Deloitte Consulting LLP

How National Initiatives have Improved eHealth Deployment in the US

An Inspiration for Other Countries?

Andrew M. Wiesenthal, MD, SMDirector

You can always count on the Americans to do the right thing—after they’ve tried

everything else.

--Winston Churchill

Has the natural order of things been reversed?

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• Summary of HITECH

• Progress to date in the US

• What’s next for the US?

• Lessons learned

• Applicability outside the US

Agenda

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NOT part of National Health Reform legislation

Key Components:

oRequires use of certified electronic health record (EHR) technology

oProvides monetary incentives for adoption by Eligible Hospitals and Eligible providers through 3 stages of

oMeaningful useA staged, increasingly more demanding, demonstration of

capability over 5 years, followed by penalties for failure to comply

oSupports Regional Extension Centers

oSupports Increased training in informatics

Summary of HITECH

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The American Recovery and Reinvestment Act (ARRA) includes the Health Information Technology for Economic and Clinical Health (HITECH) Act to accelerate the adoption of interoperable electronic health records and other health information technology.

The HITECH Act allocated $27 billion dollars of payment incentives to physicians and hospitals for achieving “Meaningful Use” (MU) of certified Electronic Health Records (EHRs).

To obtain Medicare incentive funding, providers must commence “Meaningful Use” of EHR technologies between 2011 and 2015. Medicaid funding is available between 2011 and 2021, with the last year to receive the first Medicaid incentive payment and qualify for maximum amount being 2016.

Hospitals are eligible to receive both Medicare and Medicaid Incentives simultaneously. Physicians who are eligible for both Medicare or Medicaid incentives must choose one.

Stimulus$787 billion

2008 US Federal Budget$2.9 trillion

$27+ billion total

allocated towards HITECH

expenditures

HITECH Overview

HITECH Overview

HITECH Meaningful Use

2016*201420112009

*As currently proposed by CMS

Hitech

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Stage 1

Data capture and sharing

Stage 2

Advanced clinical processes

Stage 3 Improved outcomes

On Tuesday, September 4, 2012: CMS released the Stage 2 Final Rule of the Medicare and

Medicaid Electronic Health Record Incentive Programs ONC released the 2014 Edition Standards and Certification

Criteria Final Rule

Increase implementation and adoption of EHR systems

Capture structured data

Increase exchange of health information

Demonstrate care coordination across sites of care

Empower patients with health information

Drive use of real-time data at the point of care

Use outcomes-focused clinical quality measures

Utilize clinical decision support for prevention, disease management and safety

Meaningful Use

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The CQMs are no longer a core objective, but simply a requirement to meet Meaningful Use (e.g., the 2014 CQMs are independent of MU Stage)

With Stage 2, complexity has increased and many objectives now have multiple measures to achieve

Overview of Stage 2 CriteriaStage 2 of Meaningful Use will include the same concept of Core, Menu, and Clinical Quality Measures (CQMs) as in Stage 1, however there are a few key differences, as outlined below:

Eligible Professionals15 core objectives

AND5 of 10 menu objectives= 20 total objectives

Eligible Hospitals & CAHs14 core objectives

AND5 of 10 menu objectives= 19 total objectives

Eligible Professionals17 core objectives

AND3 of 6 menu objectives

= 20 total objectives

Eligible Hospitals & CAHs16 core objectives

AND3 of 6 menu objectives

= 19 total objectives

MU Stage 1 Objectives MU Stage 2 Objectives

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Core Objective Delta Measure Key Points

1. CPOE Increased Threshold

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology orders

− Optional for denominator in when attesting for Stage 1: No. of orders during the EHR Reporting Period (as opposed to unique patient)

− Decreased % threshold for lab and radiology

2. Demographics Increased Threshold

Record demographics for more than 80% of all patients

3. Vital Signs Increased Threshold

Record vital signs for more than 80% of all patients − Change in Age Limit: age 3 for Blood Pressure

− No age limit for Height/Weight

4. Smoking Status Increased Threshold

Record smoking status for more than 80% of all patients

5. Interventions Increased Threshold

Implement 5 clinical decision support interventions + drug/drug and drug/allergy checking

− Change from “rule” to “intervention”

− 5 CDS interventions must be related to the CQMs that will be reported

6. Labs Increased Threshold

Incorporate lab results for more than 55% of labs that have been ordered

− Now a Core measure

7. Patient List Same Generate patient list by specific condition − Now a Core measure

8. eMAR New eMAR is implemented and used for more than 10% of medication orders

− Using RFID or Barcode Technology

Stage 2 EH Core Objectives / MeasuresEHs must select all 16 core objectives below. Changes from Stage 1 are indicated in bold.

