BBAACCKKGGRROOUUNNDD What is The Recovery Act? The American Recovery and Reinvestment Act (ARRA) was a stimulus package signed in 2009 where a portion was given to The Dept of Health and Human Services Center for Medicare and Medicaid (CMS) and The Office of the National Coordinator (ONC) programs for healthcare information technology (HIT) and quality care related spending. What is the HITECH Act? It is the pairing of the CMS EHR incentive program and ONC policy & standards in ARRA. This ‘set’ of titles are what are cited as the Health Information Technology for Economic and Clinical Health Act. What is the EHR Incentive Program? CMS is using its ARRA money to provide/issue hospitals and physicians a financial incentive for their "meaningful use" of a certified Electronic Health Record (EHR.) The goal for meaningfully using EHR technology is to effectively achieve target health and efficiency goals including error reduction, electronic ordering, and e-prescribing/refill automation will be realized. What is Meaningful Use? ONC is using its ARRA money to establish HIT standards, policy, and rules to define the “meaningful use” referenced in the EHR incentive program.  “Meaningful use” implementation and objectives are divided into 3 stages: o Stage 1: Data Capture and Clinical Information Sharing o Stage 2: Electronic Clinical Ordering & Results Processing o Stage 3: Improved Outcomes & Patient Self-Access

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M MEEAANNIINNGGFFUULL U USSEE Purpose The purpose of meaningful use is to:  Improve quality, safety, efficiency, and reduce health disparities  Engage patients and families  Improve care coordination  Ensure adequate privacy and security protections for personal health information  Improve population and public health Important Dates    

April 2011 – Attestation for the Medicare EHR Incentive Program begins May 2011 – EHR Incentive Payments expected to begin October 1, 2011 – Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 for the Medicare EHR Incentive Program December 31, 2011 – Reporting year ends for eligible professionals

Reporting Reporting Period  First year: 90 consecutive days within same calendar year in first reporting period  Second payment year and beyond: reporting period is the entire payment year Reporting Mechanism  Stage 1: Attestation  Stage 2-3: TBD in next Final Ruling (current recommendation is live data submission)  Clinical Quality Reporting o 2011 by attestation o 2012 and beyond: Electronic submission Akbar Jiwani

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O OBBJJEECCTTIIVVEESSAANNDD M MEEAASSUURREESS Summary Stage 1 – Final Rule Published July 2010  There are a total of 15 required Core Objectives o All 15 must be met o 1 of the 15 objectives will be to report 6 clinical quality measures  There are a total of 10 Menu Objectives o 5 objectives may be chosen and met  There are a total of 44 Clinical Quality Measures o Each developed by either NCQA, AMA, or CMS Stage 2 – Target Definition Final Ruling End of 2011  Implementation in 2013 Stage 3 – Target Definition Final Ruling End of 2013  Implementation in 2015 Detailed Core Measures CORE MEASURE SET (15) Number Objective #1 Use Computer Provider Order Entry (CPOE) for medication orders

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MUST MEET ALL 15

Stage 1 Measure (Final) More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE.

(TBD by Final Rule)

Proposed Stage 2 CPOE for at least 1 medication, and 1 lab or radiology order for 60% of unique patients who have at least 1 such order (order does not have to be transmitted electronically)

(TBD by Final Rule)

Proposed Stage 3 CPOE for at least 1 medication, and 1 lab or radiology order on 80% of patients who have at least 1 such order (order does not have to be transmitted electronically)

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Core Measures Continued

#2

Implement drug-drug and drug-allergy interaction checks

Functionality is enabled for these checks for the entire reporting period.

Employ drug-drug interaction checking and drug allergy checking on appropriate evidence-based interactions

Employ drug-drug interaction checking. Drug allergy checking, drug age checking (medications in the elderly), drug dose checking (e.g., pediatric dosing, chemotherapy dosing), drug lab checking. and drug condition checking (including pregnancy and lactation) on appointee evidencebased interactions

#3

Generate and transmit permissible prescriptions electronically Record patient demographics

More than 40% are transmitted electronically using certified EHR technology. More than 50% of patients’ demographic data recorded as structured data.

50% of orders (outpatient and hospital discharge) transmitted as eRx

80% of orders (outpatient and hospital discharge) transmitted as eRx

80%of patients have demographics recorded and can use them to produce stratified quality reports

Maintain up-to-date problem list of current and active diagnoses Maintain active medication list

More than 80% of patients have at least one entry recorded as structured data. More than 80% of patients have at least one entry recorded as structured data.

Continue Stage 1

90% of patients have demographics recorded (including lOM categories) and can use them to produce stratified quality reports 80% problem lists are up-to- date

#4

#5

#6

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Continue Stage 1

80% medication lists are up- todate

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Core Measures Continued

#7

Maintain active medication allergy list

#8

Record and chart changes in vital signs Weight Height Calculate and display BMI Blood Pressure Record smoking status for patients 13 and over

#9

#10

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Implement one clinical decision support rule and ability to track compliance with the rule

More than 80% of patients have at least one entry recorded as structured data. More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data.

Continue Stage 1

80% medication allergy lists are up-to-date

80% of unique patients have vital signs recorded

80% of unique patients have vital signs recorded

More than 50% of patients 13 years of age or older have smoking status recorded as structured data. One clinical support rule implemented.

80% of unique patients have smoking status recorded

90% of unique patients have smoking status recorded

Establish CDS attributes for purposes of certification:

Establish CDS attributes for purposes of certification:

1. Authenticated (source cited); 2. Credible, evidence- based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7. Integrated with EHR; 8. Presented to the appropriate party who can take action

1. Authenticated (source cited); 2. Credible, evidence- based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7. Integrated with EHR; 8. Presented to the appropriate party who can take action

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Core Measures Continued

#11

Report clinical measures to CMS or states (see list below)

#12

Provide patients with clinical summaries for each office visit

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For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures. Clinical summaries provided to patients for more than 50% of all office visits within 3 business days.

