The California HIT Landscape and the EHR Meaningful Use Incentives July 30, 2010

1. The California HIT Landscape and the EHR Meaningful Use IncentivesJuly 30, 2010 Andie Martinez Associate Director of Policy California Primary Care Association

2. Overview Federal chain of command HIE Regional Extension Centers EHR Loan Fund Broadband/Telehealth EHR and meaningful use

3. HHS Secretary Reviews ONC endorsements and approves adoption; Collaborates with CMS in the rule making process Federal Chain of Command Office of the National Coordinator • $2 billion • Regional Extension Centers • EHR Loan Fund • Health Information Exchange • $34 billion • Medicare/Medicaid EHR incentives for meaningful use CMS 3

4. Federal to State to Provider Flow of Funds Office of the National Coordinator • $2 billion • Regional Extension Centers • EHR Loan Fund • Health Information Exchange • $34 billion • Medicare/Medicaid EHR incentives for meaningful use CMS • Regional Extension Centers • CalHIPSO • LA Care • EHR Loan Fund • On hold • Health Information Exchange • Cal eConnect (State designated entity) • Medicare Incentives • Eligible providers who choose the Medicare m.u. $$ • Medicaid Incentives • State Medicaid Offices Local Extension Centers Service Providers Eligible professionals Local health information organizations 4

5. Health Information Exchange General Overview • Only states or state designated entities can apply for funding • All states have an allocation based on size • California has begun the process to apply for $38.8 million • Jonah Frohlich, Deputy Secretary of HIT, is in charge of HIE for California • Cal eConnect was chosen as the State Designated Entity • ONC must approve the Strategic and Operational plan in order to receive the full $38.8 million

6. Health Information Exchange HIE Operational Plan • Cal eConnect • Will oversee and manage the HIE build out in California • Will use majority of funds for grants to existing and new health information exchanges • Shared services • In the proposed operational plan there is a provider to provider look-up, no patient look-up

7. Health Information Exchange What will HIE Governance Entity do?

8. Regional Extension Centers General Overview • 60 nationwide, in two rounds of funding (totaling $640 million). • US-based nonprofit organization. • Must be a multi-stakeholder collaborative. • Must serve at least 1,000 Priority Primary Care Providers (PPCPs). • Cannot overlap with another REC. • Purpose: Deliver outreach, education, and technical assistance services to PPCPs to facilitate their adoption of certified EHRs and achievement of meaningful use • Disseminate best practices and education

9. Regional Extension Centers CalHIPSO • Awarded $31 million • Northern California • Total REC PPCPs - 4094 • Southern California • Total REC PPCPs – 3350 LA Care • Serving only LA County • Awarded $15.5 million to serve approximately 3,000 PPCPs

10. EHR Loan Fund General Overview • Written into HITECH as a “may” • ONC has decided not to fulfill this provision as of now What is CPCA doing? • CPCA working with CHFFA to create an EHR loan program • Concept • No interest, revolving loan • Apply for as much as you could receive in incentives • Paid back upon receipt

11. Broadband and Telehealth General Overview • NOT a HITECH Grant • California Telehealth Network awarded vendor contract to AT & T • Just announced the Interim Executive Director- Eric Brown • 863 sites • Dedicated broadband network • Still determining what value-added services to run over the network

12. Broadband and Telehealth CTN Pricing

13. Electronic Health Records and Incentive Funds General Overview: Federal • Approximately $34 billion for Medicare/Medicaid EHR Incentive Funds • CMS developing rules and regulations on incentive funds • ONC developing rules on standards and HIT certification • Eligible professional must choose Medicare or Medicaid incentive program (before CY 2015) • Medicare incentives must start October 1, 2010, but no date in statute for when Medicaid incentives must start (expected January 2011)

14. Electronic Health Records and Incentive Funds General Overview: California (Medi-Cal) • CA eligible professionals (EPs) expected to receive $1.5 billion in Medicaid EHR incentives • Incentive funds for EPs will flow through DHCS (state Medicaid office) and 100% of the funds must be distributed to providers • State Medicaid offices are eligible for a 90/10 match for administrative work related to EHR incentives. DHCS has received $2.5 million. • Created Office of Health Information Technology (OHIT) • HITECH Advisory Group • 2 Clinic/Health Center representatives on Advisory Group: CPCA and Dr. Moore, Medical Director for Clinic Ole/ RCHC • State Medicaid offices will get to set some parameters for how the funding is distributed, reporting, and measures

16. Eligible Professionals in the Medicaid Program • Who are Eligible Professionals? • Non-hospital based • Physicians (doctors of medicine or osteopathy), • Dentists, • Certified nurse-midwives, • Nurse practitioners, and • Physician assistants who are practicing in a Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) led by a physician assistant. ** None in CA

17. Eligible Professionals in the Medicaid Program • Who are Eligible Professionals? • Who have at least 30% of their patient volume (encounters) attributable to Medi-Cal, or • Who is a pediatrician and who has at least 20% of their patient volume (encounters) attributable to Medi-Cal, or • Who practices predominantly at an FQHC or RHC and has at least 30% of their patient volume (encounters) attributable to “needy” individuals. • Needy patients receive medical assistance from Medi-Cal or Healthy Families, are furnished uncompensated care by the provider, or are furnished services at either no cost or reduced cost based on a sliding scale determined by the individual’s ability to pay. • Over any continuous 90-day period within the most recent calendar year prior to reporting. • Practices Predominantly- An EP practices predominantly at an FQHC or an RHC when the clinical location for over 50 percent of his/her patient encounters over a period of 6 months in the most recent calendar year occurs at the FQHC or RHC. If the pediatrician can only reach the 20% he/she is eligible for 2/3 of the amount of incentives, but if the pediatrician can reach the 30% then he/she is eligible for the full amount.