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Core Objective Delta Measure Key Points

9. Patient Access New Provide online access to health information for more than 50% (within 36 hours of discharge) with more than 5% actually accessing

− Reduced from 10% to 5% from the Stage 2 Proposed Rule

10. Education Resources

Increased Threshold

Use EHR to identify and provide education resources to more than 10% of patients

− Now a Core measure

11. Rx Reconciliation

New Medication reconciliation at more than 50% of transitions of care

− Now a Core measure− Reduced from 65% in the

Proposed Rule

12. Summary of Care

New Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

− Merged Problem List, Medication & Allergy List into this Measures

− Reduced from 65% to 50%

13. Immunizations IncreasedPerformance

Successful ongoing transmission of immunization data

− Public Health measures− Now a Core measure− Requires real patient data

with ongoing submission14. Labs IncreasedPerformance

Successful ongoing submission of reportable laboratory results

15. Syndromic Surveillance

IncreasedPerformance

Successful ongoing submission of electronic syndromic surveillance data

16. Security Analysis

Same Conduct or review security analysis and incorporate in risk management process

− Highlighted Importance of Reviewing Encryption Practices

Stage 2 EH Core Objectives / Measures (cont.)EHs must select all 16 core objectives below. Changes from Stage 1 are indicated in bold.

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Menu Objective

Delta Measure Key Points

1. Progress Notes

New Enter an electronic progress note for more than 30% of unique patients

− Reduced from 40% to 30% from the Stage 2 Proposed Rule

2. E-Rx New More than 10% electronic prescribing (eRx) of discharge medication orders

− Measure includes Drug Formulary Checking

3. Imaging Results

New More than 20% of imaging results are accessible through Certified EHR Technology

4. Family History

New Record family health history for more than 20% of patients

− Does not include exchanging this data electronically (most likely will in Stage 3)

5. Advanced Directives

Unchanged Record advanced directives for more than 50% of patients 65 years or older

6. Labs New Provide structured electronic lab results to EPs for more than 20% of electronic lab orders received

- If the EH receives an electronic order from an ambulatory provider, they would send an electronic result back (rather than a fax)

EHs must select 3 out of the 6 below. Changes from Stage 1 are indicated in bold.

Stage 2 EH Menu Objectives / Measures

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Core Objective Delta Measure Key Points

1. CPOE Increased Threshold

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology orders

− Modified Calculation− Expanded to Lab and Radiology

2. E-Rx Increased Threshold

E-Rx for more than 50% of all prescriptions − Now a Core measure− Included Formulary Objective as part of

Measures− Reduced from 65% to 50% from Stage

2 Proposed Rule

3. Demographics Increased Threshold

Record demographics for more than 80% of all patients

4. Vital Signs Increased Threshold

Record vital signs for more than 80% of all patients

− Changed age from 2 to 3 for Blood Pressure

5. Smoking Status

Increased Threshold

Record smoking status for more than 80% of all patients

6. Interventions Increased Threshold

Implement 5 clinical decision support interventions + drug/drug and drug/allergy checking

− Change from “rule” to “intervention”− 5 CDS interventions must be related to

the CQMs that will be reported

7. Labs Increased Threshold

Incorporate lab results for more than 55% of labs that have been ordered

− Now a Core measure

8. Patient List Unchanged Generate patient list by specific condition − Now a Core measure

9. Visit Summaries

Increased performance

Provide office visit summaries for more than 50% of office visits

− Decreased from 3 days to 24 hours

Stage 2 EP Core Objectives / MeasuresEPs must select all 17 core objectives below. Changes from Stage 1 are indicated in bold.

