Meaningful Use – Eligible

Professional

Physician Office Breakfast

April 13, 2011

Briggs Pille, HIMformatics

Joe Cook, DO, Munson Family Practice

Randi Terry, IS Director and Meaningful Use Coordinator for MHC

Agenda

• Brief Meaningful Use Update and General Review - Briggs Pille

• ePrescribing and Meaningful Use – Joseph Cook, DO

• Medicaid Eligibility (how do you qualify, what insurance is listed under Medicaid, when will Michigan start paying) – Randi Terry

• Registration and Certification - Dr. Cook and Randi Terry

• Security Risk Analysis - Dr. Cook and Randi Terry

• Interconnectivity and Munson‟s role Briggs Pille and Randi Terry

• If you have an EMR, how do you look (a look at 4 Munson Hosted practices) – Briggs Pille

• Quality Measures – Briggs Pille

• Clinical Rules – Briggs Pille and Crystal Larson

• Portal requirement – Briggs Pille – there is a notion out there that Portals are REQUIRED (you need to address this and what the regulations actually say).

• MCEITA Update - Randi Terry, Lori Kissau, Kelly Bator

• Stage 2 and 3 – Briggs Pille

Brief Meaningful Use Update

and General Review

Briggs Pille

Intent of the HITECH program

1. Improve quality, safety, efficiency, and reduce health

disparities

2. Engage patients and families

3. Improve care coordination

4. Ensure adequate privacy and security protections for

personal health information

5. Improve population and public health

4 Oh yeah, reduce the cost of our healthcare system

The program emphasizes the meaningful use of an EHR to…

Medicare Incentives for EPs

• Maximum incentive amount is $44,000 over 5 years

• Must begin participation by 2012 to receive

maximum incentive

• Incentives based on 75% of Medicare-Allowed

Charges for that year

• Starting in 2015 – Penalties (reduction in Medicare

reimbursements) for EPs not demonstrating

Meaningful Use

5

Medicaid Incentives for EPs

• EPs may receive payments up to $63,750 over six

years

• Incentive based on up to 85% of state-calculated

global average costs for EHR

• Start no later than 2016

• Achievement of MU not required in first year

• No payments made after 2021

• No Medicaid penalty for failure to demonstrate

Meaningful Use

Maximum Incentives - EP

7

Incentive Program Progress

• Over 60,000 Providers have enrolled with ONC REC

(Regional Extension Centers - MCEITA in Michigan)

programs nationwide

• Over 45,000 Providers have requested Registration help

from RECs (It‟s not simple)

• Over 21,000 Providers have Registered for EHR incentive

programs

• MU Attestation capability will be available on April 28th (90

days since the program began on 1/1/11)

• CMS has paid more than $37.5M in EHR incentives in

Jan/Feb. This was Medicaid AIU

• Only $2.7M has been paid out to EP (Providers)

ePrescribing

and Meaningful Use

Joe Cook, DO

eRx Issues and Questions

1. Medicare eRx incentive/penalty process

vs

2. MU eRx requirement

MU eRX Requirement

• 40% of all Rxs

• Narcotic Rxs excluded

• eRx not e-fax

• Exclusion

• <100 Rx during reporting period

Medicare eRx

Incentive or Penalty

• 2011 Requirement

• G8553

• 25 reporting events

required

• Avoid 2012 Penalty Process

• If >10 claims with correct

G codes

• First 6 months of 2011

2010 2011 2012 2013

Incentive 2% 1% 1%

Penalty - 1% 1% 1.5%

Relationship of eRx Incentives

Medicare MU Medicaid MU

eRx No Yes

CMS clarification: Reporting eRx codes will not

impede receiving MU incentives.

eRx Recommendation

1. Report >25 eRx G codes (8553) in the

first 6 months of 2011

2. Maximize eRx utilization ASAP

Medicaid Eligibility

What qualifies as a Medicaid

encounter?

1. If you qualify for Medicaid, do it now (AIU – Adopting, Implementing and Upgrading)

2. State of Michigan administers this program over the course of 6 years, no money has been issues by the state to date

3. For example: 2011 (AIU), 2012 (Skip), 2013 (Attest for Meaningful Use for 90 days, this starts your year one of the program)

4. $$ differences that you are eligible to receive ($44,000 verses $63,750 maximum)

Randi Terry

Who Qualifies? Eligible Professionals

Medicare Medicaid

•Doctor of medicine or osteopathy

•Doctor of dental surgery or dental medicine

•Doctor of podiatric medicine •Doctor of optometry •Chiropractor

•Physicians •Dentists •Certified nurse midwives •Nurse practitioners •Physicians assistants (in rural

health clinic or FQHC led by a physician assistant)

Requires minimum 30% Medicaid patient mix (20% for Pediatrics)

Medicare EPs may not be hospital-based

What is included in the 30 %

(20% of Pediatrics) patient mix

• Asked MCEITA for further clarification, per MCEITA, the definition of Medicaid is: – For the purpose of this program, Medicaid is defined as any

program administered by the state authorized under Title 19 of the Social Security Act.

