The EHR Incentive Program – An update, tools, and a compelling story

1. The EHR Incentive Program – An update, tools, and a compelling story June 27, 2011

2. Presenters Jim Cannon, Executive Director Health Information Program, WSHA Charlie Button, Chief Executive Officer Dayton General Hospital Michelle Glatt, Consultant Washington & Idaho Regional Extension Center Melodie Olsen, Medicaid Health Information Technology Manager, State of Washington

3. Agenda • Introductions and setting the stage • The story of one hospital’s journey • The eligible professional issues and WIREC's role • The Washington State Medicaid incentive program • Wrap up • Q&A

4. HITECH ARRA’s Health Information Technology for Economic and Clinical Health (HITECH) contains both Medicare and Medicaid incentives designed to further health information technology adoption but also required jumping a number of hurdles to receive funding.

6. Organization • Public Hospital District formed in 1960 – Southeast Corner of State. Serving a rural population of approximately 6,500 Services Include: • Critical Access Hospital (Dayton General) • 12 bed acute, 13 bed swing bed • 2 Rural Health Clinics (Columbia Family Clinic and Waitsburg Clinic) • 4 full-time and 1 part-time doctors • 2 full-time and 1 part-time mid-levels • Nursing Home (Booker Rest Home) • 34 Beds

7. Vision • Vision Statement: We strive to be a leader in rural healthcare and your partner for optimal health. • Set the course for small rural hospitals • Realizing the importance of IT for survival of health district • To have an integrated IT system with EMR: • Ability to provide better care • Meet the needs of the community • Efficiencies of our staff and ability to use system • Remain competitive • 1 stop shop

8. Research • How to make our vision a reality? • Evaluation of current system • Explored options of new systems • Entrance of Meaningful use Review Included: • Cost • Functionality • System Installation • Training • Support • Meaningful Use

9. Tax Levy • Determined we needed approximately $1 million dollars • Going to the voters was the most practical approach for our facility • November 2009 • 1 year tax levy of $790,000 • Promotional campaign • Failed at 58.9% • February 2010 • 1 year tax levy of $790,000 • Stronger promotional campaign • 250 signs • Able to use marketing/promotional assistance • More education • Door to Door • Passed at 68.5%

10. IT Selection • Research on compatible systems • Site visits • Corporate office visits • Multi-disciplinary team • Strong Physician involvement • Functionality analysis • Certified for Meaningful Use • Vendor negotiations • Final selection

11. Install • Hired IT Director • Contract signing – June 2010 • Interim financing • Built IT infrastructure (examples: server room, wireless) • Go live by September 2010 (most modules) • All modules installed by December 2010…………Last being CPOE

12. Meaningful Use • Determine qualification. We qualify only for Medicare funding. • Determine provider funding. We did not qualify for provider funding. • CAH Hospital. Qualify for accelerated depreciation • Have applied for stage I. May 2011 • 90 Day period • Attestation • Stage II • Stage III

13. Lessons learned • Hard work • Physicians champions are key • IT Vendors are playing catch-up • Need top notch IT Director • Need buy-in from staff • Need to push IT vendors • Don’t skimp on peripherals • Don’t negotiate to a lower goal

14. Meaningfully Using an EHR Challenges, resources and rewards Michelle Glatt, MPH, PA-C Health IT consultant Michelleg@qualishealth.org

15. Today’s Objectives • Context: The Benefits and Challenges of an EHR • Eligible Providers • Meaningful Use Criteria • The Washington and Idaho Regional Extension Center (part of Qualis Health)

16. The Benefits of an EHR • Chronic disease/preventive medicine reporting & tracking • Continuity of care with data exchange • Evidence-based decision support & workflows • Tracking referrals and tests • Customized health interventions Quality • More efficient use of support staff • Instant access to patient data from multiple locations • Increased response time to drug recalls & guideline changes Efficiency Patient • Easy access to health record • Alternate ways to access care team, i.e. secure email • Up to date patient education materials Financial • Capturing the services provided to patients • Ease of participation with federal and state collaboratives

17. The Challenges of an EHR • Products: User interfaces that are not intuitive to providers Lack of standard functionality across products Lack of transparency regarding product features • Financing: IT staff salaries are out of reach for small PCPs Productivity losses with new implementations • Support and Knowledge: Access to best practices Access to appropriate skill sets • Organizational Change: Complex paper based workflows Legacy medical charting traditions Busy clinic schedules

18. EHR Certification HITECH ACT Products EHR Standards Increased adoption of EHR products that are designed for and used to improve health outcomes RECs Support Workforce Meaningful Use Inc. Financing State HIE NHIN HIE Guidelines Privacy/Security Beacon Comms Best Practices HIT research

