Oklahoma Electronic Health Record Incentive Program Oklahoma Health Care Authority Board Retreat Thursday, August 26, 2010 Carol McFarland, CPA, CGFM Melody Anthony, M.S. Performance & Reporting Manager Provider Services Director Adolph Maren Jr., M.A. Senior Planning Coordinator

Oklahoma EHR Incentive Program Origin: American Recovery & Reinvestment Act of 2009 Health Information Technology provisions of the ARRA The Health Information Technology for Economic and Clinical Health Act established programs under Medicare and Medicaid to provide incentive payments for the "meaningful use" of certified EHR technology. "HITECH Act" Title XIII, Division A, HIT Title IV of Division B, Medicare and Medicaid HIT

HITECH Legislation’s purpose: To improve outcomes, facilitate access, simplify care, and reduce costs of health care nationwide by providing: Major financial support to provider and States; Learning opportunities created and leverages through technical assistance from CMS and others; Will establish sustainable data-driven infrastructure that will create a framework for improving healthcare quality and outcomes Oklahoma EHR Incentive Program

Federal Partner responsibilities Centers for Medicare & Medicaid Services incentive program and meaningful use (MU) Final Rule for EHR Incentives & MU - July 13, Office of the National Coordinator of Health Information Technology certification standards program for EHR technology temporary certification program – final rule published June 18, 2010 effective June 24, 2010 permanent certification program is expected to be published this fall Oklahoma EHR Incentive Program

Incentive to... Adopt (acquire and install) Implement (commenced utilization, train staff, deploy tools, exchange data) Upgrade (expand functionality or interoperability) Or… Meaningfully Use (meet specified criteria)... a certified EHR System Oklahoma’s Program begins January 2011 Oklahoma EHR Incentive Program

Provider Eligibility, Registration and Attestation

EHR Incentive Eligibility: Qualifying Eligible Professionals (EP) 1 Current SoonerCare Provider Contract 2 Hospital-based EPs are NOT eligible 90% or more of services are performed in a hospital inpatient or emergency room setting. 3 Provider Type Physicians (MD,DO) Pediatricians Dentists Certified Nurse Midwifes Nurse Practitioners Physician Assistants (PA) practicing at a FQHC/RHC so led by a PA 4 Patient Volume over a 90 day period 30% SoonerCare 20-29% SoonerCare - Pediatricians = 2/3 of incentive payment 30% Needy Individuals* Medical EPs practicing predominantly in FQHC or RHC *Needy individuals = SoonerCare members, patients receiving uncompensated care and patients receiving services at reduced or no cost based upon ability to pay Oklahoma EHR Incentive Program

EHR Incentive Eligibility: Qualifying Eligible Hospitals (EH) 1 Current SoonerCare Provider Contract 2 Hospital Types Acute Care Hospital (includes CAHs & cancer hospitals) Avg. length of stay < 25 days CCN* last 4 of 0001 – 0879; 1300 – 1399 Children’s HospitalCCN* last 4 of 3300 – 3399 Not applicable to children’s wings of larger hospitals 3 Patient Volume over a 90 day period Acute Care Hospital10% SoonerCare Children’s HospitalsNo Requirement * CCN - CMS Certification Number Oklahoma EHR Incentive Program

Patient Volume Calculation Based upon CMS final rule A Patient Volume Documentation worksheet will be provided as part of attestation process Provider defined 90 day period in the calendar year Number of SoonerCare* member encounters Number of total patient encounters Oklahoma EHR Incentive Program * or Needy Patient encounters for EPs providing services at a FQHC/RHC

Registration EPs and EHs are required to register with the Medicare and Medicaid registration and attestation system Name, NPI, business address, phone Tax payer ID Number (TIN) Hospitals must provide the CCN EPs must select Medicare or Medicaid May switch once between programs before 2015 If Medicaid, must select one state May switch states annually Oklahoma EHR Incentive Program

OHCA will: Connect to federal repository to facilitate provider attestation Continue verification of eligibility Disburse payment after cross-checking for potential duplicative, inappropriate payments and verification of supporting documentation Disburse payment to one eligible TIN Notify the national repository upon payment Registration Oklahoma EHR Incentive Program

Electronic Attestation Process *Office of the National Coordinator for Health Information Technology – Authorized Testing and Certificaiton Body Provider registers with CMS CMS directs providers to the OHCA website for enrollment in the Oklahoma EHR incentive program Providers fill out attestation Identify your ONC-ATCB* certified EHR system Complete patient volume worksheet Electronically sign contract ammendment and fax requested documention to OHCA

Provider is not a hospital based professional Provider must provide services in Oklahoma Provider is not receiving an incentive payment from another state for that calendar year Provider has adopted, implemented or upgraded a certified EHR Provider inputs the certification number for the ONC-ATCB certified EHR system Provider list number of FTE jobs created by implementing a certified product Provider reports cash payments made for the certified EHR Provider confirms assignment of payment to a qualified TIN Providers percentage of SoonerCare patient volume is equal to or greater than the allowed Provider has specified the patient volume date range of 90 days during the calendar year Oklahoma EHR Incentive Program EP Electronic Attestation