– This includes both fee-for-service and managed care. – It does not include any other program or programs authorized

under Title 21 for the Social Security Act, including the Children's Health Insurance Program (CHIP, known as MIChild in Michigan).

• Medicaid Managed Care includes the following plans: – PHP of Mid Michigan Family Care, OMNICARE, Great Lakes

Health Plan, Midwest Health Plan, CareSource MI, HealthPlus Partners, Upper Peninsula Health Plan, Molina Healthcare of MI, Health Plan of MI, Total Health Care, Priority Health Govt Programs, BlueCaid, McLaren Health Plan, Procare Health Plan

Here is a list of the Title 19

programs in Michigan that can

be included in Medicaid portion

of the eligible patient volume

ALMB Additional Low Income Medicare

Beneficiary BMP Beneficiary Monitoring Program CWP Children's Home and Community Based

Services Waiver SED Children's Serious Emotional Disturbance

Waiver Program SED-

DHS Children‟s Serious Emotional Disturbance

Waiver-DHS CMH Community Mental Health ESRD End Stage Renal Disease Plan

First Family Planning Waiver

MA Full Fee-for-Service Medicaid HSW Habilitation Supports Waiver Program MI

Choice Home and Community Based Waiver

Services Hospic

e Hospice

Hospic

e-18 Hospice Medicare Benefit Plan

INCAR-

ESO Incarceration - Emergency Services

INCAR-

MA Incarceration - MA

INCAR-

MA-E Incarceration - MA - Emergency Services

INCAR Incarceration - Other ICF/MR-

DD Intermediate Care Facility for Mental

Retarded - DD MA-MC Medicaid Managed Care MA-

ESO Medical Assistance Emergency Services

Spendo

wn Medical Spend-down

NH Nursing Home PIHP Prepaid Inpatient Health Plan PACE Program All-Inclusive Care for Elderly QDWI Qualified Disabled Working Individual QMB Qualified Medicare Beneficiary - All Inclusive SLMB Special Low Income Medicare Beneficiary SPF State Psychiatric Hospital SA Substance Abuse

Registration and Attestation

• Registration

• Medicaid AIU Submission

• Attestation

Randi Terry and Joe Cook, DO

Registration

• Do it NOW (even the CMS says to register now, there is no downside

other than you can only change from Medicaid to Medicare)

• What is needed to register:

– Active NPI number and NPPES Web User Account

– Tax Identifier Number (SS #)

– Medicare verse Medicaid

– Address, email (doesn‟t have to be yours

– Latest version of Internet Explorer

• Resources available

– https://ehrincentives.cms.gov

– Helpdesk number (MCEITA (888-MICHEHR) and CMS (888-734-

6433)

• April 18th Proxy Rights (you can attest, Meaningful Users Jan, Feb and

March)

Medicaid AIU Submission

• You do not have to be a meaningful use, YET

to submit for AIU

• Must first register at the CMS site

• Sent a letter to log into the state (Michigan

Department of Community Health) with your

NLR Registration Number.

• Must have an approved CHAMPS number

• www.michiganhealthit.org/EHR

• Must have encounter and discharge data

Attestation

• ONCE you have achieved Meaningful Use (with 90

consecutive days in the calendar year), you can

attest

• Must go to CHPL List and obtain an # (Certified HIT

Product List) – http://onc-chpl.force.com/ehrcert.

• Must go to Ambulatory Practice Type, select vendor

name (add to cart), select “Get CMS E.H.R

Certification ID”

• If you use one vendor for all requirements, the

number will be the same for everyone, but if you

certify using different modular certification, your

number will be unique

Security Risk Analysis

Joe Cook, DO

Randi Terry

MU Security

Risk Analysis Requirement

• “Conduct or review a security risk analysis

in accordance with 45 CFR 164.308 (a)

(1) and implement security updates as

necessary and correct identified security

deficiencies as part of it‟s risk

management process”

45 CFR 164.308 (A) (1)

“Implement policies and procedures to

prevent, detect, contain, and correct

security violations.”

45 CFR 164.308 (a) (1)

1. Risk Analysis

2. Risk Management

3. Sanction Policy

4. Information System Activity Review

45 CFR 164.308 (a) (1)

RISK ANALYSIS

“Conduct an accurate and thorough

assessment of the potential risks and

vulnerabilities to the confidentiality, integrity,

and availability of electronic protected health

information held by the covered entity”.