18. Getting the first year of payment An EP must submit the following: • Name of EP • National Provider Identifier (NPI) • Business address and phone number • Taxpayer Identification Number (TIN) which may be the EP’s Social Security Number (SSN) to which the EP’s incentive payment should be made. • EPs are permitted to reassign their incentive payments to their employer or to an entity with which they have a contractual arrangement allowing the employer or entity to bill and receive payment for the EP’s covered professional services. • EPs may also assign their incentive payments to a TIN for an entity promoting the adoption of EHR technology • Each EP may reassign the entire amount of the incentive payment to only one employer or entity. • If you qualify as both a Medicare EP and a Medicaid EP you must tell CMS which program you choose

19. Getting the first year of payment AND attest to one of the following: • Adopting/implementing/upgrading an EHR • Adopting: acquire, purchase or secure access to certified EHR technology • Implementing: install or commence utilization of certified EHR technology capable of meeting meaningful use requirements • Upgrading: expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology per the ONC EHR certification criteria. • THERE IS NO REPORTING PERIOD • Achieving the meaningful use objectives and clinical measures over a continuous 90 day period within a calendar year.

20. Getting the second year of payment The EP must re-attest to the patient volume criteria and • If the EP chose to A/I/U in the first payment year, he/she must now report on the meaningful use objectives and measures over a continuous 90 day period within the calendar year. The third and remaining years (up to 6) of participation will require a full calendar year of reporting. B. If the EP chose to attest to achieving meaningful use in the first year of payment, the EP must report on meaningful use for a full calendar year. The EP is required to report on a full calendar year for the remaining years (up to 6) of participation. Participation in the Medicaid Meaningful Use EHR program does not need to be consecutive. An EP can participate in 2011 and postpone until 2013. EP can only receive 6 years of payment for a total of $63,750.

21. Eligible Professionals in the Medicaid Program • Encounters to report • To be a meaningful EHR user an EP must have 50 percent or more of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR • technology. • An EP for who does not conduct 50 percent of their patient encounters in any one practice/location would have to meet the 50 percent threshold through a combination of • practices/locations equipped with certified EHR technology. • As long as an EP has certified EHR technology available for 50 percent or more of their patient encounters during the EHR reporting • period they only have to include those encounters where certified EHR technology is available at the start of the EHR reporting period.

22. Meaningful Use Incentives • Costs • Incentives are not based on the cost of purchasing EHR technology. As long as a EP meets all necessary requirements for qualifying for incentive payments, they may receive the maximum allowed amount regardless of what their EHR technology or implementation costs were. • Net average allowable costs are 85% of $25K for the first year, and 85% of $10K for 5 subsequent years • Incentive funds are directed at providers, not clinics or health centers • Funds from federal government received by clinic or FQHC do not count against incentive payments an EP can receive.

23. Meaningful Use Stages and Final Rule • Stage 1 • Electronically capturing health information in a coded format, • Using that information to track key clinical conditions and communication for care coordination purposes • Reporting clinical quality measures and public health information. • Stage 2 • Health information exchange in the most structured format possible, • Example: computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis) • There will likely be a Stage 3

24. Meaningful Use Stages

25. Meaningful Use Stages and Final Rule • Stage 1 • Must report on 15 core objectives and associated measures and 5 objectives and associated measures from the menu set; 1 measure from the menu set must be related to public health. • * Expect all of the menu set objectives to be included in Stage 2 • Additionally, EPs must report on 3 core clinical measures, and then choose 3 additional clinical measures to report on. • If any of core clinical measures are not applicable to the EP, he/she may choose to report on one of the 3 alternative core measures. And if the alternative measures are not applicable the EP must attest to this and the EP does not have to report on that measure.

26. Additional Rules Impacting EHRs HIT Certification Rule (Office of the National Coordinator) • Can only receive incentives if you are meaningfully using certified- EHR technology • Temporary Certification Program- anticipated to run through Q1 of FY 2012 • Permanent Certification Program- anticipated to start Q1 FY 2012

27. Meaningful Use Criteria Health outcomes policy priorities • Improving quality, safety, efficiency and reducing health disparities • Engage patients and families in their health care • Improve care coordination • Ensure adequate privacy and security protections for personal information

28. NCQA Patient Centered Medical Home = Meaningful Use Core Objectives and Measures Stage 1 1. Improving quality, safety, efficiency and reducing health disparities • Objective: Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. • Measure: More than 30% of unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE. • Objective: Implement drug-drug and drug-allergy interaction checks • Measure: The EP has enabled this functionality for the entire EHR reporting period.

