Meaningful Use, the Maine Regional Extension Center, and Critical

Access Hospitals

Office of Rural Health and Primary CareCAH CEO Meeting

October 6, 2010

Shaun Alfreds – HealthInfoNet & Maine Regional Extension Center

HealthInfoNet: Maine’s Health Information Exchange Organization

• Our mission is to develop, promote and sustain an integrated, secure and reliable regional information network dedicated to delivering authorized, rapid access to person-specific healthcare data across points of care that will support:

• Improved patient safety

• Enhanced quality of clinical care

• Increased clinical and administrative efficiency

• Reduced duplication of services

• Enhanced identification of threats to public health

• Expanded consumers access to their own

personal health care information

• Independent 501(c)(3) Tax Exempt Public-Private Partnership

• Multi-stakeholder “private/public” Organization Involving Consumers, Providers, Payers, Business and Government

22

Acronym Soup!• ARRA-American Recovery and Reinvestment Act of 2009• CMS-Centers for Medicare and Medicaid Services• EMR-Electronic Health Records• HHS-Health and Human Services• HIN-HealthInfoNet• HIE-Health Information Exchange• HIT-Health Information Technology• IOO – Implementation Optimization Organization• MEREC-Maine Regional Extension Center• PPACA-Patient Protection and Affordable Care Act (sometimes also referenced as “ACA” –

Affordable Care Act)• ONC-Office of the National Coordinator for Health Information Technology• QC-Quality Counts• REC-Regional Extension Center• SEMRV – Supported EMR Vendor

3

Objectives

• Introduce ARRA/CMS incentives for EMR adoption• “Meaningful Use” – what it means for Maine CAHs• MEREC core & direct services

• Support structure• Technical assistance

• Next steps – input on assistance needed

4

Federal Stimulus Funding & Health Care Reform: Why?

Currently US healthcare system is…• Expensive: we spend more on healthcare than any other

nation• Ineffective: many low quality outcomes on standards

comparable to other countries• Fraught with high rates of medical errors• Not universally accessible• Structured in manner that is unsustainable with

impending workforce shortages

5

Why Emphasis on HIT?

HIT and EMRs have potential to:• Improve quality, safety, efficiency, and reduce

health disparities• Engage patients and families in their health care• Improve care coordination• Protect privacy and security of personal health

information• Improve population and public health

6

Known Barriers to EMR Adoption

7

• Cost• Lack of standards (interoperability)• Privacy and confidentiality concerns• Resistance to change• Workforce issues• Complexity of the change

ARRA & HITECH

• Feb 17, 2009 – a day that changed everything!• ARRA - $19B for adoption of health IT

• $17B in incentives for EMR adoption - starting 2011• Penalties for non-EMR use by 2015

• Supported by subsequent federal healthcare reform (PPACA) with increased focus on transparency, payment reform, accountability for outcomes

• (For light-hearted look, see “HITECH: An Interoperetta in Three Acts”: http://www.youtube.com/watch?v=Gv1s8fM3mMk)

8

A Busy Year…

ARRAHITECH Act

David Blumenthal Named National Coordinator

FOA Release for RECs

ONC Reorganized;Interim Meaningful Use Rule

Cycle 2: MEREC Awarded

Meaningful Use Final Rule

Cycle 1 RECs Awarded

Feb ‘09 Aug ‘09 Feb ‘10 Mar ‘10 Jul ‘10Apr ‘09 May ‘10Dec ‘09

EMR Certification Rule

Jun ‘10

Healthcare Reform

9

Bending the Curve Towards Transformed Health

Achieving Meaningful Use of Health Data

2009 2011 2013 2015

10

11

Quality reporting

Clinical Decision Support

Improving care coordination

Engaging patients

Managing Population Health

Meaningful Use

Quality Im

provement

Techn

ology

Practice

Redesig

n

Exchange

Meaningful Use = Health Care Transformation

How Does a Provider/Hospital Achieve Meaningful Use?

• Use of a “Certified EMR” in a meaningful manner– Certification Commission for HIT (CCHIT)

– Drummond Group Inc. (DGI)

– InfoGard Laboratories Inc.

