12TH ANNUAL SUMMER INSTITUTETUESDAY, JULY 19, 2011 12:30 P.M.

HILTON SEDONA RESORT - SEDONA, AZ

Patricia MacTaggart

Patricia.mactaggart@gwumc.edu

CHANGING YOUR WORLDHEALTH INFORMATION

TECHNOLOGY

What ?

•Transformation of Health,

Care & You

Why?

•Better Health, Better

Care, Lower Costs thru

• Care & Connection

(Health IT),

• Communication

(Standardization)

• Quality (Effective

& Efficient Use)

CHANGING YOUR WORLD

HEALTH IT

WHY NOW – WHY CARE???

• Health Care Issues /

Medical Errors

• Health IT Options

WHERE TO START?State/Federal Government Role Baseline

• Medicaid as of 1/11: 15 States initiated Medicaid EHR Incentive Programs & paid $83 M incentive payments

• Medicare as of 5/19/11: first round of $75 M to providers who signed up in first two weeks

AL

AK

AZAR

CA

CO

CT

MD

FL

GA

HA

ID

IL IN

IA

KS KY

LA

ME

0

NH

MI

MN

MS

MO

MT

NE

NV

NJ

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VR

VA

WA

WV

WI

WY

DE

MA

SOURCE: CMS EHR Incentive Program : Commonwealth

What’s the Consumer Baseline?

What’s the Provider Baseline? US 2001-09 and Preliminary 2010: Commonwealth

Notes: An EMR/EHR is a medical or health record system that is either all or partially electronic, excluding systems solely for billing. The 2010 data are preliminary estimates, based only on the National Ambulatory Medical Care Survey. Estimates through 2009 include additional physicians sampled from community health centers. Estimates of basic and fully functional systems prior to 2006 were not collected in the survey. Fully functional systems are a subset of basic systems; a change in survey instruments and definitions of fully functional systems between 2009 and 2010 may have contributed to some of the increase in fully functional systems during that year. Includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists.SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey, and Hsiao et al., 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf

HOW IS HEALTH CARE DELIVERY TRANSFORMING?Focus on Where “Going” – Not Where “From”

• Accountable Care Plans:– Start 1/1/12 for 3 Yrs. & Voluntary for Patient/Providers– Coordinate Treatment across Continuum of

Care(Physicians, Hospitals, SNFs, LTC Hospitals, Other Providers & Supplier)

• Integration:– Physical and Behavioral Health– Integration Public-Private: Premium Based Subsidies– Integration Medicare-Medicaid: Standardized Assessment,

Extensive Data Analysis & Sharing, Financial Incentives for Quality

Triple Aim: Better Care, Better Health, Lower Costs 7

WHAT ARE NEW REIMBURSEMENT TRANSFORMATION OPPORTUNITIES?

• Bundling Payment Episode of Care Pilot

Medicare & Medicaid Program

• Medicaid Safety Net Global Payment Demo

• 1% FMAP increase for states that eliminate cost-sharing for preventive services (Sec. 4106, starts 2013)

WHAT ARE STATES DOING TO SUPPORT MEDICAID/MEDICARE PROVIDER TRANSFORMATION

THRU MU?

• entralized Provider Registry/Directory:

– Access: through a secure web-interface

– Authentication: individual and entity identity management

– Specific Levels of Security: authentication and access controls and necessary firewalls

ecure Messaging:

– Technical Functionality of a Secure Web Service using direct messaging or email attachments using national standards

– Role Based: access and management, message and data validation, privacy and security (encryption and signed data user agreement-DURSA), monitoring and auditing

HOW IS HEALTH CARE ADMINISTRATION TRANSFORMATING?

• Patient Centric: Consumer Engagement & Education

• Administrative Simplification:– No More Paper– e-Signature

• Standardization: – Public/Private– Across State Agencies

– State to National

10

11

EHR (Electronic Health Record) &EMR (Electronic Medical Record)

HIE (Health Information Exchange) & HIE (Health Insurance Exchange)

Health IT (EHRs, HIEs, Registries, Tele-health)

m-Health (Mobile-IPAD, IPhone,)

TRANSFORMATION OF YOU?

-everything

-EVERYTHING ≠ INTEROPERABILITY

HIT:

• Non-electronic Level of Interoperability: Paper

• Machine-transportable data : Fax/e-mail

• Machine-organizable data: Structured messages & unstructured content (pdf)

• Machine-interpretable data: Structured messages & standardized content

12

Health IT

WHAT IS THE INFRASTRUCTURE REQUIRED TO GET US TO WHERE WE NEED TO GO?

14

IF HEALTH IT USED IN A MEANINGFUL USEGets Us Where We Need to Go

Better Health, Better Care, Lower CostsTO SUPPORT BETTER HEALTH, BETTER CARE,

LOWER COSTS?

