Slide 1 - Harvard School of Public Health

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					  Meaningful Use of HIT:
Getting There is Half the Fun!

         16 November 2009
                                       Karen M. Bell, MD, MMS
                Senior Vice President, HIT Services, MASSPRO
                   Former Director, Office of Health IT Adoption
                           Office of the National Coordinator for
                          Health Information Technology (ONC)
Why “meaningful use?”

 Appropriate and immediate access to secure and
 reliable comprehensive health information by
 appropriately authorized parties to:
  • Coordinate safer, more effective and timely patient care
    among providers
  • Communicate with and care for patients, whenever and
    wherever they may be
  • Enable individuals to better manage their own health
  • Support community
    health efforts through
    public health, surveillance,
    and enhanced research

State EHR (EMR) Adoption:
US Physicians, 2008 Desroches et al:   NEJM July 3, 2008

   • Range up to 30% using some functions
   • 17% with electronic note keeping, lab and
     med orders, and ability to obtain lab
   • 9% of solo physicians
   • 30%, 11-50 physicians in practice
   • 50%, >50 physicians in practice
   • 3X more prevalent in metropolitan areas

State of Adoption: 2008

  • Hospitals: 11% fully implemented (not full
    MD use), but >80% can view lab/radiology

  • Regional Health Information Organizations
    (RHIO): Handful exchanging lab and/or
    administrative data

  • Patients: Very low uptake of PHRs, though
    higher access to clinical data through
    portals into provider based EHRs.            4
Office of the National Coordinator/HHS

  Identify barriers and enablers of widespread
  national adoption of HIT and coordinate
  Federal activities which will address these
  barriers and enablers through:
   • Legislation, regulation, and guidance
   • Reimbursement
   • Procurement (contractual conditions)
   • Grants, pilot projects, demonstrations
   • Partnerships and collaborations

A Hierarchy of Recommendations
for Widespread Adoption of HIT


                    Education and O
                  Payment: enhanced
                   reimbursement or
                   Products: secure,
                 interoperable, usable,
                functional, inexpensive

              Privacy: principles, policies,
                 procedure, protections

Privacy Foundation

• Health Information Portability and
  Accountability Act of 1996
     - Constructed in a paper environment
     - Did not anticipate information sharing beyond the
       clinical and payer settings.
• Protection from discrimination based
  on disclosure of genetic information
  (GINA) April, 2006
• Privacy Principles for Secondary Uses,
  December, 2007, NCVHS Subcommittee
• Privacy Principles, December 2008
• “Harmonization” of state based regulation
Privacy and the ARRA (Title XIII, Section D)

  Definitions: (18) Breach to Vendor of PHR
  Security Provisions: updating security
   standards annually
  Notification of breach in <60 days and how
  Education: national initiative re uses of PHI
  Restrictions on disclosure: to health plans
   except when paid in full out of pocket,
   minimum for intended purpose, not
   applicable to de-identified data
Privacy and the ARRA (2)

  Prohibitions on sale of PHI
  Conditions on contacts as part of Health
    Care operations excludes marketing and
    remunerated communications
  Breaches from PHR vendors and other non-
    HIPAA covered entities
  Business Associate arrangements extended
    to HIEOs, PHRs, e-prescribing gateways
Privacy and the ARRA (3)

  Enforcement and penalties by states
   Attorneys General
  Damages not to exceed $25,000 in
  Corrective action conditions
  Provisions for periodic audits of
   covered entities and business
Product: Secure, Interoperable, Functional, Useable

  CCHIT founded in 2005, a Recognized Certifying
   Body, for ambulatory and inpatient EHRs
  • Multi-stakeholder public/private partnership with a public
  • Criteria for functionality, security, and interoperability

  HIT Standards Committee now focusing on
    interoperability of elements supporting
    meaningful use, with implementation guidance

  New certification processes which focus on
   meaningful use                                                11
Paying for HIT:
the Business Case for the Delivery System
  • Stark amendment and anti-kickback relief
    allowing hospital donations to physicians
  • HRSA grants to rural and community based
    federally qualified health centers
  • Malpractice fee credits
  • Selected private and public (CMS demonstration
    project) insurer incentives based on adoption
    and effective use of EHR functions

  Stimulus Package Incentives for
   Meaningful Use of EHRs!!!!!!!