29. Meaningful Use Core Objectives and Measures Stage 1 1. Improving quality, safety, efficiency and reducing health disparities • Objective: Generate and transmit permissible prescriptions electronically. • Measure: More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology. • Objective: Record demographics: preferred language, gender, race, ethnicity, and date of birth • Measure:More than 50% of all unique patients seen by the EP have demographics recorded as structured data. • Objective: Maintain up-to-date problem list of current and active diagnoses • Measure:More than 80% of all unique patients seen by EP have at least one entry or an indication that no problems are known for the patient recorded as structured data.

30. Meaningful Use Core Objectives and Measures Stage 1 1. Improving quality, safety, efficiency and reducing health disparities • Objective: Maintain active medication list • Measure:More than 80% of all unique patients seen by EP have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data • Objective: Maintain active medication allergy list • Measure: More than 80% of all unique patients seen by EP have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data

31. Meaningful Use Core Objectives and Measures Stage 1 1. Improving quality, safety, efficiency and reducing health disparities • Objective: Record and chart changes in the following vital signs: height, weight, and blood pressure and calculate and display body mass index; plot and display growth charts for children 2-20 years, including BMI. • Measure: For more than 50% of all unique patients age 2 and over seen by EP record height, weight, and blood pressure are recorded as structured data. • Objective: Record smoking status for patients 13 years old or older • Measure:More than 50% of all unique patients 13 years and old and older seen by EP have smoking status recorded as structured data.

32. Meaningful Use Core Objectives and Measures Stage 1 1. Improving quality, safety, efficiency and reducing health disparities • Objective: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance to that rule • Measure: Implement one clinical decision support rule • Objective: Report ambulatory quality measures to CMS or the States. • Measure:For 2011, provide aggregate numerator, denominator, and exclusions through attestation. For 2012, electronically submit the clinical quality measures

33. Meaningful Use Core Objectives and Measures Stage 1 2. Engage patients and families in their health care • Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request • Measure: More than 50% of all patients of the EP who request an electronic copy of their health information are provided it within 3 business days. • Objective: Provide clinical summaries for patients for each office visit. • Measure: clinical summaries are provided for at least 80% of all office visits.

34. Meaningful Use Core Objectives and Measures Stage 1 3. Improve care coordination • Objective: 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. • Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

35. Meaningful Use Core Objectives and Measures Stage 1 4. Ensure adequate privacy and security protections for personal health information • Objective: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. • Measure: Conduct or review a security risk analysis per 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process

36. Meaningful Use Menu Objectives and Measures Stage 1 ** Must choose 5 menu objectives, and 1 must be public health related 1. Improving quality, safety, efficiency, and reducing health disparities • Objective: Implement drug-formulary checks • Measure: The EP has enabled this functionality and has access to at least one internal or external drug formulary for the entire EHR reporting period. • Objective: Incorporate clinical lab-test results into certified EHR technology as structured data • Measure: More than 40% of all clinical lab tests results ordered by the EP 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.

37. Meaningful Use Menu Objectives and Measures Stage 1 1. Improving quality, safety, efficiency, and reducing health disparities • Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and research and outreach. • Measure:Generate at least one report listing patients of the EP with a specific condition. • Objective: Send reminders to patients per patient preference for preventive/follow up care. • Measure: More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period.

38. Meaningful Use Menu Objectives and Measures Stage 1 2. Engage patients and families in their health care • Objective: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. • Measure: More than10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP’s discretion to withhold certain information. • Objective:Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. • Measure: More than10% of all unique patients seen by the EP are provided patient-specific education resources.

39. Meaningful Use Menu Objectives and Measures Stage 1 3. Improve Care Coordination • Objective:The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medicatio reconciliation. • Measure: The EP performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP. • Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral. • Measure: The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals.

40. Meaningful Use Menu Objectives and Measures Stage 1 • 4. Improve population and public health • Objective: Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice. • Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the EP submits such information have the capacity to receive the information electronically). • Objective:Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice. • Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow up submission if the test is successful (unless none of the public health agencies to which an EP submits such information have the capacity to receive the information electronically.

41. Meaningful Use Core Clinical Measures Stage 1

42. Meaningful Use AlternativeCore Clinical Measures Stage 1

43. Resources • CPCA • HIT Newsletter- bimonthly, send Andie an email if you want to be on list to receive • On-demand webinar coming soon! • HIT Policy Page- http://www.cpca.org/govaffairs/caissues/HealthInformationTechnology.cfm • Centers for Medicare and Medicaid Services • Website on EHR Incentives- http://www.cms.gov/ehrincentiveprograms/ • PDF version of 864 page rule (not federal register version)- • http://www.ihs.gov/recovery/mu_documents/CMS%20Final%20Rule.pdf • California’s Office of Health Information Technology • Website about Medi-Cal EHR Incentives- • http://www.dhcs.ca.gov/Pages/DHCSOHIT.aspx

44. Questions? Concerns? Andie Martinez, MPP Associate Director of Policy California Primary Care Association amartinez@cpca.org 916-440-8170