• Electronically exchange health information (between unaffiliated organizations) to improve the quality of care

– Connect to HealthInfoNet

– Connect directly (point-to-point)

• Report on clinical quality measures

12

Meaningful Use – Who is Eligible?

Eligible Providers - Medicare Eligible Providers - Medicaid

Eligible Professionals (EPs)* Eligible Professionals (EPs)Doctor of Medicine or Osteopathy Physicians (Pediatricians have special eligibility

& payment rules)

Doctor of Dental Surgery or Dental Medicine Nurse Practitioners (NPs)

Doctor of Podiatric Medicine Certified Nurse-Midwives (CNMs)

Doctor of Optometry Dentists

Chiropractor Physician Assistants (PAs) who lead a FQHC) or rural health clinic

Eligible Hospitals* Eligible Hospitals

Acute Care Hospitals Acute Care Hospitals, Critical Access Hospitals

Critical Access Hospitals (CAHs) Children’s Hospitals

* Hospital-based professionals excluded from incentives

What is “Meaningful Use” of EMR for CAHs?

• Core Objectives (14 of 14)– Certified Provider Order Entry (CPOE)– Maintain Active Problem Lists– Reporting on Clinical Quality Measures (CQMs) (15

of 15 CQMs)

• Menu Set Objectives (5 of 10)– Generate lists of patients by specific conditions– Capture clinical lab results in structured format– Implement drug formulary checks

14

Medicare Incentives for CAHs

• Reasonable costs incurred for:– Purchase of depreciable assets (hardware /

software) necessary to administer a certified EMR during the reporting period

– Any similar incurred costs from previous cost reporting periods to the extent they have not been fully depreciated

– CAHs Medicare Share = Medicare Share for Eligible Hospitals including charity care +

• 20 percentage points (used instead of the 101% typically applied to reasonable costs)

15

Medicare Incentives for CAHs

• Must achieve MU by 2013 to receive full incentive

• Only consecutive annual payments available• Payment duration – 2011-2016 (4 yrs)• Reductions in reimbursement if not a

meaningful user in FY 2015– FY2015: 101% of reasonable costs to 100.66%– FY2016: to 100.33%– FY2017 and Subsequent Years: 100%

• Exemptions and appeals allowed

16

Medicaid Incentives for CAHs

• 1st Year Alternative for Meaningful Use– Adopt, implement or upgrade – Certified EMR by ONC (see above)– Qualifies for 1st year payment

• Reports on Clinical Quality Measures– 1st year by self attestation– Report numerator, denominator, and exclusion data– Subsequent years – electronic submission

• $2M base year plus $ per discharge• Non-consecutive payments available• MaineCare currently developing strategy

17

Stage 1 Meaningful Use Criteria for EHs

Core (all 14)

1. CPOE2. Drug-drug / drug-allergy 3. Demographics4. One CDSS rule implemented5. Up to date problem list6. Active medication list7. Active medication/allergy list8. Record and chart vital signs9. Smoking status (13 and older)10. Hospital CQMs11. Patient e-copy of records12. Patient e-copy of discharge

instructions13. Health Information Exchange14. Protection of Privacy

Menu (select any 5)1. Drug formulary checks2. Record advance directives3. Incorporate lab results as structured

data4. Generate lists of patients by specific

conditions5. Patient specific education provisions

through EMR6. Medication reconciliation7. Summary of care record for each care

transition8. Capability to submit data to

immunization registries9. Capability to submit lab results to

public agencies10. Capability to submit syndromic

surveillance to public agencies

18

Stage 1 Meaningful Use Criteria for EPs

Core (all 15)1. Patient demographics2. Vital signs 3. Problem list 4. Medication list 5. Allergy list6. Smoking status 7. Clinical summaries 8. E-copy of health information 9. E-RX10. CPOE11. Drug-drug-allergy check12. E-information exchange13. Clinical decision support rule14. Protection of Privacy15. Clinical Quality Measures

Menu (select any 5)

1. Drug formulary checks2. Incorporate structured lab data3. Generate patient lists for QI

etc.4. Indentify pt specific education

material5. Medication reconciliation6. Summary of care in transitions7. E-submission of immunizations8. E-submission of surveillance

data9. Patient reminders10. Electronic patient portal

19

Clinical Quality Measures: Eligible Hospitals and CAHs

1. Emergency Department Throughput – admitted patients median time from ED arrival to ED departure for admitted patients

2. Emergency Department Throughput – admitted patients – Admission decision time to ED departure time for admitted patients