19. Meaningful Use Incentive Programs Eligible Provider Hospital

20. Who is an Eligible Professional? • Must be practicing in an outpatient clinic setting • Providers who see 90% of their patients in an inpatient or ER setting are not eligible • Qualifying providers seeing patients in both inpatient and outpatient settings may only use data gathered from the outpatient setting in meeting meaningful use. • The incentive money goes to the individual provider not to the practice

21. Medicare Eligible Professionals Medicare Eligible Professionals include: • Doctors of medicine or osteopathy • Doctors of dental surgery or dental medicine • Doctors of podiatric medicine • Doctors of optometry • Chiropractors

22. Medicaid Eligible Professionals Medicaid Eligible Professionals include: • Physicians • Nurse practitioners • Certified nurse-midwives • Dentists • Physician assistants working in a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is so led by a physician assistant

23. Programmatic Highlights Providers may switch programs, but only once • Medicare • Is based on total allowed Medicare Part B physician fee schedule charges (many RHCs and CHCs will not qualify) • Must bill 24,000 per EP to receive full incentive • Pays up to $44,000 over 5 years • Decreases in total value if you begin after 2012 • 10% increase for HPSA • Penalties may begin in 2015 • Medicaid • Must see 30% Medicaid volume or 20% if Pediatrician • Allows RHCs and CHCs to count “needy individuals” • Pays up to $63,750 over 6 years • Offers AIU (adopt, implement & upgrade) program

24. Medicare Incentive

25. Medicaid Incentive

26. Meaningful Use Criteria for Eligible Providers

27. Core Set: Must Do All Menu Set: Must Do 5 of 10 Stage 1 objectives for EPs Must be using an ONC-ATCB Certified Product • Use CPOE for medications • e-prescribing • Drug-drug & drug allergy checks • Medication list • Allergy list • Problem list • Decision support • Record demographics • Smoking status • Vital signs • Clinical summaries to patient • Electronic exchange • Health info to patients • Clinical quality measures • Protect health information • Incorporate clinical labs • Medication reconciliation • Implement drug-formulary checks • Generate patient list • Patient electronic access • Send reminder • Patient-specific education • Clinical summaries to provider • Submit electronic data to immunization registry* • Submit electronic syndromic surveillance data* • *At least 1 public health objective must be selected.

28. Core Measures Alternate Core Measures Clinical Quality Measures Pts at least 18 y/o with BMI within 6 months. Follow up plan if abnormal. Hypertensive Pts at least 18 y/o, seen at least twice, who have BP recorded Pts at least 18 y/o, seen at least twice, with smoking status documented. Cessation intervention documented if a smoker. Pts at least age 50 adequately immunized for influenza Pts age 2-17 with BMI, & counseling on nutrition & physical activity Percentage of patients who are two years old with all scheduled immunizations

29. 38 additional CQMs Asthma: Age 5-40 evaluated for sxfrequency Persistent asthma with Rx Cancer: Colon CA w/chemotherapy Prostate CA w/out bone scan Mental Health and Addiction: Receive quit advice New AOD dx with 2 visits w/in 30 days Remain on antidepressant therapy OB: HIV screening RH-neg with Rhogam Other: Glaucoma w/ optic nerve head eval 2-18 given strep test w/antibiotic LBP w/out imaging BrCa and hormonal therapy Diabetes: A1c > 9% A1c < 8% LDL < 00 BP < 140/90 Diabetic retinopathy w/ eye exam (3) Foot exam Nephropathy Heart Disease: CAD and prior MI on beta blocker therapy CHFw/LVEF < 40% on beta blocker/ARB/ACE-I CAD on antiplatelet therapy CAD on lipid therapy A-fib on warfarin Hosp for cardiac dx w/BP <140/90 Hosp for cardiac dx on antithrombotic therapy Hosp for cardiac dx with LDL <100 HTN and controlled BP IVD and BP/ASA/lipid profile Preventive: ≥ 65 with pneumovax Women with a mammogram Adults with CRC screening Women w/pap test Sexually active women 15-24 w/CT test

30. WIREC Expedition Guide Service: “Provisioning, route-finding and crevasse rescue”

31. The Regional Extension Center Program Goal:100,000 small primary care practices to Meaningful Use Targeting: Small PCPs The affiliated primary care practices of Public and Critical Access Hospitals Community Health Centers and Rural Health Clinics

32. WIRECs Scope and Strategy . • Vendor-neutral EHR selection support & contracts • EHR implementation planning • Data migration guidance • Go-live guidance • Staff training guidance • System stabilization guidance • Workflow redesign work • Privacy and Security reviews • Quality improvement reporting • Direct Consultative Assistance • Peer to Peer Networking • Educational Workshops and Webinars • Group Purchasing Agreements