Risk Analysis

Recommendation and Tools

1. Individual practice due diligence

2. Proprietary tools

3. Examples

– Ambulatory EHR Security Risk Analysis A (sample

copy provided on Munson Website for physicians)

– Ambulatory EHR Security Risk Analysis B (sample

copy provided on Munson Website for physicians)

4. Timing

– During 2011

Interconnectivity and

Munson‟s Role

Briggs Pille

Randi Terry

Interconnectivity

• We are pursuing CEMR (Community

EMR) for hosted EMR‟s (Next Gen and

eCW).

• Non Hosted and other EMR‟s: – Talk to your vendor about requirements

– Munson Healthcare is willing to assist with Stage 1

testing of data exchange. (ie. Munson will be test

recipient.)

– There may be a cost from your vendor related to

the interface

If you have an EMR, how do

you look?

Inside 4 practices we

evaluated

Briggs Pille

Rating Scale

The following rating scale is used in the next two slides

Sample Hosted Practice – Core Requirements

Practic

e

1

Practic

e

2

Practic

e

3

Practice

4

The chart below shows the status of two sample practice for each ambulatory solution.

The first table is for the Core Stage 1 requirements that all EPs must meet to achieve MU.

Sample Hosted Practices – Menu Requirements

Practic

e

1

Practic

e

2

Practic

e

3

Practice

4

The following Menu requirements are considered good targets for most EPs:

• #1 Drug-Drug Formulary Checks

• #3 Structure Lab Results

• #4 Generate Patient Lists by Condition

• #8 Medication Reconciliation on Transfer

• #10 Submission to Immunization Registry

Each EP must select 5 Menu items to complete for Stage 1,

including at least one public health measure (10, 11, or 12).

Clinical Decision Support Rule

Briggs Pille

• Objective: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule

• Drug-Drug and Drug-Allergy interactions cannot be used to meet this objective

CDS Rule Example

• A rule should use EMR data to provide an

appropriate notification at an appropriate time

• For Example:

– Medication to be avoided during pregnancy.

– Diabetes A1C test reminder

– Mammogram -- Women 40 and over: yearly

• EP‟s must find a rule appropriate for their practice

• Other examples:

– See your vendor (MCEITA will have examples for NextGen

and eCw after meeting)

– www.informatics-review.com/wiki/index.php/cds

Clinical Decision Support Rule

• The Federal Drug Administration has published guidelines for labeling medications for potential teratogenic effects. These guidelines establish 5 risk categories.

– Category A: Adequate and well controlled studies in pregnant women have not shown an increase in risk of fetal abnormalities.

Examples: Levothyroxine,Potassium Chloride, Folic Acid

– Category B: Animal reproductive studies have failed to show risk and no adequate or well-controlled studies in pregnant women.

Examples: Ampicillin, Insulin, Budesimide, Vancomycin

– Category C: Animal reproductive studies have shown a risk the fetus and no adequate or well-controlled studies in pregnant women. The labeling does include that potential benefit of the drug may outweigh the potential risk.

Examples: Albuterol, Heparin, Miconizole, Digoxin

– Category D: Positive evidence of human fetal risk based on use or studies in humans. Includes a risk/benefit statement for use in serious or life threatening disease.

Examples: Lithium, Diazepam, Vincristine, Imipramine, Doxycycline

– Category X: Positive evidence of animal or human fetal abnormalities. Risk the use of the drug clearly outweighs benefit.

Examples: Ribaviron, Estradiol, Isotretinoin

Clinical Decision Support Rule

Patient overdue for hemoglobin A1c

• if the patient

– has diabetes on their problem list,

– is <100 years old,

– is not terminally ill,

– does not have a flag indicating that the HbA1c is

not clinically indicated,

– has not had a HbA1c in the last 12 months

• Then suggest a HbA1c

• Clinical reminders example:

– Mammogram -- Women 40 and over: yearly

Quality Measures

Have to report, You don‟t have to be “good”

PQRI Measures verses Quality Measures

Specialty Practices

Core/Menu Requirements verses Quality Measures

Briggs Pille

Stage 1 EP Quality Measures

2011-2012

• The HITECH Act required that in selecting clinical quality measures CMS give preference to those endorsed by the National Quality Forum.

• All of the measures selected have current electronic specifications and broad applicability to the range of Medicare-designated specialties and the services provided by Eps

• The 44 clinical quality measures are comprised of three types: – three core measures,

– three alternate core measures,

– and 38 additional measures.