3. Ischemic stroke – Discharge on anti-thrombotics4. Ischemic stroke – Anticoagulation for A-fib/flutter5. Ischemic stroke – Thrombolytic therapy for patients arriving within

2 hours of symptom onset6. Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 27. Ischemic stroke – Discharge on statins8. Ischemic or hemorrhagic stroke – Stroke education9. Ischemic or hemorrhagic stroke – Rehabilitation assessment10. VTE prophylaxis within 24 hours of arrival11. Intensive Care Unit VTE prophylaxis12. Anticoagulation overlap therapy13. Platelet monitoring on unfractionated heparin14. VTE discharge instructions15. Incidence of potentially preventable VTE

2020

Framework for The Regional Extension Center (REC)

• Based on Agricultural Extension Service Model• Organized out of the Office of National Coordinator

(ONC) - HIN was awarded to service the State of Maine• Total grant award =$4.7 Million over 2010-2011• $1 Million committed to “core service” requirements• $3.7 Million paid to EMR vendors/suppliers for “direct services”

for 1002 “Priority Primary Care Providers”• $264K for Critical Access Hospitals (CAH)

• Focused on optimizing EMR adoption and utilization by PCPs and CAHs

• REC gets 90/10 federal match years 1 & 2

21

Framework for The Regional Extension Center (REC) Cont.

• REC supports to be delivered to Primary Care Providers and CAHs. Primary care providers include: • Licensed doctors of medicine or osteopathy in:

• Family practice, • Obstetrics and gynecology, • General internal or pediatric medicine,

• PAs, NPs in these specialties.

• To qualify, practitioners must also treat patients in:• Individual and small group practices that are predominantly

focused on primary care• Outpatient clinics associated with public and non-profit CAHs• Community Health Centers and Rural Health Clinics• Other settings that primarily serve uninsured, underinsured, and

medically underserved populations

22

The Maine Regional Extension Center (MEREC)

Mission: Over the next 2 years HealthInfoNet, the Maine REC will manage a process of group purchasing, service contracting and support services targeted at implementing and optimizing the use of EMRs in Maine. The objectives are to:•Drive down the cost of investment in interoperable EMRs•Help providers and CAHs successfully implement and optimize the use of EMRs in conjunction with “meaningful use” criteria•Deliver interoperability between individual EMR implementations and the Health Information Exchange to

• Better coordinate care, • Improve patient safety, • Improve quality outcomes, and • Manage reductions in duplicate testing and other areas of

cost.23

Maine Regional Extension Center (MEREC) Service Area

Service Area Statistics

All Counties within Maine ME Congressional

Districts 1 & 2 Total Population : 1.3 M 3,500 Providers 1,634 Primary Care Providers 1,002 Priority Primary Care

Providers 15 CAHs Total Patients Served by HIE:

792,722

24

How Does The Money Flow?

• Funds awarded to Maine REC - paid to suppliers/vendors delivering EMR installation, implementation and optimization services

• Payments spread over three milestones:– Contract executed between provider organization & REC– Provider organization achieves use of certified EMR including

use of e-prescribing & quality reporting– Provider achieves “Meaningful Use” criteria and is exchanging

information with the statewide HIE

• REC reports achievement of milestones to ONC quarterly to release funds

25

Maine REC Services Structure

HealthInfoNet(Prime Contractor)

HealthInfoNet(Prime Contractor)

HealthInfoNet Contract Office

(REC Direct Service

Brokerage)

HealthInfoNet Contract Office

(REC Direct Service

Brokerage)

Brokerage for REC Direct

Services• Request for Proposal (RFP)

Process for all Direct REC

Services• Vendor Neutral Contracting• Implementation

Optimization

Organizations (IOOs)• EMR

• Vendors• Wholesale Providers

Brokerage for REC Direct

Services• Request for Proposal (RFP)

