 1 � Diabetes Hemoglobin A1c Poor Control PQRI 2 � Diabetes Low density Lipoprotein (LDL) Management and Control PQRI 3 - Diabetes Blood Pressure Management PQRI 5 � Heart Failure ACE Inhibitor or ARB Therapy for LVSD PQRI 7 � Coronary Artery Disease Beta Blocker Therapy for CAD Patients with Prior MI PQRI 111 � Pneumonia Vaccination Status for Older Adults PQRI 112 � Breast Cancer Screening PQRI 113 � Colorectal Cancer Screening PQRI 6 � Coronary Artery Disease Oral Antiplatelet Therapy Prescribed for Patients with CAD PQRI 8 � Heart Failure Beta Blocker Therapy for LVSD PQRI 9 � Anti-depressant medication management PQRI 12 � Primary Open Angle Glaucoma Optic Nerve Evaluation PQRI 18 � Diabetic Retinopathy Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy PQRI 19 � Diabetic Retinopathy Communication with the Physician Managing Ongoing Diabetes Care PQRI 53 � Asthma Pharmacologic Therapy PQRI 64 � Asthma Assessment PQRI 66 � Appropriate Testing for Children with Pharyngitis PQRI 71 � Oncology Breast Cancer Hormonal Therapy for Stage IC-IIIC ER/PR Positive Breast cancer PQRI 72 � Oncology Colon Cancer Chemotherapy for Stage III Colon Cancer Patients PQRI 102 � Prostate Cancer Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients PQRI 115 � Smoking and Tobacco Use Cessation Medical Assistance PQRI 117 - Diabetes Eye Exam PQRI 119 � Diabetes Urine Screening PQRI 163 � Diabetes Foot Exam PQRI 197 � Coronary Artery Disease Drug Therapy for Lowering LDL PQRI 200 � Heart Failure Warfarin Therapy Patients with Atrial Fibrillation PQRI 201 � Ischemic Vascular Disease Blood Pressure Management PQRI 204 � Ischemic Vascular Disease Use of Aspirin or Another Antithrombotic NQF 0004 � Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NQF 0012 � Prenatal Care Screening for HIV NQF 0014 � Prenatal Care Anti-D Immune Globulin NQF 0018 � Controlling High Blood Pressure NQF 0032 � Cervical Cancer Screening NQF 0033 - Chlamydia Screening for Women NQF 0036 � Use of Appropriate Medications for Asthma NQF 0052 - Low Back Pain Use of Imaging Studies NQF 0075 - Ischemic Vascular Disease Complete Lipid Panel and LDL Control NQF 0575 � Diabetes Hemoglobin A1c Control (<8.0%)

41. Current Quality Reporting Meaningful Use Clinical Quality Measures do not replace any other reporting at this time. In 2011 we attest that we can generate them electronically from a certified EHR, if we can. We do not send them to CMS until 2012. All current quality reporting mechanisms stay in place and grow as new requirements are issued

42. Current Quality Reporting Meaningful Use Clinical Quality Measures do not replace any other reporting at this time. In 2011 we attest that we can generate them electronically from a certified EHR, if we can. We do not send them to CMS until 2012. All current quality reporting mechanisms stay in place and grow as new requirements are issued

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45. Questions?