33. Envisioning Evaluating Selecting Implementing Meaningful Use Meaningful Use Readiness Assessment & Guidance • Identifying the gap • Developing a roadmap • Providing customized guidance with a quality improvement and workflow redesign approach

34. WIREC Provider Enrollment

35. Reaching the MU Summit • Respect the scope of the project • Form a team & empower them to make change: • Software: IT professionals, vendor representatives • Reporting: Report writers, database experts • Workflow: Clinical Staff – provider champion • Project Management • Use respected process improvement tools: PDSA, Lean • Optimize workflows • Value and build reporting skill sets among practice staff • Don’t wait for the vendor. • Use available resources (RECs)

36. Certified Product List http://onc-chpl.force.com/ehrcert WIREC: www.wirecqh.org CMS: http://www.cms.gov/ehrincentiveprograms/ Michelle Glatt MPH, PA-C - Provider Health IT Consultant Washington and Idaho Regional Extension Center - Qualis Health michelleg@qualishealth.org

37. Working Together: Transforming Health Care Service Delivery & Improving Patient Care Melodie Olsen Medicaid Purchasing Administration June 27, 2011

38. The Road Ahead The Road Ahead….. 2021 Last CALL 2016 Meaningful USE 2012 2011 EHR 38

39. Creating Opportunities TogetherTransforming Health Care Service Delivery And Improving Patient Care HEALTH ECOSYSTEM 39

40. Medicaid EHR Program: Notes of Interest • GOOD NEWS! Hospitals and EP’s can apply for incentives during year one for AIU only • 88 hospitals in Washington State may qualify if they reach the 10% Medicaid patient volume threshold • The average hospital incentive payment in Year 1 will be approximately $725,000 • Hospital average for all four years: $1.8 Million • Total hospital payments anticipated through 2021: nearly $160 Million • Estimate 704 EP’s participate in year 1 - estimated $16M

41. Must be certified EHR technology! Year 1: Need only address AIU (not MU

42. ELIGIBLE HOSPITALS Acute Care Hospitals Children's Hospitals Stand-alone Cancer Hospitals ELIGIBLE PROFESSIONALS Physicians MD/DO Nurse practitioner Certified nurse-midwife Dentist Physician Assistant (PA) delivering care in FQHC/RHC led by a PA Who Can Participate – Medicaid Incentives 42

43. Eligibility - Incentives For Individual EPs • Clinics as organizations are not eligible for incentives • Within group practice, each EP may qualify for incentive • Each EP is eligible for one incentive payment per year • EPs Can Voluntarily Assign Incentive Payment to Others • Only one payment to single TIN– funds taxable • EP’s who deliver more than 90% of services in hospital setting are not eligible

44. Patient Volume: Definitions • “Encounter” - Services rendered to an individual on any one day where Medicaid paid for part or all of service premiums, copayments and cost-sharing • “Needy individuals” - FQHC/RHC/Tribal Health Clinics • Medicaid or CHIP paid for all or part of the service; or individual’s premiums, copayments or cost-sharing • Services furnished at no cost; • Services paid for at reduced cost based on sliding scale determined by an individual’s ability to pay • “Group Proxy” - The clinic or group practice uses the entire practice or clinic’s patient volume; if group meets the patient volume threshold, all EP’s associated with the group qualify 44

45. Why would EP/Clinic use Group Proxy? • Less time analyzing Medicaid patient data • WA Medicaid can provide reasonable estimate of eligible encounters for each billing NPI • Most inclusive option • Group estimate for one billing NPI applies to all • Auditable data • MPA can validate the EP relationship to the billing provider and estimate group encounters 45

46. Patient Volume Thresholds 46

47. Calculation for Hospitals – Key Facts • Initial Amount = a base amount of $2 million + discharge-related amount • Subsequent payments will factor in average annual growth rate and transition factor • Washington state Medicaid will pay incentives out over four years: • Year 1 = 40% • Year 2 = 25% • Year 3 = 20% • Year 4 = 15% 47

48. Calculation for Hospitals – Sample 48

49. Payments Planned To Begin By September • Medicaid intends to begin distributing incentive payments no later than September of 2011 allowing: • Washington’s EH’s and EPs opportunity to select certified EHR products, and adopt, implement or upgrade technology • Medicaid to finalize and integrate business processes, and develop tools and instructions • Medicaid to put the EHR Incentive Program registration tool in place

50. How do EH’s and EP’s pursue incentives? • Register with CMS • Medicaid issues tools • Apply/ Attest/ Submit - state application - eMIPP • Medicaid Review Process • Notification/Payment • Medicaid intends to begin distributing incentive payments in September of 2011 50