An Update on Implementing Meaningful Use

Across Indian Country

Joint MU Conference, Albuquerque, NMJanuary 19, 2011

Stephanie Klepacki, IT SpecialistMU Program Manager

Indian Health Service (IHS), Office of Information Technology (OIT)

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Today’s Session

• What is Meaningful Use?• CMS EHR Incentive Program Eligibility

Requirements• Demonstration of Meaningful Use• Implementing Meaningful Use Across Indian

Country• RPMS Reporting & Meaningful Use Toolkit• CMS & REC Registration Information

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What is Meaningful Use?• Meaningful Use is using certified EHR

technology to:• Improve quality, safety, efficiency, and reduce health

disparities• Engage patients and families in their health care• Improve care coordination• Improve population and public health• All the while maintaining privacy and security

• CMS provides incentive payments to promote adoption and meaningful use of a certified EHR

Slide content provided by CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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What isMeaningful Use?• 3 stages of Meaningful Use• Requirements will increase over time…more work

lies ahead

Stage 12011-2012

Stage 22013-2014

Stage 32015+

Slide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

CMS EHR Incentive Program Eligibility Requirements

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EP Eligibility – General

• Eligible Professionals (EPs) • Must choose the Medicare OR Medicaid incentive

program; not eligible for both• Eligibility determined by law• Hospital-based EPs are NOT eligible for incentives

• DEFINITION: 90% or more of their covered professional services in either an inpatient or emergency room (Place of Service codes 21 or 23) of a hospital

• Incentives are based on the individual, not the practice

Slide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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EP Eligibility – Medicare

• Medicare Eligible Professionals include:• Doctors of medicine or osteopathy• Doctors of dental surgery or dental medicine• Doctors of podiatric medicine• Doctors of optometry• Chiropractors

• Specialists are eligible if meet one of above criteria

Slide content provided by CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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EP Eligibility –Medicaid

• Medicaid Eligible Professionals include:• Physicians• Nurse practitioners• Certified nurse-midwives• Dentists• Physician assistants working in a Federally Qualified

Health Center (FQHC) or rural health clinic (RHC) that is so led by a physician assistant

Slide content provided by CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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EP Eligibility – Medicaid (cont’d)

• Medicaid Eligible Professionals must also meet one of the three patient volume thresholds:• Pediatricians: Have a minimum of 20% Medicaid

patient volume• Have a minimum of 30% Medicaid patient volume• EPs that work primarily in FQHC or RHC: Have a

minimum of 30% Needy Individual patient volume, defined as patients:• Enrolled in Medicaid or CHIP,• Received uncompensated care, or• Received care on a reduced fee scale

Slide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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Hospital Eligibility

• IHS hospitals are eligible to participate in both the Medicare and Medicaid incentive programs

• Eligibility determined by law• Eligible IHS Hospitals include:

• Acute Care Hospitals• Critical Access Hospitals (CAHs)

• For Medicaid, must meet a 10% Medicaid patient volume requirement; no requirement for Medicare

Slide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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IncentivesSummary

MEDICARE MEDICAID

Eligible Providers

HospitalsEligible

ProvidersHospitals

Incentives Start

CY 2011 FY 2011 CY 2011 FY 2011

IncentivesEnd

CY 2016(max. 5 years)

FY 2015(max. 4 years)

2021(max. 6 years, must start by

2016)

2021(max. 6 years,

must start by 2016)

Incentive Amount

Up to $44,000 total per provider; based on %

Medicare claims (bonus for EPs in

HPSAs)

Varies, depending on % Medicare

inpatient bed days. CAHs paid based on EHR costs and

% Medicare inpatient bed days

Up to $63,750 total per provider;

based on 85% of EHR costs

Varies, depending on % Medicaid

inpatient bed days

Reimbursement Reduced

CY 2015 FY 2015 No penalties No penalties

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Do I Have toDemonstrate MU?

