Overcoming Barriers to Meaningful Use of EHR Technology in the U.S.

1. Meaningful Use of EHR Technology Joseph Francis, MD, MPH Director, Clinical Analysis and Reporting Office of Informatics and Analytics

2. Barriers to Adopting EHR in the U.S. • Economics of Fee-for-Service Healthcare • Daunting for most practices and hospitals • Most practices are “small businesses” so risk is too high • EHR is not enough to promote health information exchange • fax machine analogy • Concerns about privacy and security

3. Poll Question In 2008, only 17% of physicians and 12% of hospitals used EHRs • True • False

4. “Meaningful Use” • Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) • Part of the American Recovery and Reinvestment Act (“Stimulus Bill”) • Meant to promote adoption & use of EHR through financial incentives & other forms of support • $29 Billion investment • $27 Billion for Medicare and Medicaid incentive payments • $2 Billion for grants in support of EHR adoption

5. Balancing Act • Congress could have simply created a mechanism to pay for the purchase of an EHR • But…no guarantee it would be used effectively OR … • Congress could have given extra dollars for better patient outcomes • But…no guarantee of a consistent approach across the nation

6. Poll Results

7. Meaningful Use – simply defined

8. At a Minimum, Congress wanted: • Electronic prescribing • Health information exchange among providers • Electronic reporting of Clinical Quality Measures (CQMs) • Other requirements deemed essential for quality, safety, and efficiency • Progressive increase in requirements over time

9. Meaningful Use is using a Certified EHR to: • Improve quality, safety, and efficiency • Reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health • All the while maintaining privacy and security

10. Meaningful Use – A Work in Progress • Huge undertaking for HHS & U.S. • U.S. needs approx 50,000 health information professionals to implement nationwide EHR • ONC had only 35 FTE at time of launch • Definitions and standards still evolving • HHS Revised Final Rule, July 2010 (Stage 1) • Notice of Proposed Rulemaking for Stage 2, January 2011 • Stage 3 discussions underway • Much ongoing work on S&I

11. Stage 3 2015+ Stage 2 2013-14 Stage 1 2011-12 Stages of Meaningful Use

12. Meaningful Use Stage 1 Objectives

13. EHR Support Provisions in HITECH • Beacon Community Program • Grants for State Health Information Exchange programs • Grants for Health IT Regional Extension Centers • Strategic Health IT Advanced Research Projects • Health IT Education to build capacity: • Community College consortia • Curriculum development centers • Assistance for University-based training • Health IT competency exams

14. HITECH Framework

15. Privacy and Security Provisions • Increased reporting requirements and penalties under HIPAA for breaches • Up to $1.5 million per violation • Restricts use of EHR for marketing or fund raising • Authorizes ONC to develop additional approaches to consumer control over health information

16. “Certification” • “Consumer protection” for prospective buyers • Means EHR has passed basic tests of MU capability • May be complete or modular • 6 organizations have been granted ability to certify • Certification is NOT a guarantee of ease or success

17. Poll Question As of June 2012, there were over 1000 certified complete Electronic Health Records • True • False

18. Certification Process Creates requirements for incentive payments Defines requirements for Certification and Meaningful Use Develops EHR Certification Test requirements, cases, & tools Authorized Testing and Certification Body

19. The Incentive for Meaningful Use: $$$$ • CMS pays hospitals and providers extra when they demonstrate meaningful use • Hospitals can get both Medicare and Medicaid $ • Professionals can get either Medicare or Medicaid $ • Incentives begin 2011 and end after 5th year • Max. $44,000/provider (Medicare), $63,750 (Medicaid) • After 2015, Medicare will reduce payment to hospitals and professionals that do not demonstrate MU • Attestation and audits

20. Poll Results

21. Concerns about Meaningful Use • Multiple concurrent health information initiatives • Workload demands • Usability Concerns • Inadequacy of current CQMs: • Privacy and Security