Process for all Direct REC

Services• Vendor Neutral Contracting• Implementation

Optimization

Organizations (IOOs)• EMR

• Vendors• Wholesale Providers

Direct Services• Practice Workflow

Redesign• EMR Implementation• eRx Implementation

Support• Meaningful Use

Compliance• Quality Improvement

Services

Direct Services• Practice Workflow

Redesign• EMR Implementation• eRx Implementation

Support• Meaningful Use

Compliance• Quality Improvement

Services

REC Contracts

REC Contracts

Core Services (HIN and Partners)• Vendor Selection and Group

Purchase• Education and Outreach• National Learning Consortium • Functional Interoperability HIE• Privacy and Security Best

Practices• Quality & Reporting• Local Workforce Development

through Partnership with OSC

Core Services (HIN and Partners)• Vendor Selection and Group

Purchase• Education and Outreach• National Learning Consortium • Functional Interoperability HIE• Privacy and Security Best

Practices• Quality & Reporting• Local Workforce Development

through Partnership with OSC

Retail(Unaffiliated Practices)

•Private Practices•Small-Med Groups•Independent Clinics / Hospitals

Retail(Unaffiliated Practices)

•Private Practices•Small-Med Groups•Independent Clinics / Hospitals

26

Wholesale(Affiliated Practices)

•Eastern Maine•MaineGeneral•Central Maine•Maine Health•Maine PCA•Nova Health•Franklin Memorial•Maine Coast•Martin’s Point•Mercy•St. Joseph’s•Western ME PHO•CAHs

Maine REC Technical Assistance Program

27

Role of REC “Wholesale” Partners

• Support owned/affiliated practices • EMR implementation and optimization • Meaningful use

• Drive meaningful quality improvement across organizations through the use of HIT• Optimize practice workflow and evidenced based practice• Drive quality by having the “right” information at the “right”

time leveraging HIE• Meet meaningful use criteria to enable CMS incentives

funding to flow• Meet statewide quality improvement guidelines

28

• Support EMR implementation for unaffiliated practices:

• Provide access to supported, low-cost EMR product(s)

• Vendor support for practice workflow redesign• EMR vendors and Implementation Optimization

Organization(s) (IOO)• Direct assistance for EMR implementation

• Vendor and IOO• Quality reporting• Education – through core supports

Maine REC Support – “Retail” Market

29

• “Wholesale” + “Retail” practices - i.e. all REC Supported practices:

• Educational tools, resources, & information• Collaborative learning opportunities

• Bi-annual “Learning Sessions” in 4 regions

• 1:1 Practice Quality Improvement Coaching• Encouraged for Wholesalers, provided to Retail practices• Build on existing provider/PHO QI staff

Maine REC Supports – All Providers

30

MEREC Education & Outreach

• One goal of the MEREC is to educate providers about EMR benefits, implementation and meaningful use

• MEREC will host regional forums, biannually to educate and enroll providers including primary care and critical access hospitals • First series late Oct – early Nov 2010• Subsequent series – Spring 2011, Fall 2011, Spring

2012, Fall 2012

31

MEREC Regional Forums

• Offered in partnership with Quality Counts• Four regional forums in Hallowell, Bangor,

Houlton and Portland• Audience – Primary care providers & CAH

hospital staff• Topic – EMR adoption and meaningful use in

primary care

32

Forum Objectives

• Raise awareness of MEREC services • Provide overview of technology and processes

involved in adopting EMR systems and demonstrating meaningful use.

• Discuss key considerations in implementing an EMR or optimizing existing systems

• Explain linkage between EMR use and medical home and quality improvement initiatives and requirements.

33

Forum Details

• Vendor area and networking• Refreshments provided• 1 CME credit offered• 4:00 – 8:00pm

– Hallowell,10/26– Houlton, 10/27– Bangor, 10/28– Portland, 11/9

• RSVP to rec@hinfonet.org

34

THANK YOU! For More Information:

• HealthInfoNet:• Shaun T. Alfreds, COO (salfreds@hinfonet.org )• Todd Rogow, REC Director (trogow@hinfonet.org)• Web resources:

• http://www.hinfonet.org• http://www.youtube.com/user/HealthInfoNet

• CMS: http://www.cms.gov/EMRIncentivePrograms

35