Hospital is not currently receiving an incentive payment from another state for that federal fiscal year Hospital must be located in Oklahoma Hospitals (Medicaid only) have adopted, implemented or upgraded a certified EHR, or meaningfully used a certified EHR ONC-ATCB EHR Certification number is included Hospital list number of FTE jobs created by implementing a certified product Hospital (acute care) percentage of SoonerCare discharges is at least 10%; Children's hospitals have no discharge percentage Oklahoma EHR Incentive Program EH Electronic Attestation

Adopt / Implement / Upgrade Oklahoma EHR Incentive Program Adopted – Acquired and Installed Implemented – Commenced Utilization Upgraded – Expanded Upgraded to certified EHR technology or added new functionality to meet the definition of certified EHR technology Must be certified EHR technology capable of meeting meaningful use No EHR reporting period Only for first participation year

Oklahoma EHR Incentive Program Meaningful Use (MU) of EHR The Recovery Act specifies the following 3 components of Meaningful Use: Use of certified EHR in a meaningful manner Use of certified EHR technology for electronic exchange of health information to improve quality of health care Use of certified EHR technology to submit clinical quality measures(CQM) and other such measures selected by the Secretary

Meaningful Use of EHR – Health Outcome Priorities Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their health care Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information Oklahoma EHR Incentive Program

Meaningful Use of EHR 3 Stages currently proposed Stage 1 EP: 20 of 25 Objectives / Measures EH: 19 of 24 Objectives / Measures To meet certain objectives/measures, 80% of patients must have records in the certified EHR technology Reporting Period –90 days for first year; one year subsequently Oklahoma will adopt MU measures as published. CMS intends to propose 2 additional stages through future rulemaking. At this time, CMS plans on transitioning the Stage 12 menu set into the Stage 2 core set. Oklahoma EHR Incentive Program

Eligible Professionals –15 Core Objectives 1.Computerized Physician Order Entry (CPOE) 2.E-Prescribing (eRx) 3.Report ambulatory clinical quality measures to CMS/States 4.Implement one clinical decision support rule 5.Provide patients with an electronic copy of their health information, upon request 6.Provide clinical summaries for patients for each office visit 7.Drug-drug and drug-allergy interaction checks 8.Record demographics 9.Maintain an up-to-date problem list of current and active diagnoses 10.Maintain active medication list 11.Maintain active medication allergy list 12.Record and chart changes in vital signs 13.Record smoking status for patients 13 years or older 14.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 15.Protect electronic health information

Oklahoma EHR Incentive Program Eligible Hospitals –14 Core Objectives 1.CPOE 2.Drug-drug and drug-allergy interaction checks 3.Record demographics 4.Implement one clinical decision support rule 5.Maintain up-to-date problem list of current and active diagnoses 6.Maintain active medication list 7.Maintain active medication allergy list 8.Record and chart changes in vital signs 9.Record smoking status for patients 13 years or older 10.Report hospital clinical quality measures to CMS or States 11.Provide patients with an electronic copy of their health information, upon request 12.Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request 13.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 14.Protect electronic health information

Oklahoma EHR Incentive Program Eligible Professionals –10 Menu Set Objectives 1.Drug-formulary checks 2.Incorporate clinical lab test results as structured data 3.Generate lists of patients by specific conditions 4.Send reminders to patients per patient preference for preventive/follow up care 5.Provide patients with timely electronic access to their health information 6.Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate 7.Medication reconciliation 8.Summary of care record for each transition of care/referrals 9.*Capability to submit electronic data to immunization registries/systems 10.*Capability to provide electronic syndromic surveillance data to public health agencies *At least 1 public health objective must be selected

Oklahoma EHR Incentive Program Eligible Hospitals –10 Menu Set Objectives 1.Drug-formulary checks 2.Record advanced directives for patients 65 years or older 3.Incorporate clinical lab test results as structured data 4.Generate lists of patients by specific conditions 5.Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate 6.Medication reconciliation 7.Summary of care record for each transition of care/referrals 8.*Capability to submit electronic data to immunization registries/systems 9.*Capability to provide electronic submission of reportable lab results to public health agencies 10.*Capability to provide electronic syndromic surveillance data to public health agencies *At least 1 public health objective must be selected

Incentive Payments Oklahoma EHR Incentive Program

Eligible Professional Payments Paid in alignment with the Calendar year First year amount consistent regardless of stage (AIU or MU) Maximum incentives are $63,750 over 6 years Incentives are same regardless of start year The first year maximum payment is $21,250 Must begin by 2016 to receive incentive payments No requirement for “consecutive years” participation Incentives available through 2021 Only 1 incentive payment per year Oklahoma EHR Incentive Program