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Core Objective

Delta Measure Key Points

10. Preventive Reminders

Revised Denominator

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years

− Removed age restriction − Decreased % threshold

11. Patient Access

New Provide online access to health information for more than 50% with more than 5% actually accessing information

− Access on demand via portal or PHR

− Requires Action by Patient

12. Education Resources

Revised Denominator

Use EHR to identify and provide education resources to more than 10% of patients

− Now a Core measure

13. Secure Messages

New More than 5% of patients send secure messages to their EP

14. Rx Reconciliation

Unchanged Threshold

Medication reconciliation at more than 50% of transitions of care

− Now a Core measure− Reduced from 65% to 50% from

Stage 2 Proposed Rule

15. Summary of Care

New Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

− Must meet both Measures for Stage 2

− Merged Problem List, Medication & Allergy List into this Measures

16. Immunization

Increased Performance

Successful ongoing transmission of immunization data

− Now a Core measure− Requirement changed from ‘test’ to

‘ongoing transmission’

17. Security Analysis

Unchanged Conduct or review security analysis and incorporate in risk management process

− Highlighted Importance of Reviewing Encryption Practices

Stage 2 EP Core Objectives / Measures (cont.)EPs must select all 17 core objectives below. Changes from Stage 1 are indicated in bold.

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Menu Objective

Delta Measure Key Points

1. Imaging Results

New More than 20% of imaging results are accessible through Certified EHR Technology

− Can include indication and link to another technology

2. Family History

New Record family health history for more than 20% of patients − Does not include exchanges data electronically

3. Syndromic Surveillance

Unchanged Successful ongoing transmission of syndromic surveillance data

− Public Health Core Measures

− Requires real Patient Data with ongoing submission

4. Cancer New Successful ongoing transmission of cancer case information

5. Specialized Registry

New Successful ongoing transmission of data to a specialized registry

6. Progress Notes

New Enter an electronic progress note for more than 30% of unique patients

Stage 2 EP Menu Objectives / MeasuresEPs must select 3 out of the 6 below. Changes from Stage 1 are indicated in bold.

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• Adoption of Basic EHRs by Office-Based Practices

Progress to Date in the US

National National National National National2008 2009 2010 2011 2012

0

5

10

15

20

25

30

35

40

45

50

Overall (Percent)

Primary Care (Percent)

Rural Practices (Percent)

Small Practices (Percent)

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Hospital Adoption of EHRs

Progress to Date in the US

Region National National National National NationalTime Period 2008 2009 2010 2011 2012

0

10

20

30

40

50

60

Hospitals Overall

Rural Hospitals

Small Hospitals

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Progress to Date in the US

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• CMS routinely releases key statistics that result from the adoption of EHRs through Meaningful Use requirements.  As of the end of June 2013,

• More than 309,000 health care providers have been paid by the Medicare and Medicaid EHR Incentive Programs

• Over 405,430 health care providers (including eligible professionals, eligible hospitals and critical access hospitals) are actively registered for the Medicare and Medicaid EHR Incentive Programs

• Total of over $15.2 billion in Medicare and Medicaid EHR Incentive Program payments since May 2011• Over $9.35 billion in Medicare EHR Incentive Program payments have been disbursed between

May 2011 and the end of June 2013

• Over $5.83 billion in Medicaid EHR Incentive Program payments were disbursed between January 2011 (when the first states launched their programs) and the end of June 2013

• As of June 2013, over 76 percent of EPs have registered for the Medicare and Medicaid EHR Incentive Programs and almost 55 percent have been paid

• As of June 2013, over 89 percent of hospitals have registered for the Medicare and Medicaid EHR Incentive Programs and over 80 percent have been paid

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html

Progress to Date in the US

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• A flurry of hospital implementations is anticipated in the next 14 months due to both MU and ICD-10 conversion deadlines

• As physician practices consolidate, more of the outliers will also be EHR-enabled

• The vendors are continuing to adapt to the certification standards

• Comparison based on data flowing from EHRs will become more available to government, insurers/payors, and consumers

• Increased assumption of accountability for outcomes is a likely consequence

What’s Next for the US?

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• Money awarded, or the threat of withholding it, is a profound influencer of institutional and individual behavior

• In a low margin environment, it doesn’t require much money to build this influence

• It is possible to create an environment of inevitability

• Deadlines that do not shift are very influential; deadlines that shift breed cynicism

• A small national agency with an obvious, high-profile leader, has been effective

• The national government can set standards but need not be involved in procurement in any way

Lessons Learned

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• National leadership, standard-setting, and incentives could translate smoothly into most environments outside the US

• In particular, monetary reward and punishment gets local health authority attention

• Demanding “meaningful use” looks promising, but the data has not begun to flow yet

Applicability Outside the US

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