15

ResearchInstitute

Beacon Community

IntegratedDelivery System

Community Practice

Health Information Exchange

Health CenterNetwork

FederalAgencies

State Public Health

Aggregation

Analysis

Dissemination

State Agencies

Adapted from ONC

Diagram

15

CARE & CONNECTIONNationwide Exchange of Health IT

Policy & Legal

Governance

Technical

Technical & Business Operations

WHO IS ESTABLISHING THE STANDARDIZED “RULES OF THE ROAD”?

• ONC = lead for standards and certification of EHR

• CMS = lead for Medicaid/Medicare Incentive Program

• Incentives to Standardize: Meaningful Use: – EMR = $0

– Certified EHR = Maximum of $63,500 (Medicaid) & $43,000 (Medicare)

STRATEGIES TO GET STANDARDIZATION THRU AIU & MEANINGFUL USE

Follow the Money

• State Activities for 2011-2012: State Strategic/Operational Plans, State Medicaid HIT Plans & State HIT to Support MU

• Provider Activities for 2011-2012:

– Medicaid: Adopt, Implement, Upgrade of certified EHRs (AIU)

– Medicare: Meaningful Use for EPs & EHs (Medicaid Optional)

17

MEANINGFUL USE STAGE ONE EP Core Measures (15)

Medications

• CPOE *

• Drug Interaction Checks *

• e-Prescribing

• Active Medication List *

• Medication Allergy List

Management of Care

•Maintain Problem List *•Record Vital Signs *•Record Smoking Status *•Record Demographics *•Clinical Decision Support *•E-Exchange of Clinical *

Quality Measures * Patient Centric Engagement

•Electronic Copy of Health Information *•Clinical Summaries *•Protect Electronic Health Information *

EH Core Measures (14)

MU STAGE 1 QUALITY MEASUREMENT

Core – Alternative

EP• 3 Core Clinical:

– Hypertension– Smoking

Assessment/Intervention– Adult Weight

Screening/Follow Up

• 3 Alternative Clinical:– Children Weight Assessment &

Counseling **– Child Immunization Status **– 50+ Influenza Immunization

• 3 Additional Clinical:– Select from 38 Options

** Overlap CHIPRA National

4 Total

EH - 15• VTE Prophylaxis within 24 hrs• Intensive Care Unit VTE prophylaxis• VTE discharge instructions• Incidence of potentially preventable VTE • Anticoagulation overlap therapy• Platelet therapy on unfractionated heparin • Thrombolytic therapy for patients arriving

within 2 hours of symptom onset• Ischemic stroke: Discharge on Anti‐thrombotics• Ischemic stroke: Anticoagulation for Arterial

Fibrillation/flutter• Ischemic or hemorrhagic stroke: Antithrombotic

Therapy by day 2• Ischemic stroke: Discharged on Statin

Medication• Ischemic or hemorrhagic stroke: Stroke

Education• Ischemic or hemorrhagic stroke: Rehabilitation

Assessment • Admission decision time to ED departure for

admitted patients• Median time from ED arrival to ED departure

for admitted patients

MEANINGFUL USE EP Menu Measures (5 of 10)

Medications•Drug Formulary Checks *•Medication Reconciliation *

Management of Care•Clinical Lab Test Results *•Patient Lists *•Transition of Care Summary *

20

Patient Centric Engagement

•Patient Reminders•Patient Electronic Access•Patient-specific Education Resources *

Public Health

•Immunization Registries Data Submission *•Syndromic Surveillance Data Submission *

EH: 5 of 10, including Advanced Directives & Lab ResultsEHs/EPs: 1 must be from PH

STRATEGIES TO GET STANDARDIZATION OF MEDICAID ELIGIBILITY SYSTEMS

Single Doorway = Computer Screen

• Design, development, installation or enhancement (DDI) of a state eligibility determination and redetermination and/or enrollment system• 90% federal-10% state for DDI up to 2015 • 75% federal-25% state for ongoing operation

21

STRATEGIES TO STANDARDIZE COVERAGEAccountable Care Act Health Insurance Exchanges

•Single Integrate Pathway •Easy for Individuals to Explore Health Coverage Options•Individuals can Quickly and Accurately Enroll into Coverage

•Common systems and High Levels of Integration: No “Gap” in Coverage

•100% FFP for IT Infrastructure

Medicaid138% FPL

22

Basic Health Plan139% to 200%

Tax Subsidy138% to

400%

OPTIONS/REQUIREMENTS FOR IT COST ALLOCATION Exchanges- Medicaid- CHIP – State Programs

• Health Care Coverage Portal: direct input and interface from other systems for single, streamlined application.

