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• A New Landscape
• Meaningful Use
  – Definition
  – Overview of Final Rule
  – Approach
  – Payment Alignment
  – Final Rule: Objectives and Measurements
• Key Success Factors
    A New Landscape

  Health Information Technology
  Federal Landscape
• Office of the National Coordinator (ONC)
   – Created in 2004 through an Executive Order
   – Set up to promote development of a nationwide HIT and health
     information exchange (HIE) structure, HIT policy coordination,
     establishing governance for the Nationwide Health Information
     Network (NHIN), etc.
• Nationwide Health Information Network
   – Ambitious modernization plan proposed by the U.S. government
     will move an entire nation from paper medical records to secure
     electronic medical records
   – ONC began to develop in 2004
   – Limited data exchange via several pilots

  Health Information Technology
  Federal Landscape continued
• Health Information Technology for Economic and Clinical
  Health Act (HITECH) – Part of the American Recovery and
  Reinvestment Act of 2009 (ARRA)
   – Appropriates billions of dollars in grants, loans, incentive
     payments, etc. to advance Health Information Technology (HIT)
     and Health Information Exchange (HIE) efforts across the nation
       • Codification and expansion of ONC
       • Creation of national IT policy and standards
       • Support for HIT adoption via “HIT Extension Program” (Regional
         Extension Centers)
       • State grants to promote HIE and support the development of HIT
       • Medicare and Medicaid incentives for EHR adoption based on
         “Meaningful Use” (MU)
       • Other funding for broadband technologies, telemedicine, comparative
         effectiveness research, etc.

    Meaningful Use

  What is Meaningful Use?

• Definition Components
   – Use of a certified EHR in a meaningful manner (e.g. e-
   – Use of certified EHR technology for electronic exchange of
     health information to improve the quality of care
   – Use of certified EHR technology to submit clinical quality
     measures (CQM) and other measures selected by the Secretary
• Definition harmonizes criteria across CMS programs as
  much as possible and coordinates with existing CMS
  quality initiatives
• Allows for staged implementation

  What is Meaningful Use? continued
• Closely aligns with ONC developed certification
   – Final rule on standards and certification criteria released July 13,
       • Established required capabilities, related standards and
         implementation specifications that certified EHR technology will
         need to minimally support meaningful use Stage 1
   – Final rule for temporary certification program released
       • Way for organizations to be authorized by ONC to test and certify
         EHR technology

  MU Final Rule Overview
• Released July 13, 2010
• Changes from Interim Final Rule published earlier this
   – Initial meaningful use criteria is “Stage 1”; two additional updates
     anticipated – “Stage 2” and “Stage 3” with criteria for Stage 2 to
     be updated by the end of 2011 and Stage 3 by the end of 2013
   – Allow for flexibility of choice; allowing providers to take different
     pathways to meaningful use
   – Stage 1: Reduction in achievement measurement levels
   – Reporting period – 90 days for first year; one year subsequently

Meaningful Use: Changes from the
                  NPRM                                            Final Rule
Meet all MU reporting objectives (“all or       Must meet “core set”/can defer 5 from optional
nothing”)                                       “menu set” (flexibility)

25 measures for EPs/23 for eligible hospitals   25 measures for EPs/24 for eligible hospitals

Measure thresholds range from 10% to 80%        Measure thresholds range from 10% to 80% of
of patients or orders (most at higher range)    patients or orders (most at lower to middle range)

Denominators – To calculate the threshold,      Denominators – No measures require manual
some measures required manual chart             chart review to calculate threshold
Administrative transactions (claims and         Administrative transactions removed
eligibility) included
Measures for Patient-Specific Education         Measures for Patient-Specific Education
Resources and Advanced Directives               Resources and Advanced Directives (for
discussed but not proposed                      hospitals) included

Meaningful Use: Changes from the
NPRM continued
                  NPRM                                              Final Rule
States could propose requirements                 States’ flexibility with Stage 1 MU is limited to
above/beyond MU floor, but not with               seeking CMS approval to require 4 public health-
additional EHR functionality                      related objectives to be core instead of menu
Core clinical quality measures (CQM) and          Modified Core CQM and removed specialty
specialty measure groups for EPs                  measure groups for EPs
90 CQM total for EPs                              44 CQM total for EPs – must report total of 6

CQM not all electronically specified at time of   All final CQM have electronic specifications at
NPRM                                              time of final rule publication

35 CQM total for eligible hospitals and 8         15 CQM total for eligible hospitals
alternate Medicaid CQM
5 CQM overlap with CHIPRA initial core set        4 CQM overlap with CHIPRA initial core set

 Meaningful Use
 Phased and Incremental Approach
                          HIT-Enabled Health Reform

          Stage 1
       Capture data in
       coded format;
                                           Stage 2
        data sharing
                                    Expand exchange of
                                   information in the most
                                 structured format possible;
                                      advanced clinical                          Stage 3
                                         processes             Focus on clinical decision support for high
                                         (est. 2013)                priority conditions, patient self
                                                                     management and access to
                                                               comprehensive data; improved outcomes
                                                                               (est. 2015)
Sources: eHI Webinar, January 8, 2010
and MU final rule July 13, 2010