• For the 2011 and 2012 reporting periods, EPs must submit calculated results for a total of six measures: three core measures and three of the 38 additional quality measures

• In instances where the denominator for one or more of the core measures is zero, the provider must report results for up to three of the alternate core measures

No Reporting Exclusions

• CMS does not delineate which measures may or may not apply for particular specialties

• EPs need only report the required clinical quality measures. Value may be zero for the numerator, denominator, or exclusions for any or all of those fields, if these are the results as displayed by the certified EHR technology

• For reporting in 2011 and 2012, CMS does not require the measures to meet any particular thresholds or, in all cases, to have patients that fall within the denominator of the measure.

• The final rule does not include exemptions. An EP will not be excluded from reporting any core, alternate, or additional clinical quality measures because the measure does not apply to the EP‟s scope of practice or patient population

• EPs are not excluded if zeros are reported in the denominator values. EPs are not penalized in the Stage 1 reporting years as long as they have adopted a certified EHR, it calculates the measures, and the EP submits the required information as defined in the final rule

Stage 1 Core and Alternative Measures

NQF Measure Number &

PQRI Implementation

Number

Clinical Quality Measure Title

NQF 0013 Title: Hypertension: Blood Pressure Measurement

NQF 0028 Title: Preventive Care and Screening Measure Pair:

a. Tobacco Use Assessment

b. Tobacco Cessation Intervention

NQF 0421 PQRI 128 Title: Adult Weight Screening and Follow-up

Alternative Core Measures

NQF 0024 Title: Weight Assessment and Counseling for Children and

Adolescents

NQF 0041 PQRI 100 Title: Preventive Care and Screening: Influenza Immunization

for Patient > 50 Years Old

NAF 0038 Title: Childhood Immunization Status

Detailed specification for each measure can be found at:

http://www.cms.gov/QualityMeasures/03_ElectronicSpecifications.asp#TopOfPage

Portal Requirements

Briggs Pille

Patient Information Related

Stage 1

• None of these requirements specifically require or mandate a patient

portal

• A portal could help an EP of Practice achieve these requirements

Vendor Specifics

• eCW requires eHx Hub for Stage 1

requirements. eHx Hub also includes a

portal

• Next Gen indicates that their “preferred”

solution is the Patient Portal

• Check with your ambulatory EMR

vendor for their requirements

Stage 2 and Stage 3

Briggs Pille

Stage 2 Meaningful Use

• Stage 2 Meaningful Use Requirements Hospitals and EPs

that qualify for meaningful use in 2011 under Stage 1 will

need to meet Stage 2 requirements in 2013 in order to

receive an incentive payment.

• Hospitals and EPs whose first payment year is 2012 will need

to meet Stage 2 criteria in 2014.

• All hospitals and EPs will need to possess an EHR in 2013

that is certified against the certification criteria adopted for

Stage 2 regardless of the year they first enter the Medicare or

Medicaid EHR incentive programs.

Goals by Stages

Key Dates for Stage 2

• Q4 2011

– CMS publishes NPRM on Stage 2 Criteria

– ONC publishes Interim Final Rule on

standards and certification for Stage 2

• Mid-to-late 2012

– Final rules for Stage 2 published

Stage 2 & 3: Major changes from Stage 1

50

Requirements Stage 2 Stage 3

CPOE Increase to 60%

Include med, lab & rad orders

80%

eRX 50% med orders (EP & hospital

discharge)

80%

Clinical Quality

Measures

TBD TBD

Clinical Decision

Support (CDS)

Use CDS Rules on high priority

conditions

Use CDS Rules to improve

performance

Patient lists Generate pt list for multiple

parameters

Use pt lists to manage

high-priority patients

HIE Connect to at least 3 external

providers in primary referral

network or 1 HIE

Connect to 30% of external

providers or 1 HIE

Med Rec 80% 90%

Other All Stage 1 menu items required Problem list, meds, allergy

lists are „up-to-date‟

Stage 2 & 3: Major New Criteria

51

Requirement Hospital EP

Clinical

Documentation

Physician, PA, NP Notes

Electronic MAR

Physician Notes

Patient Portal Electronic „relevant

information‟ about

hospital encounter

Download relevant information

about a clinical encounter

Download data from a longitudinal

record

20% of patient use a web-based

portal (30% in Stage 3)

Use online patient messaging

Continuity of

Care

List of care team

members

Longitudinal care plan for

pts with high-priority

conditions

List of care team members

Longitudinal care plan for pts with

high-priority conditions

Help and Questions

E.H.R. Helpline

MCEITA – Peggy Losey, 517-614-8636

MCEITA General Number – 888-MICHEHR

CMS Website (cms.gov/ehrincentiveprograms)