Continue per Quality Measures Workgroup and CMS

Continue per Quality Measures Workgroup and CMS

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human- readable and structured forms (HITSC to define)

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human- readable and structured forms (HITSC to define)

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Core Measures Continued

#13

#14

#15

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Provide patients with electronic copy of their health information including diagnostic test results, problem list, medication lists, medication allergies Implement capability to electronically exchange key clinical information among providers and patient-authorized entities

More than 50% of requesting patients receive electronic copy within 3 business days.

Continue Stage 1

90% of patients have timely access to copy of health information from electronic health record, upon request

Perform at least one test of EHR’s capacity to electronically exchange information.

Connect to at least three external providers in primary referral network (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange

Connect to at least 30% of external providers in —primary referral network or establish an ongoing bidirectional connection to at least one health information exchange

Implement systems to protect privacy and security of patient data

Conduct or review a security risk analysis and implement security updates as necessary, and correct identified security deficiencies.

Additional privacy and security objectives under consideration via the HIT Policy & Security Tiger Team

Additional privacy and security objectives under consideration via the HIT Policy & Security Tiger Team

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MENU MEASURE SET (10) Number Objective #1 Implement drug formulary checks

#2

Incorporate clinical laboratory test results into EHRs as structured data

#3

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. Send reminders to patients (per patient preference) for preventive and followup care

#4

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MUST MEET 5

(TBD by Final Rule)

(TBD by Final Rule)

Stage 1 Measure (Final) Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period. More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data. Generate at least one listing of patients with a specific condition.

Proposed Stage 2 Move current measure to core

Proposed Stage 3 80% of medication orders are checked against relevant formularies

Move current measure to core, but only where results are available

90% of lab results electronically ordered by EHR are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available

Make core requirement. Generate patient lists for multiple patientspecific parameters

Patient lists are used to manage patients for high- priority health conditions

More than 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders.

Make core requirement.

20% of active patients who prefer to receive reminders electronically receive preventive or follow-up reminders

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Menu Measures Continued

#5

Provide patients with timely electronic access to their health information, including laboratory results, problem list, medication lists, medication allergies

More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR.

#6

Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate Perform medication reconciliation between care settings

More than 10% of patients are provided patient-specific education resources.

#7

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Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human readable and structured forms (HITSC to define) Continue Stage 1

Medication reconciliation is Medication reconciliation performed for more than 50% conducted at 80% of care of transitions of care. transitions by receiving provider (transitions from another setting of care, or from another provider of care, or the provider believes it is relevant)

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human readable and structured forms (HITSC to define) 20% offered patient-specific educational resources in common primary language

Medication reconciliation conducted at 90% of care transitions by receiving provider

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Menu Measures Continued

#8

#9

#10

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Provide summary of care record for patients referred or transitioned to another provider or setting Submit electronic immunization data to immunization registries or immunization information systems

Summary of care record is provided for more than 50% of patient transitions or referrals.

Move to Core

Summary care record provided electronically for 80% of transitions and referrals

Perform at least one test of data submission and followup submission (where registries can accept electronic submissions).

Submit electronic syndromic surveillance data to public health agencies

Perform at least one test of data submission and followup submission (where public health agencies

EH and EP: Mandatory test. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law Move to core. Public Health Button for EH and EP: Mandatory test and submit if accepted. Submit notifiable conditions using a reportable public-health submission button. EHR can receive and present public health alerts or follow up requests.

EH and EP: Mandatory test. Immunizations are submitted to IIS, if accepted and as required by law. During well child/adult visits, providers review IIS records via their EHR. Mandatory test; submit if accepted

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CLINICAL QUALITY MEASURES (44) Number Description GPRO DM-1 Diabetes Mellitus: Hemoglobin A1c Testing GPRO DM-2 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus GPRO DM-3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus GPRO DM-5 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus GPRO DM-6 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy GPRO DM-7 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient GPRO DM-8 Diabetes Mellitus: Foot Exam GPRO DM-9 Diabetes Mellitus: Lipid Profile GPRO HF-1 Heart Failure: Left Ventricular Function (LVF) Assessment GPRO HF-2 Heart Failure: Left Ventricular Function (LVF) Testing GPRO HF-3 Heart Failure: Weight Measurement GPRO HF-5 Heart Failure: Patient Education GPRO HF-6 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) GPRO HF-7 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or ARB for LVSD GPRO HF-8 Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation GPRO CAD-1 Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD GPRO CAD-2 Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol

Developer NCQA NCQA NCQA NCQA NCQA NCQA NCQA NCQA AMA-PCPI CMS AMA-PCPI AMA-PCPI AMA-PCPI AMA-PCPI AMA-PCPI AMA-PCPI AMA-PCPI

GPRO CAD-3 GPRO CAD-7

AMA-PCPI AMA-PCP

GPRO HTN-1

Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior MI Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or LVSD Hypertension (HTN): Blood Pressure Measurement

GPRO HTN-2

Hypertension (HTN): Blood Pressure Control

NCQA

GPRO HTN-3 GPRO Prev-5

Hypertension (HTN): Plan of Care Preventive Care and Screening: Screening Mammography

AMA-PCPI NCQA

GPRO Prev-6

Preventive Care and Screening: Colorectal Cancer Screening

NCQA

GPRO Prev-7 GPRO Prev-8

Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older

AMA-PCPI NCQA

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MUST REPORT 6

AMA-PCPI

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