  Incentive Payments for Eligible
• Payments based on Federal fiscal year; amount based
  on several factors, beginning with a $2 million base
  payment + per discharge amount (based on
  Medicare/Medicaid share)
• Hospitals meeting Medicare MU requirements may be
  deemed eligible for Medicaid payments
• Medicare payment adjustments begin in 2015; no
  Federal Medicaid payment adjustments
• Medicare hospitals: No payments after 2016
• Medicaid hospitals: Cannot initiate payments after 2016

Payments Aligned to Stages

  First                        Payment Year
  Year        2011      2012      2013        2014   2015+

     2011    Stage 1   Stage 1   Stage 2   Stage 2   TBD
     2012              Stage 1   Stage 1   Stage 2   TBD
     2013                        Stage 1   Stage 1   TBD
     2014                                  Stage 1   TBD
     2015+                                           TBD

   Eligible Hospital “Core” Objectives
• Use CPOE for medication orders       • Report quality measures to
• Implement drug to drug to drug         CMS or the states
  and drug allergy interaction         • Electronically exchange key
  checks                                 clinical information
• Record demographics                  • Provide patients with an
• Maintain an up-to-date problem         electronic copy of their health
  list                                   information, upon request
• Maintain active medication list      • Provide patients with an
• Maintain active medication allergy     electronic copy of their
  list                                   discharge instructions, upon
• Record and chart changes in vital    • Protect electronic health
  signs                                  information created or
• Record smoking status (age 13          maintained by certified EHR
  and older)
• Implement one clinical decision
  support rule (related to high-
  priority hospital condition)

   Eligible Hospital “Menu ” Objectives
• Drug-formulary checks                  • Summary of care record for
• Record advanced directives for           each transition of care/referrals
  patients 65 years or older             • Capability to submit electronic
• Incorporate clinical lab test            data to immunization registries/
  results as structured data               systems*
• Generate lists of patients by          • Capability to provide electronic
  specific conditions                      submission of reportable lab
• Use certified EHR technology             results to public health
  to identify patient-specific             agencies*
  education resources and                • Capability to provide electronic
  provide to patient, if                   syndromic surveillance data to
  appropriate                              public health agencies*
• Medication reconciliation
              *at least one public health objective must be

  Eligible Hospital Measurement Levels
  Revision Examples
• Use CPOE
   – Clarified to “more than 30% of unique patients” and “at least one
     medication order entered using CPOE”
• Record demographics
   – Changed from “at least 80%” to “more than 50% have
     demographics recorded as structured data”
• Record and chart changes in vital signs
   – Changed from “at least 80%” and “record blood pressure and
     BMI; additionally plot growth chart for children age 2 to 20” to
     “more than 50%...height, weight and blood pressure are
     recorded as structured data”
• Submit quality measures
   – For 2011 submit summary information to CMS based on
     attestation methodology of reporting clinical data; for 2012,
     electronically submit the measures

  Clinical Quality Measures (CQM)
• Submit aggregate CQM numerator, denominator, and
  exclusion data to CMS or the States by attestation in
• Electronically submit aggregate CQM numerator,
  denominator, and exclusion data to CMS or the States
  by attestation in 2012
• CMS’ goal to coordinate development and reporting with
  implementation of the Patient Protection and Affordable
  Care Act (ACA) and align PQRI and RHQDAPU

    Clinical Quality Measures (CQM)
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-thrombotics
4. Ischemic stroke –Anticoagulation for A-fib/flutter
5. Ischemic stroke –Thrombolytic therapy for patients arriving within 2 hours of symptom
6. Ischemic or hemorrhagic stroke –Antithrombotic therapy by day 2
7. Ischemic stroke –Discharge on statins
8. Ischemic or hemorrhagic stroke –Stroke education
9. Ischemic or hemorrhagic stroke –Rehabilitation assessment
10. VTE prophylaxis within 24 hours of arrival
11. Intensive Care Unit VTE prophylaxis
12. Anticoagulation overlap therapy
13. Platelet monitoring on unfractionated heparin
14. VTE discharge instructions
15. Incidence of potentially preventable VTE

  Key Success Factors
• Implement open architected systems that demonstrate
  interoperability; data must be exchanged intra-
  organizationally as well as inter-organizationally
   – Stage 2 will include greater emphasis on health information
     exchange across institutional boundaries
• Start collecting data now; establish benchmarks so that
  quality improvements can be demonstrated
• Utilize systems that illicit a high degree of flexibility;
  Stages 2 and 3 not finalized so eligible hospitals must be
  prepared; measures will be re-evaluated – possibly
  higher thresholds

  Contact Information
Denise Reeser, Founder and Managing Principal
New Heights Consulting, LLC
(410) 552-0360


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