• To receive incentive payments, EPs and hospitals must meet all eligibility requirements and:• 1st Participation Year, Medicaid: Both EPs and

hospitals only have to adopt, implement, or upgrade to a certified EHR• This does not have to start in 2011

• All Other Participation Years, Medicaid: Demonstrate Meaningful Use of a certified EHR

• All Participation Years, Medicare: Demonstrate Meaningful Use of a certified EHR

Demonstration of Meaningful Use

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What it Means toDemonstrate MU

Providers HospitalsReport on 15 core objectives & 5 objectives from a menu set of 10

- Must meet performance targets on most objectives

Report on 14 core objectives & 5 objectives from a menu set of 10

- Must meet performance targets on most objectives

Report on 6 total Clinical Quality Measures (3 core, 3 menu set)

- No performance targets

Report on 15 total Clinical Quality Measures

- No performance targetsSlide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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MU Stage 1Core Set Objectives

CORE SET TARGETS AND OBJECTIVES

Eligible Professionals (15) Eligible Hospitals (14)

>30%: Computerized physician order entry (CPOE): Unique patients w/at least 1 medication on medication list have at least 1 medication ordered w/CPOE

>40%: E-Prescribing (eRx) N/A 

Report ambulatory clinical quality measures to CMS/States Report hospital clinical quality measures to CMS or States

Yes/No: Implement one clinical decision support rule

>50%: Provide patients with an electronic copy of their health information, upon request

>50%: Provide clinical summaries for patients for each office visit >50%: Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request

Yes/No: Implement drug-drug and drug-allergy interaction checks during the entire EHR reporting period

>50%: Record demographics

>80%: Maintain an up-to-date problem list of current and active diagnoses

>80%: Maintain active medication list

>80%: Maintain active medication allergy list

>50%: Record and chart changes in vital signs

>50%: Record smoking status for patients 13 years or older

Test Performed (Yes/No): Capability to exchange key clinical information among providers of care and patient-authorized entities electronically

Yes/No: Conduct or review a security risk analysis per CFR 164.308(a)(1) and implement security updates as necessary & correct deficiencies 15

MU Stage 1Menu Set Objectives

MENU SET TARGETS AND OBJECTIVES

Eligible Professionals Eligible Hospitals

Yes/No: Implement drug-formulary checks for entire EHR reporting period

>40%: Incorporate clinical lab test results as structured data

Yes/No: Generate lists of patients by specific conditions

>10%: Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate

>50%: Medication reconciliation at transitions of care

>50%: Summary of care record for each transition of care/referrals

Performed Test (Yes/No): Capability to submit electronic data to immunization registries/systems*

Performed Test (Yes/No): Capability to provide electronic syndromic surveillance data to public health agencies*

>20%: Send reminders to patients per patient preference for preventive/follow up care

>50%: Record advanced directives for patients 65 years or older

>10%: Provide patients with timely electronic access to their health information (within 4 business days)

Performed Test (Yes/No): Capability to provide electronic submission of reportable lab results to public health agencies*

*At least 1 public health objective must be selected

NOTE: States have the option to require one or more of the items shown in italic font as core objectives 16

Clinical Quality Measuresfor EPs

• Clinical Quality Measures (CQM) – Core Set for Eligible Professionals

NQF Measure Number & PQRI Implementation Number

Clinical Quality Measure Title

NQF 0013 Hypertension: Blood Pressure Measurement

NQF 0028 Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention

NQF 0421PQRI 128

Adult Weight Screening and Follow-up

Slide content provided by CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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Clinical Quality Measures for EPs (cont’d)

• CQM – Alternate Core Set for Eligible Professionals

NQF Measure Number & PQRI Implementation Number

Clinical Quality Measure Title

NQF 0024 Weight Assessment and Counseling for Children and Adolescents

NQF 0041PQRI 110

Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older

NQF 0038 Childhood Immunization Status

Slide content provided by CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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• Must also choose 3 of 38 menu set measures

Clinical Quality Measures for Hospitals and CAHs

• CQM for eligible hospitals and CAHs - must report on all1. 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 onset

Slide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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Clinical Quality Measures forHospitals and CAHs