  Medicare Incentives for Eligible Professionals (Physicians)

  •   Incentives are paid through Medicare Part B and are for eligible
      professionals that are “meaningful” EHR users. These payments are not
      available for providers based primarily in hospitals. Incentive amounts can
      be up to the following:

       1st year - $15K ($18K if 2011 or 2012)
       2nd year - $12K
       3rd year - $8K
       4th year - $4K
       5th year - $2K

  •   No incentive payments for those adopting after 2014. All incentives end in

  •   10% increase in incentive payments for providers in a “health professional
      shortage area.”
ARRA, Title IV

  Medicare Incentives for Hospitals

  •   For hospitals that are meaningful users of certified EHRs, paid out of Medicare Part A
      beginning in 2011. Secretary to improve use of EHRs and quality over time by
      requiring more stringent measures of meaningful use, and Secretary will select quality

  •   Payments equal to up to $2 million, plus formula-determined payments based on
      number of Medicare payments and transitional considerations. For discharges
      between 1150 and 23,000 patients, hospitals receive $200 per discharge.

  •   Four year incentive payment schedule: 100%, 75%, 50%, 25%. No incentives for
      adoption after 2015.

  •   CMS website to post list of hospitals that are meaningful EHR users.

  •   Hospitals that fail to adopt will be penalized beginning in 2015.

  •   Secretary may exempt hospitals on a case-by-case basis, not to exceed 5 years   .
ARRA, Title IV

  Medicaid Incentives
  • Professionals who are not hospital-based and have at least 30
    percent patient volume attributable to individuals on Medicaid;
  • Pediatricians who are not hospital-based and who have at least 20
    percent patient volume attributable to Medicaid;
  • Professionals who practices predominantly in a Federally qualified
    health center or rural health clinic and have at least 30 percent
    patient volume attributable to needy individuals;
  • Children's hospitals; and
  • Acute-care hospitals that have at least 10 percent of the hospital's
    patient volume attributable to Medicaid.
  • The Medicaid incentive payments are up to 85% of the costs for
    certified EHR technology and support services, up to a maximum of
    $21,250 in the first year and $8,500 in a subsequent year.
  • Payments can only be made for a maximum of five years, and in no
    event after 2021.
  • CMS is to receive $100 million annually to run this program.
Meaningful Use

  Five Priorities, each with its own care Goals,
    Objectives, and Measures for 2011, 2013, and
  • Improve quality, safety, efficiency and reduce
  • Engage patients and families
  • Improve care coordination
  • Improve population and public health
  • Ensure adequate privacy and security
    protections for personal health information
“Executive Summary”: Meaningful Use

  Capture and use structured data in EHR
  • population management and CDS
  • E-prescribe
  • Coordinate care across multiple providers
  • Administrative simplification

  Provide patients access to their personal health information
  Report out data in reliable, secure, interoperable formats

  Optimize workflows and information access to demonstrably improve
    care and patient safety

  denotes HIE dependency
Provider Support/Education

  $600 M HIT Regional Extension Program to assist health
    care providers to adopt, implement, and meaningfully
    use certified EHR technology through 70 Centers.

  • Prioritizes Critical Access, not for profit or public hospitals; FQHCs;
    underserved areas; solo or small group practices in primary care

  • Announced in August, first set preliminary applications Sept 11, final
    applications Nov 3, funding December 11

  • Average funding per MD: $5000

  • RECs to be self-sustaining in two years

  • Incentives for all prescribers, but MU and REC’s narrowly scoped to
    primary care
Population Health and Health Information Exchange

  • Multiple and multiple types of efferent and
    afferent nodes
  • Requires multi-stakeholder governance
  • Incorporates HITSP interoperability standards
  • Requirements for master patient index, patient
    identity proofing, authentication, authorization
  • Consistent statutes, regulation, and processes
    across state lines for interstate exchange
  • Elusive business case at the local level, a
    robust business case for third party users (gov)
$600 M to States (or SDE’s) for HIE

  ARRA Title XIII, Section 3013

   Directs the Secretary, acting through ONC, to establish a
    program to facilitate health information exchange and
    expand the electronic movement and use of health
    information among organizations according to national
    standards for care, public health, and quality reporting

   Grants may be Planning Grants or Implementation

   To qualify for an implementation grant a State must
    submit a strategic plan for HIT that describes how the
    work will progress for the Secretary’s approval.
Key Issues for Statewide HIE

  Architecture (e.g., federated vs centralized data)
  Level of granularity of patient control
  Creation of master patient index, record locator
    services, authentication processes
  Encryption processes
  Priorities for HIE
  Types of information appropriate for Statewide HIE
    (within state legal framework)
  Business case for sustainability
Summary: 24 months to go after NPRM

 Meaningful Use of EHRs requires careful
  attention to its prerequisites (including HIE)
  and how they fit together
 • Statewide/Nationwide HIE needs to be built right, or
   “they will not come”
 • HIE beyond care in a specified (firewalled) environment
   will require enhanced privacy protections and security
 • Attention must be paid to product design/ cost, and
   provider support/engagement for EHR adoption and MU
 • Will need to accommodate all providers and required
   recipients of health care data
For More Information: