WIREC UpdateWIREC Update

Jeff Hummel, MD, MPHMedical Director

June 23 2011June 23, 2011

ObjectivesObjectives

Review WIREC perspective several facetsReview WIREC perspective several facets of HIT work required for success•Programs for distributing the incentive•Programs for distributing the incentive•Meaningful Use•The WIREC experience to date– Enrollment– What we’re finding the pain points to be– How we are working with practicesg p

Medicare Stimulus Money (6/16)

• First payments to hospitalsFirst payments to hospitals– In the US: 36

In Washington: 0– In Washington: 0• First payments to eligible providers

S– In the US: 284– In Washington: 8– Among WIREC participants: 0, although

several are preparing to attest.

Medicare Incentives for CAHsMedicare Incentives for CAHs

2010 2011 2012 2013 2014 2015 2016 2017Stage 1Payment

Stage 1Payment

Stage 2 Payment

Stage 2 Payment Stage 3 Stage 3 Stage 3

Stage 1 Stage 1 Stage 2 Stage 3 St 3 St 3Stage 1 Payment

Stage 1Payment

Stage 2 Payment

Stage 3Payment Stage 3 Stage 3

Stage 1Payment

Stage 2 Payment

Stage 3Payment Stage 3 Stage 3

Stage 1 Stage 3Stage 1Payment

Stage 3Payment Stage 3 Stage 3

Stage 3Payment Stage 3 Stage 3

Stage 3 Stage 3

Penalties for not achieving stage 3: Reasonable cost reimbursement of 101% would be reduced to: 100.66% 100.33% 100%

Incentive payments calculation based on the Medicare Share of the EHR cost

Washington Medicaid StimulusWashington Medicaid Stimulus• WA Medicaid on-line registration serviceWA Medicaid on line registration service

will be ready in July 2011• Attestation for AIU will begin in September• Attestation for AIU will begin in September• Assistance in determining the numerator

f ti t l l t th i t ffor practices to calculate their percent of Medicaid visits will be ready

MU as moving target definitionMU as moving target - definition• Precise Definitions are constantly refinedPrecise Definitions are constantly refined• ePrescribing means turning the feature on

and being registered with SureScriptsand being registered with SureScripts• Many practices are wrestling with who

t h t i f ti C MAenters what information. Can an MA or a nurse re-order a chronic medication?

• For Medicaid, what is the data definition for a needy patient

MU as moving target Stage 2MU as moving target – Stage 2• Meaningful Use Policy Committee voted toMeaningful Use Policy Committee voted to

postpone Stage 2 until 2014Implication for strategic planning incentive to– Implication for strategic planning, incentive to postpone is removed

– Pressure from providers who haven’tPressure from providers who haven t implemented EHRs yet

– Pressure from industry for slower pace ofPressure from industry for slower pace of feature development and roll out

WIREC Structure & StrategyWIREC Structure & Strategy• Led by Qualis Health with strategic partners

including Community Choice• Goal: 2,369 priority providers in WA & ID, p y p• 8 – 10 consultants across both states• Strategy:• Strategy:

– Consulting at no charge to practice– Gap analysis to next Milestone: go-live or MU– Gap analysis to next Milestone: go-live, or MU– Workflow redesign workshops offered to all– Monthly Webinar series: national content expertsy p– Practices near next milestone get intense help

Meeting our enrollment targetMeeting our enrollment targetWIREC Recruitment by Month

1 9831,9922,033

190020002100220023002400

Goal: 2369

1,3181,516

1,684

1,9181,983

1300140015001600170018001900

Number of Providers

625734

851

980

1,138

597740 747

818

600700800900100011001200

0 0

191

480572 625

0 0 26

159 166 191 215279 301 301 326

494597

0100200300400500600

Mar '10 May' 10 Jul '10 Sept '10 Nov '10 Jan '11 Mar '11 May' 11 Jul '11 Sept '11 Nov '11

Enrollment Goal Total Recruited Sum

WA Sites & Opport nit b ZipcodeWA Sites & Opportunity by Zipcode

A Respectable Position NationallyA Respectable Position Nationally

117%107%103%102% 94% 92% 91% 90% 88% 86% 85% 84% 84% 80% 80% 77% 77% 76% 71% 69% 69% 66% 65% 63% 62% 61% 61% 60% 60% 59% 59% 57%

0%50%

100%150%

57% 56% 56% 55% 55% 54% 54% 54% 52% 52% 51% 51% 49% 46% 42% 39% 39% 39% 39% 37% 35% 34% 33% 32% 31% 28% 24% 24%15% 14%20%

40%60%

0%

Overview of enrolled practices

2 036 i di id l id

Overview of enrolled practices

• 2,036 individual providers• 80% in Washington – 20% in Idaho• 483 practices• 74% in Washington – 26%in Idaho74% in Washington 26%in Idaho• 38% have EHR installed

700

8001,575 Providers By Setting - Washington

500

600

300

400

14 28 234 746 74 334 24 1210

100

200

0

180

Community Choice - Enrolled Providers By Setting

120

140

160

80

100

120

20

40

60

6 0 157 12 0 108 2500

Private Practice 1 -

10

Private Practice 11+

Community Health Center

Rural Health Clinic

Public Hospitals

Critical Access

Hospitals

Other Underserved

Setting10 Center Hospitals Setting

Challenges on the Front LinesMU Type MU element Wor

kflow

Feature set-up

Receiving capacity

Data definition

Report Writing

Challenges on the Front Linesw up

Data Gathering

DemographicsVS, SmokingMeds & Allergies ✓✓

Clinical Decisions

CPOE, Problem List

✓✓Decision support

Med-Med/Allergy alerts, CDS, Patient Lists, AVS, Clinical Reminders ✓✓ ✓

Data sharing

Reports to Public Health, Immunization registry, Quality Reporting, Pt copy of record, eRx, Transmit key data set, ✓ ✓ ✓ ✓ ✓eRx, Transmit key data set, CCR, Med reconciliation

W kfl d I f tiWorkflows and Information

Specific Pain PointsSpecific Pain Points• Smoking Status:Smoking Status:

– workflow change– Plan for intervention for smoking & BMIg

• Medications– Pt & MA knowledge– Delegation & oversight

• Providers entering structured data– eRx, CPOE & Problem Lis– Other data on ad hoc basis – teaching others

• Clinical Summaries & After Visit Summaries

More Specific Pain PointsMore Specific Pain Points• HIEHIE

– lack of clarity about what meets the measure– lack of infrastructure, – misinformation from vendors

• Immunization Registry –– some vendors have more difficulty than others – state registry priorities (childhood vs adult) – Additional costs charged by vendors to clinics to set

up interface versus ability to use State HIE– VARS lacking interfacing capability capacities– VARS lacking interfacing capability capacities,

More Specific Pain PointsMore Specific Pain Points• Lab interfacesLab interfaces• Barriers to upgrading to certified EHR products

– certified EHRs requiring add’l hardware forcertified EHRs requiring add l hardware for upgrades

– Rip & Replace decisions• Organizational priorities

– CAHs prioritizing inpatient MU work primary care– Multispecialty groups decide to delay features

• Reporting – Calculate patient volumes for Medicaid incentive– Non-transparent data definitions

WIRECExpedition GuideGuide Service:  Provisioning route‐finding and crevasse rescue

“We’ll make sure you have everyhave every thing you need, but you do have to climb the mountain yourself.”

Concept al Frame orkConceptual Framework• The PCMH is our best vision for a resilient• The PCMH is our best vision for a resilient

and sustainable model to deliver high-value healthcare at an affordable costhealthcare at an affordable cost

• An EHR, used correctly (meaningful use) is th i f ti t i f t tthe information management infra-structure for powering the workflows in a PCMH

• “Meaningful use” is simply an operational definition of the information management requirements for supporting a PCMH

EmpanelmentInitial EmpanelmentAgree on rules

for primaryDevelop and run

Care teams Assign initial

Initial Empanelment

Process

for primary attribution protocol

and run protocol program

teams review & correct

Assign initial attribution

Master Demographic

File

Scheduler hchanges PCP

assignment

Pt ll t S h d l

No

S h d l

PCP Verification Process

Pt calls to schedule

visit

Scheduler confirms PCP assignment

Correct?Yes Scheduler

completes appointment

Team-based Care & role definitionTeam based Care & role definitionWhat do I

d ?