• CQM for eligible hospitals and CAHs (cont’d)6. Ischemic or hemorrhagic stroke – Antithrombotic therapy

by day 2

7. Ischemic stroke – Discharge on statins

8. Ischemic or hemorrhagic stroke – Rehabilitation assessment

9. VTE prophylaxis within 24 hours of arrival

10. Intensive Care Unit VTE prophylaxis

11. Anticoagulation overlap therapy

12. Platelet monitoring on unfractionated heparin

13. VTE discharge instructions

14. VTE discharge instructions

15. Incidence of potentially preventable VTE

Slide content adapted from CMS (EHR_Incentive_Program_EP_Training_Final ONC changes 8 10 10.pptx)

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Role of the States andMedicaid MU

• Medicaid Eligibility, Patient Volume Calculation• Each State can pick from the proposed methodologies,

OR, • Propose a new method for CMS review and approval• If CMS approves a method for one state, it may be

considered an option for all states

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Role of the States andMedicaid MU (cont’d)

• MU Objectives: States can seek CMS prior approval to require the 4 Public Health MU objectives to be core for their Medicaid providers• Generate lists of patients by specific conditions for quality

improvement, reduction of disparities, research, or outreach (can specify particular conditions)

• Reporting to immunization registries, • Reportable lab results, and/or • Syndromic surveillance (can specify for their providers

how to test the data submission and to which specific destination)

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Implementing Meaningful Use Across Indian Country

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Certification/MU(C/MU) Team

• MU Federal Lead/COTR: Stephanie Klepacki• EHR Cert. Federal Lead: Chris Lamer• C/MU Contractor PM: MB Leaf• 3 C/MU Teams

National MU Team: 5 FTEs EHR Certification Team: 2 FTEs MU/IPC Field Team: 12 IHS Area MU Coordinators

+ 16 contractor IPC-MU Consultants

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National MU Team• Role

o Analysis of ONC & CMS rule requirementso Training/educationo Outreach & communicationo Stakeholder collaboration & coordinationo MU web site and ListServ managemento RPMS gap analysiso Develop requirements for MU tools

o Medicaid Patient Volume Reporto MU Performance Report for EPs and Hospitalso Coordinate development of MU Clinical Quality Measure reports

o Field Team support

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EHR CertificationTeam

• Roleo Analysis & implementation of EHR certification requirements

and testingo RPMS gap analysiso Coordination of RPMS development for required changeso Conduct baseline, pre-certification, and certification testingo Complete all paperwork/requirements for EHR certification in

both ambulatory and inpatient settings

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MU/IPC Field Team

• Roles• Ensure MU is implemented within all facilities at each Area• Provide MU training within each Area• Determine each State Medicaid Program’s requirements for MU

and payment• Monitor each State’s readiness for MU• Identify each State’s health information exchange (HIE)

requirements (e.g. can they connect to the Nationwide Health Information Network-NHIN)

• Coordinate with EHR Deployment Team, Improving Patient Care (IPC) & State and National Indian Health Board National Regional Extension Center (REC) staff

• Compile information and provide assistance as needed to register with CMS, State Medicaid, and to complete Provider Agreement with an REC 27

Area MU Coordinators

Area MU Coordinator Contact Information

Aberdeen CAPT Scott Anderson Scott.Anderson@ihs.gov; (605) 335-2504

Alaska

Richard HallKimi GosneyErika Wolter

rhall@anthc.org; (907) 729-2622kgosney@anthc.org; (907) 729-2642ewolter@anthc.org; (907) 729-3907

Albuquerque

CAPT Theresa Tsosie-Robledo (Acting) Theresa.Tsosie-Robledo@ihs.gov; 505-414-2769

Bemidji Jason Douglas Alan Fogarty, CIO

Jason.Douglas@ihs.gov; (218) 444-0550 Alan.Fogarty@ihs.gov; (218) 444-0538

Billings CAPT James

Sabatinos James.Sabatinos@ihs.gov; (406) 247-7125

California Marilyn Freeman,

RHIA

Marilyn.Freeman@ihs.gov; (916) 930-3981, ext. 362

Nashville CDR Robin Bartlett Robin.Bartlett@ihs.gov ; (615) 467-1577

Navajo LCDR Andrea Scott Andrea.Scott@ihs.gov; (928) 292-0201

Oklahoma CDR Amy Rubin Amy.Rubin@ihs.gov; (405) 951-3732

Phoenix CAPT Lee Stern Keith Longie, CIO

Lee.Stern@ihs.gov; (602) 364-5287 Keith.Longie@ihs.gov; (602) 364-5039

Portland CAPT Leslie Dye Donnie Lee, MD

Leslie.Dye@ihs.gov; (503) 326-3288 Donnie.Lee@ihs.gov; (503) 326-2017

Tucson Scott Hamstra, MD Scott.Hamstra@ihs.gov; (520) 295-2532

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Area MU Consultants(Contractors,15-mos Term)

