Medicare & Medicaid EHR Incentive Program Final Rule

1. Medicare & Medicaid EHR Incentive Program Final Rule Implementing the American Recovery and Reinvestment Act of 2009 Presented by: Kevin R. Burchill, Esq., FACHE Director Date: August 19, 2010

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 and Did Not Change Did Change • MU 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 Did Not Change • Adopted statutory provider eligibility and payment requirements • MU Matrix Goals • Hospital Definition • EPs must demonstrate MU • Clinical Quality Reporting Timeline

4. 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)

5. 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

6. 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

7. 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.

8. Meaningful Use: Changes from the NPRM to the Final Rule

9. Meaningful Use: Changes from the NPRM to the Final Rule (cont’d)

10. 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 commenter's

11. 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 • Example: Dentists who do not perform immunizations; Chiropractors do not e-prescribe

12. How Were 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 commenter's regarding non-participation by pharmacies and patient preference

13. Meaningful Use – Stage 1 Core Set

14. Meaningful Use – Stage 1 Core Set (cont’d)

15. Meaningful Use – Stage 1 Core Set (cont’d)

16. Meaningful Use – Stage 1 Menu Set

17. Meaningful Use – Stage 1 Menu Set (cont’d)

18. Meaningful Use – Stage 1 Menu Set (cont’d)

19. 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

20. 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)

21. 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

22. 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)

23. 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. • 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.

24. CQM: Eligible Professionals • Core, Alternate Core, and Additional CQM sets for EPs • EPs must report on 3 required core CQM. 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

25. CQM: Core Set for EPs

26. CQM: Alternate Core Set for EPs

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

28. CQM: Additional Set for EPs (cont’d) • Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients • 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 • Diabetes: Eye Exam • Diabetes: Urine Screening • Diabetes: Foot Exam • Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol • Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation • Ischemic Vascular Disease (IVD): Blood Pressure Management • Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement • Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) • Prenatal Care: Anti-D Immune Globulin • Controlling High Blood Pressure • Cervical Cancer Screening • Chlamydia Screening for Women • Use of Appropriate Medications for Asthma • Low Back Pain: Use of Imaging Studies • Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control • Diabetes: Hemoglobin A1c Control (<8.0%)

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

30. Participation in HITECH and other Medicare Incentive Programs for EPs

31. 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 begin a month following the start of attestations • 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

32. Questions Regarding the Regulation • CMS website http://www.cms.gov/EHRIncentivePrograms • CMS subject matter experts will be working with ONC and the states to do webinars and other information sessions to help answer questions • CMS will develop FAQs to respond to various questions and provide toolkits and other materials to assist providers • CMS will issue additional guidance on how to register and attest to meaningful use • Requirements in the regulation can only be modified through further rulemaking

33. So, what are we to do next? Internal approach to Readiness Assessment

34. Leadership

35. Top CEO Issues • The American College of Healthcare Executives’ annual survey asked CEOs to identify their top three issues *New issues added for 2009 Source: American College of Healthcare Executives

36. Project Management Methodology

37. Challenges Financial Access to capital Sustainable model Technical Integration with legacy systems Security and privacy Data management • Political • Champions • Supportive environment • Organizational • Governance • Shared goals and objectives • Operating rules

38. Self-Assessment • Who should we be aligned with to move our vision, mission and values forward? • Where can we best contribute to the improvement efforts, quality, care and safety? • What are the timelines and milestones to which our organization must strive to achieve meaningful use? • How will our organization differentiate in the market place?

39. Clinical IT Adoption Process Go-Live Support / Improvement Planning Design Implementation Training

40. Clinical IT Adoption • Have your organizational goals and expected results for the clinical IT project been identified in the planning stage? • Speed Bump: A project that has not involved both the executive leadership and clinicians in setting a vision is initially set up as just another IT project • Is your organization designing the system from the clinician perspective? • Speed Bump: It is well documented that attempts to implement a system by excluding clinicians in the design phase can lead to resentment, lack of confidence in the organization and counter-productive behaviors that will challenge the success of the project

41. Clinical IT Adoption (cont.) • Have you incorporated a formalized project charter into your implementation process, identifying challenges and overcoming obstacles? • Speed Bump: Without a formalized process it is difficult for clinicians to recognize that the clinical implementation project represents a true commitment to success • What is your training approach; do you have different models for different roles in your organization? • Speed Bump: Physicians have rigorous time restraints; therefore the lack of adequate staff and planning for one-on-one physician training will decrease willingness for physicians to adopt the system

42. Clinical IT Adoption (cont.) • Have you built in adequate time and resources for your Go-Live and Support phase with the clinicians’ day-to-day routine in mind? • Speed Bump: Clinician buy-in will dramatically drop at this juncture if the process does not adequately sustain clinician use with day-to-day support and incorporate feedback to further improve the system, producing greater benefits for the clinician, the organization and the patients

43. Next Steps in the Journey Towards Meaningful Use

44. Linear View of MU Assessment

45. Assessment Matrix • Technology Platforms and Applications Review • Capital Budget Planning and Prioritization • IT Staffing Plan Review • Physician Alignment Summary • On-Site Interview Notes • Other Operational Considerations • Privacy and Security Overview • HIE

46. Other Considerations • Calculate ARRA Incentives • Define IT Projects in Relation to MU grid • Complete GAP Analysis • Prioritize Capital and Operational Investment

47. Important Areas of Focus • Vendor Sustainability and Focus • Patient Throughput and Clinical Integration • Quality Reporting • Capital Spending and Incentive Reimbursements

48. Questions & Answers Interactive Session

49. Thank You! Kevin R. Burchill, Esq., FACHE kburchill@beaconpartners.com