Gather the right

Organize the

i f tiMake the d i

Carry out the d i i

Step 1 Step 2 Step 3 Step 4

Teams are defined by how they handle this sequence

do? right information information

correctlydecsion decision

• If the team is defined as “people standing around waiting to do what I tell them”...

This process doesn’t start until the doctor walks into the exam room– This process doesn t start until the doctor walks into the exam room– Only the 4th step is delegated

• In a PCMH care team: – Many “What do I do?” questions can be decided in the team huddle– Gathering the right information is delegated to other team – The provider-lead educates and supports team members in what p pp

information to gather and how to gather it– Organizing the information can be greatly enhanced with HIT

Getting lab results to patientsGetting lab results to patients

Lab Test Ordered

Lab Test Run

Result Arrives in Ordering

Provider’s In-box

Provider Reviews Lab

ResultLab result crosses Interface

Result i

NoProvider d t

Provider d l b requires

action?

Yes

documents lab reviewed

sends lab results to Pt

Provider creates plan

& orders intervention

Team set plan into action/ contacts Pt

Med List Mgmt in Ambulatory Practiceg y

Pt corrects meds &

allergies in waiting room

Pt makes Appt

Reminder Call from

Clinic “remember med list”

Care team reviews chart in AM huddle

Pt arrives at clinic

Pt given Pre-Visit Summary

(PVS) with med & allergy

list

Nurse/MA greets Pt

and gets VS in hallway

DemographicsPt copy

of health

Nurse/MA rooms Pt

Decision SupportMed List Med List

DemographicsDemographicsrecord

EHR

Nurse/MA opens Med

List

Med Listg p

Nurse/MA places check mark beside

medications on Med List that Pt is taking

Medication Reconciliation

If new allergies are

reported, type of reaction is

entered

MA opens allergy tab,

reviews allergies and asks Pt about new allergies

MA marks Medications as reviewed

MA ask patient about any medications taken that are not on Med List and enters

them as Historical Meds

Nurse/MA discontinues

meds no longer taken

MA secures chart, lets pt know

provider will be in shortly, and leaves room

Reconciliation

Medication Med-Med/Allergy

List Medication Reconciliation

Med-Med/Allergy/

Formulary Alerts

List

PopulationPopulation ManagementManagement

Care Coordination – Referral TrackingCare Coordination Referral Tracking

Health Information ExchangeHealth Information ExchangeOn Admission to the SNF, care plan data are downloaded from PHR At D/C from SNF the Care Plan is updated with:

1. Electronic interface with SNF clinical data

SNFAt D/C from Hospital, the care plan is updated with data from:1. Electronic interface with hospital clinical data system2 U I t f

system2. Data from user interface

2. User Interface

Finished Care Plan data are saved into Pt’s PHR

PHR

Hospital At home the patient, caregiver and Home Health view data from the care plan in PHR

Home

`

Health view data from the care plan in PHR. They may also add or modify other data fields in PHR through User Interface

On admission to the Hospital care plan data are downloaded from PHR

Clinic

In the clinic updated clinical information from PHR is used

to update the EHR

ConclusionConclusion• HIT is necessary, but insufficient for a PCMH• Without HIT, the burden of work-arounds to get

the right information to the right person at the i ht ti b th li iti f tright time become the limiting factor

• Without a vision for practice transformation, HIT becomes just one more expensive not so magicbecomes just one more expensive not-so-magic bullet that won’t fix our broken healthcare systemsystem

• The optimal planned HIT implementation strategy is ideally suited for staged conversion tostrategy is ideally suited for staged conversion to a PCMH

QuestionsQuestions

jeffh@qualishealth.orgwww.wirecqh.orgwww.wirecqh.org