Area MU Consultants Contact Information

Team Lead (ABQ) JoAnne HawkinsJoanne.Hawkins@ihs.gov; (505) 263-

6917

Regional Consultant #1 TBD

Regional Consultant #2 TBD

Aberdeen Carol Smith Carol.Smith3@ihs.gov; (605) 355-2500

Alaska

1) Karen Sidell2) Rochelle (Rocky) Plotnick

Karen.Sidell@ihs.gov; (907) 729-2624Rochelle.Plotnick@ihs.gov; (907) 729-2679

Albuquerque TBD

Bemidji TBD

Billings Jeremy LougeeJeremy.Lougee@ihs.gov ; (406) 247-

7125

California Tim CampbellTim.Campbell@ihs.gov; (707) 889-

3009

Nashville Robin KitzmillerRobin.Bartlett@ihs.gov; (615) 467-

1577

Navajo TBD

Oklahoma Ursula Hill Ursula.Hill@ihs.gov; (405) 365-6069

Phoenix Kelly Morris Kelly.Morris@ihs.gov; Phone TBD

Portland Angela BoechlerAngela.Boechler@ihs.gov ; 503-858-3330

Tucson Rick BowmanRichard.Bowman@ihs.gov; (520) 603-

6817

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RPMS Reporting & MU Toolkit

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• Patient Volume Report• MU Performance Report for EPs and Hospitals• MU Clinical Quality Measures Report • EHR MU Guide• EHR Costs Guidance• IHS Cost Report Guidance for State Medicaid Offices• Facility MU Status/Readiness Assessment tool

• Provider Inventory  • EHR Status Verification• CMS Bulk Registration Guidance

Coming Soon

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Patient Volume Report

• Nearing completion of requirements documentation• Anticipated mid-March release• Calculates

• Whether EP/hospital meets the Medicaid minimum patient volume thresholds• Group practice rate in lieu of calculating the rate for each

individual EP  • Will be added to RPMS Third Party Billing (TPB)• Relies on information stored in RPMS TPB• Sites using a COTS TPB will not be able to run this

report

• Show performance on all MU objectives that calculate a rate, e.g., CPOE rate, demographic rate, e-prescribing rate, etc.

• May also include measures that require a yes/no answer, e.g., performance of a test of facility’s ability to electronically exchange key clinical information

• If all objectives included, then may suffice as the attestation report for submittal to CMS or the respective State

• Included in PCC Management Reports initially and subsequently added to a new MU tab in iCare

• Two versions of the Stage 1 report:o 1st release: All objectives that we can report now without

the need to wait for changes to be made to RPMS.  (Mid-March release)

o 2nd release: All objectives, including those for which changes needed to be made to RPMS. (TBD)

MU Performance Reports for EPs & Hospitals

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MU Clinical Quality Measures Report• 2 new reports added to the RPMS Clinical Reporting

System (CRS) (EP and Hospital Report)• Release Plano 1st Release

9 EP measures (3 core/3 alternate core/3 menu set [pap, mammogram, and colorectal cancer screening)

CRS v11.0 Patch 1, est. mid-Marcho 2nd Release

All 15 hospital measures  CRS v11.0 Patch 2, est. late April 

o 3rd Release Remaining 35 EP menu set measures CRS v11.1. est. June 30

• The reports will also be added to a new MU tab in iCare

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Other Resources

• EHR MU Guide  o EHR Deployment Team + MU Teamo Documentation showing steps for entering MU information into

the EHR GUI o Release: TBD

• EHR Costs  o MU Team developing formula/calculation for hospitals to

determine their EHR costso Release: February

• IHS Cost Report Guidance for State Medicaid Officeso Required by states to determine incentives as IHS does not

routinely submit cost reportso IHS is working with CMS to develop a uniform approach for all

stateso Release: TBD

Other Resources (cont’d)