Eligible Hospital Payments Paid in alignment with the Federal Fiscal year (FFY) First year amount consistent regardless of stage (AIU or MU) $2M base + per discharge amount (based on Medicare/ Medicaid share) Medicare Meaningful Use requirements may be deemed eligible for Medicaid payments Payment is calculated, then disbursed over 3-6 years; we have proposed 3 year disbursement No annual payment may exceed 50% of the total calculation; no 2-year payment may exceed 90%; we have proposed 50% / 40% / 10% Hospitals cannot initiate payments after 2016 and payment years must be consecutive after 2016 States must use auditable data sources in calculating the hospital incentive (e.g., cost report) Payments through 2021 Oklahoma EHR Incentive Program

Eligible Hospitals Calculate total incentive in base year Calculated on a 4 year payment basis Payment over 3 years Year 1: 50% Year 2: 40% Year 3: 10% Oklahoma EHR Incentive Program

Eligible Hospitals (Overall EHR Amount) * (Medicaid Share) Defined as {Sum over 4 year of [(Base Amount)+ Discharge Related Amount Applicable for Each Year) * Transition Factor Applicable for Each Year]}... multiplied by... [Medicaid inpatient-bed-days / {(Total inpatient-bed- days) * (estimated total charges – charity care charges) / (estimated total charges)}] Oklahoma EHR Incentive Program

Monitoring, Oversight & Audit Oklahoma EHR Incentive Program

Monitoring / Oversight / Audit Attest to specific requirements Provide required documentation Keep supporting documentation on file Random sample and targeted sample reviews will be conducted Oklahoma EHR Incentive Program

Oklahoma EHR Incentive Program Thank You!

CostsYear 1Years 2-6 Average Allowable Costs (AAC)$54,000$20,610 Maximum allowed cash payments from other sources directly paid to the individual provider for certified EHR technology (do not include: in-kind, employer provided, grant to entity) $29,000$10,610 Net Average Allowable Cost (NAAC)$25,000$10,000 Deduct cash payments from other sources above maximum allowed 00 Deduct Provider Investment (must be at least 15% of NAAC - include: in- kind, employer provided, grant to entity) $3,750$1,500 Incentive Payment$21,250$8,500 Oklahoma EHR Incentive Program Incentive Payment Calculation Eligible Professional

EP Annual Payments Payment Year Net Average Allowable Cost Cap Incentive % Maximum Incentive Payment Pediatrician (PV= 20-29%) Incentive % Pediatrician (20-29% PV) Max Incentive Payment 1 st $25,000 * 85% $21,250 * 66.67% $14,167 2 nd $10,000$8,500$5,667 3 rd $10,000$8,500$5,667 4 th $10,000$8,500$5,667 5 th $10,000$8,500$5,667 6th$10,000$8,500$5,667 Total$75,000$63,750$42,500 Oklahoma EHR Incentive Program

EP AIU or MU Payments Oklahoma EHR Incentive Program

EH AIU or MU Payments Oklahoma EHR Incentive Program

EH Payment Calculation Step 1 Base Amount (per statue) = $2,000,000 Add... Discharge related amount = Year 1: $200 per discharge for 1,150 th – 23,000 th discharge Years 2 - 4: Oklahoma’s overall average hospital discharge growth rate = Subtotal Oklahoma EHR Incentive Program

EH Payment Calculation Step 2 Subtotal from previous calculation Multiplied by... Transition Factor = Year 1: 1 Year 2: ¾ Year 3: ½ Year 4: ¼ = Overall EHR Amount Oklahoma EHR Incentive Program

EH Payment Calculation Step 3 Overall EHR Amount Multiplied by... Medicaid Share: Estimated Medicaid inpatient-bed-days Divided by... The results of Estimated total inpatient-bed-days Multiplied by... Estimated total charges minus charity care charges divided by estimated total charges = Aggregate EHR Hospital Incentive Amount Oklahoma EHR Incentive Program

EH Payment Calculation Step 4 = Aggregate EHR Hospital Incentive Amount Multiplied by... Year 1: 50% Year 2: 40% Year 3: 10% EH Annual Incentive Oklahoma EHR Incentive Program

Encounter Definitions Oklahoma EHR Incentive Program Definition of Encounter Eligible Professionals: services rendered to a patient on any one day Eligible Hospitals:services rendered to an individual per inpatient discharge or in an emergency room on any one day Definition of a SoonerCare Encounter Eligible Professionals: services rendered to an individual on any one day where (1) SoonerCare paid for part of all of a service, or (2) SoonerCare paid for part of all of the individual’s premiums, co-payments and cost sharing Eligible Hospitals: services rendered to an individual per inpatient discharge where (1) SoonerCare paid for part of all of a service, or (2) SoonerCare paid for part of all of the individual’s premiums, co-payments and / or cost sharing, or services rendered to an individual in an emergency room on any one day where (1) SoonerCare paid for part of all of a service, or (2) SoonerCare paid for part of all of the individual’s premiums, co-payments and cost sharing Definition of a Needy Patient Encounter – services rendered to an individual on any one day where (1) SoonerCare paid for part or all of the service, or (2) SoonerCare paid all or part of the individual’s premiums, co-payments, or cost sharing or services were furnished at no cost or were paid for at a reduced cost based on a sliding scale determined by the individual's ability to pay