22. Overlapping Timelines: FY 2011 FY2012 FY2013 FY2014 FY2015 FY2016 5010 Standards ICD-10 Implementation Health Reform/Value Based Purchasing EHR Meaningful Use HIPAA Privacy Changes

23. Balancing the Standards Innovation & Usability Standardization & Interoperability

24. Frustration among EHR Users

25. Clinical Quality Measures (CQMs)

26. Examples of Clinical Quality Measures • Percent of: • HTN pts with BP < 140/90 • pts screened for tobacco use AND offered cessation counseling • women receiving mammogram • adults receiving colorectal cancer screening • women receiving screening and therapy for osteoporosis • older patients screened for falls

27. Clinical Quality Measures - Concerns • Lack of measure harmonization • Capturing concepts electronically is not trivial • Many measures lack “e-Specification” • “Hard wiring” limits future flexibility • Patient risks, preferences, & transitions in care not addressed • “Measure button” not enough • Need validation and audit • Few “patient centered” measures • Patient Reported Outcomes still in their infancy

28. Privacy and Security • HIPAA and HITECH are not aligned with current “best practices” in information security • NIST standards • ISO standards • Requirements are falling behind the rapid advances in technology (e.g., mobile apps; social networking)

32. Progress in EHR Adoption

33. Slow Growth in Functionality

34. Incentives for VA • VA is not eligible for Meaningful Use $$ • OMB and White House CTO require all Federal agencies to support universal attainment of Meaningful Use

35. Real Reason for Meaningful Use in VA • Maintain our leadership position in Health IT • Share health information across providers and systems!! • Improve safety, efficiency, effectiveness • Assist our Clinical Partners to implement EHR • Public health and clinical quality reporting

36. Poll Question Meaningful Use supports our Core Values of Integrity, Commitment, Advocacy, Respect, and Excellence • True • False

37. Status of VA EHR System Passing Stage 1 Certification

38. Meaningful Use: Milestones As of 08/02/2012 12/31/2012 09/30/2012 Completed On Schedule At Risk Late Major Deliverables 2010 2011 2012 2013 Stage 1 EHR gap analysis completed 08/05/2011 05/24/2012 12/31/2010 5/31/2011 Business Requirement Document Submitted CCHIT Certification Contract Passed Security Certification Certification of Additional Modules Stage 2 Gap EHR Gap Analysis PRE-DECISIONAL DRAFT VHA/OHI/CHIO

39. Poll Results

40. Standards & Interoperability • CDA consolidation - will be used in MU Stage2 • Model Driven Health Tool (MDHT) will simplify future EHR certification validation & help VLER Health partners meet the requirements of health information exchange • Lead (with DoD) on Common Information Interoperability Framework development • Pilot project mapping 3M Data Dictionary System SNOMED terminology for data compatibility testing with DoD • VistA security certification May, 2012

41. Patient-centered aspects of MU • Comprehensive health data available to care team • Clinical decision support at the point of care • Generate lists of patients needing care, education & outreach (e.g. reminders, care instructions) • Report information for QI & public health • Provide patients and families with timely access to data to make informed decisions and manage their health • Exchange meaningful clinical information among professional health care team • Ensure privacy and confidentiality

42. Stage 2 of Meaningful Use • For years 2014 – 2015 • New and revised certification criteria, performance measures and clinical quality measures • Final rule should be issued in August 2012 • A gap analysis of the MU requirements against VA’s EHR system will be performed • Gaps will become iEHR project requirements

44. Resources Office of the National Coordinator for Health IT: healthit.hhs.gov Centers for Disease Control (Public Health options): cdc.gov/EHRmeaningfuluse Centers for Medicare & Medicaid Services: cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms National Institute of Standards & Technology: healthcare.nist.gov/use_testing Indian Health Service: ihs.gov/meaningfuluse Health Information and Management Systems Society: himss.org/ASP/topics_meaningfuluse.asp National Quality Forum: qualityforum.org/HealthIT

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