• Facility MU Status/Readiness Assessment Toolo Post-deployment MU status for use by IPC-MU Consultantso Based on EHR Deployment & IPC assessment toolso Release: TBD

• Provider Inventoryo In concert with REC provider sign-up & sub-recipient collaboration, Area

MU Consultants are compiling provider lists o Baseline for status tracking, reporting

• EHR Status Verificationo In concert with Provider Inventory, Area MU Consultants are reviewing

EHR Deployment Team data o Baseline for status tracking & reporting

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Other Resources (cont’d)

• CMS Bulk Registration Guidanceo IHS is working with CMS on secure bulk upload of registration datao Process to save time & effort for providers & hospitalso IHS is checking on capability for Tribes and State Medicaid siteso Release: TBD

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CMS and REC Registration Information

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Register with Whom for What?!• You must REGISTER for incentive payments via:

o Medicare Incentives Only: CMS national website for Medicareo Medicaid Only OR Both Medicaid & Medicare: BOTH CMS

national website + State Medicaid website o You must register with CMS first even if you are participating in ONLY

the Medicaid program

• You should COMMIT to a Regional Extension Centero NIHB National REC vs. State RECso Per Dr. Cullen, IHS providers should sign up with the NIHB National

RECo Tribal providers are encouraged to sign with a REC (National or

State) of their choosing  o Sign-up ASAP by completing a provider agreement!!!o Release of critical ONC funding to support RECs is dependent upon

the expedited receipt of provider agreements 39

Registering for theCMS Incentive Program

• If you will participate in the Medicaid EHR Incentive Program, you must register with CMS and your respective State

• Registration open now- Alaska - Mississippi

- Iowa - North Carolina

- Kentucky - South Carolina

- Louisiana - Tennessee

- Oklahoma - Texas

- Michigan

• Registration opens in February 2011- California

- Missouri

- North Dakota

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Registering (cont’d)• Currently must register each EP separately. • CMS estimates secure batch registration available in April. • Not required to provide information on which certified EHR you are

using when you register.• First register on the CMS website and then with your respective

State, if applying for Medicaid incentives.• EPs may switch between the two programs anytime prior to first

payment; after that, may only switch once before 2015.• CMS recommends hospitals register for both programs, even if you

don’t know yet if you meet the Medicaid patient volume requirements.

• Visit CMS website for more information• http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestati

on.asp#TopOfPage

CMS recommends waiting until State Medicaid site is available

before initiating registration.41

Regional Extension Centers

• All federal sites must register with the National Indian Health Board’s National Regional Extension Center (NIHB National REC)o Registration occurring now via NIHB website

http://www.nihb.org/rec/rec.php

• Tribal sites may register with an REC of their choice, including the NIHB National RECo ONC list of RECs

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1495&mode=2

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Resources to Get Help andLearn More

• IHS Meaningful Use Websitehttp://www.ihs.gov/recovery/index.cfm?module=dsp_arra_meaningful_use

• Sign up for the IHS Meaningful Use listserv (see instructions at the top of the Meaningful Use website)

• Get information, tip sheets, and more at CMS’ official website for the EHR incentive programswww.cms.gov/EHRIncentivePrograms

• Learn about EHR certification and certified EHRs, as well as other ONC programs designed to support providers as they make the transitionhttp://healthit.hhs.gov

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Contact Information

• IHS Meaningful Use Contacts• Theresa Cullen, RADM, MD, MS IHS Chief Information Officer (301) 443-9848 Theresa.Cullen@ihs.gov

• Stephanie Klepacki, Meaningful Use Project Lead, IHS (505) 821-4480 Stephanie.Klepacki@ihs.gov

• MB Leaf, Meaningful Use Project Manager, DNC (301) 704- 2608 MaryBeth.Leaf@ihs.gov

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Question & Answer Session

It’s time to…

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