• Business Rules Management/Operations System: eligibility system functionality/processing logic for individuals covered by MAGI

• Interfaces: federal data services hub & other verification sources

• Account Creation and Case Notes: e-case file

• Notices & Customer Service Technology Support: assist applicants, including interfaces to community assisters or other outreach organizations.

Get the Data Once – Use it Multiple Times

ONC’S KEY STRATEGIES TO GET/KEEP CONSUMERS ENGAGED

Consumer Ecosystem

• Access:

– Freeing Data

– Infrastructure Building

– Data Sharing Incentives

• Action

– Tools to take Action

– Ensuring Vulnerable Groups are not left out)

• Attitude

– Individuals Engage

– Providers Partner with Patients

– Beacon Communities/states

WHAT ARE THE COMPETING IT DEMANDS WHILE BUILDING THE DIGITAL HIGHWAY?

• 4010 TO 5010: Updating the Book (1/1/12)

• ICD-9 to ICD-10:

Whole New Book

(10/1/13)

• Privacy & Security

Requirements: “Breaches”

25

WHAT ARE THE COMPETING IMPLEMENTATION DEMANDS ON PROVIDERS & STATES?

New Requirements on States & Providers•Administrative Simplification & Program Integrity Provisions•Interfaces with HIEs (Information & Insurance)

Medicaid/Medicare Changes• Provider Rates-Incentives-Penalties• Payment Methodologies•Service Delivery Innovations

26

Increased Volume • Transactions• Providers

New Aged & Disabled Consumer Benefits & State Opportunities

•Dependent Adults up to 26 on Parent’s Plans even Married (2011)•No Pre-existing Condition Exclusions for Children (2011)• Prohibitions against Lifetime Benefit Caps & Rescissions (2011)•Preventive Care Coverage & No Cost-Sharing Medicare (2011)

QUALITY HEALTH AND HEALTH CAREHow Do We Know We Aren’t Stalled?

Data on Performance:

• CHIPRA Quality Measures for Children

• MU Measures

• ACA Quality Measures for Adults

• HCBS Measures for Waivers

• PQRI Measures

• MCOs: External Reviews & Quality Improvement

• ACO Measurement

WHAT ARE THE NEXT STEPS FOR QUALITY? Critical for Community Integration

Transition of Care Summary Vocabulary of Transition of Care

• “Scope”

• Time Line

• Performance Standards

QUALITY & PATIENT SAFETY THRU PUBLIC- PRIVATE Partnerships for Patient

•Patient Safety: CMS Center for Innovations $500 million to organizations to safely transition patients between settings of care.

•Preventable Hospital-Acquired Conditions: By 2013 Decrease by 40% Compared to 2010.

•Preventable Complications during a Transition from 1 Care Setting to Another: By the end of 2013, all hospital readmissions would be reduced by 20-percent compared to 2010.

•Portion of Hospital Medicare Payments linked to delivering safer care, using information technology effectively and meeting patient needs by 2015. (Also Medicaid Payment Incentives/Supports )

Berwick: “Against Cutting – For Improving Care To Save Money” 29

Transform HC thru Rapid Learning & Technological

Advancement

Empower Individuals with HIT to Improve Care

and HC System

Inspire Confidence & Trust in HIT

Better Care, Better Health, Lower Costs through HIT

Achieve Adoption & Information

Exchange through

Meaningful Use of HIT

HHS STRATEGICPLAN 2010-2015

KNOCKING ON THE DOOR TO GET INHIT for Behavioral Health

• Behavioral Health Information Technology Act of 2011 (S 539) – Sen. Sheldon Whitehouse (D-R.I.) to expand Medicare &

Medicaid Meaningful Use Incentive Payment Eligibility to Behavioral Health, Mental Health and Substance Misuse Treatment Professionals and Facilities.

– Eligible Providers would include Licensed Psychologists and Clinical Social Workers & Eligible Hospitals would include Psychiatric Hospitals

• Medicare Proposed Community MH Center Reg– emphasizing the need for communication regarding client

needs at the time of discharge or transfer

– evaluating outcome and client satisfaction data

“Traction” Hard to get in Environment of “Cuts” 31

LAST BUT NOT LEASTInitial Question: Is it worth it? Real Question: Is the

destination worth the journey? Can we afford not to do it?

Benefits• Improved Information

Availability (value of information)

• Clinical Benefits

• Financial B e.g., greater efficiency, lower administrative costs, better coding

Costs

• Investment Costs

– Equipment

– Personnel/productivity

– Training

• Maintenance Costs

– IT support staff

– Future upgrades

– Continued training

32

NEED MORE INFORMATION?

* AHIMA * HIMSS

* NAMD * NCIO

* NASHP

* NeHC

* CMS * ONC