Criteria for HIT Stimulus Funding: Meaningful Use and Certification Requirements May 4, 2010 Meaningful Use Critical Access Hospital September 16, 2010

Meaningful Use and Certification Requirements Infrastructure and Federal Standards Funding Provider Financial Incentives Meaningful Use Certification Standards

Establishing and Governing the National Health Information Network National Coordinator to develop a nationwide health information technology infrastructure for the electronic exchange of health information to: –ensure that each patient's health information is secure and protected –improve health care quality, reduce costs and medical errors –endorse standard and certification for electronic exchange and use of health information –Provide Incentives to Adopt by 2014

Standards and Implementation Specifications HIT Policy Committee responsible to make recommendations in a number of areas, including: Technologies that protect the privacy of health information and promote security in a qualified electronic health record a nationwide health information technology infrastructure that allows for the electronic use and accurate exchange of health information Technologies that as part of a qualified electronic health record allow for an accounting of disclosures made y a covered entity Any other technology that the HIT Policy Committee finds to be among the technologies with the greatest potential to improve the quality and efficiency of health care

HIT STANDARDS COMMITTEE –Recommend to the National Coordinator Standards, Implementation Specifications, and Certification Criteria for the Electronic Exchange of Health Information –Harmonization of standards in order to achieve uniform and consistent implementation –Pilot Testing of Standards and Implementation Specifications –Serve as a Forum for Broad Stakeholder Input with Specific Expertise in the development, harmonization, and recognition of standards, implementation specifications, and certification criteria

Governmental Incentives Medicare and Medicaid EHR Programs are estimated to provide incentives in the amount of: $9.7Billion to $27.4 Billion

GENERAL RULE “Eligible Professionals” who adopt and “meaningfully use” “certified” electronic health records are eligible for Medicare and Medicaid Financial Incentives

Who is Eligible? Eligible Professionals The Final Rule finalizes that hospital based eligible professionals to exclude only those physicians that provide 90% or more of their services in either an inpatient or emergency department. Hospitals –Acute Care Hospitals that are paid on PPS Critical Access Hospitals –The Final Rule Includes Critical Access Hospitals in the definition of eligible hospital for Medicaid incentives. Children's’ Hospitals are eligible under Medicaid program

Eligible Professionals Medicare A physician as defined in section 1861(r) of the Social Security Act*, which includes the following five types of professionals: –Doctor of medicine or osteopathy –Doctor of dental surgery or medicine –Doctor of podiatric medicine –Doctor of optometry –Chiropractor

Medicaid Program Medicaid Eligible Professionals (30% population) Physicians –Pediatricians (20% population) Dentists Certified nurse-midwives Nurse practitioners Physician assistants who are practicing in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) led by a physician assistant. Hospitals -10% Medicaid Patient Volume Childrens Hospitals

Medicare Incentives Incentives for Adoption and Meaningful Use of Certified EHR Paid to the Eligible Professional or Facility or Employer No payments after 2016 No incentive if first adopting after 2014 HPSA EP eligible for 10% increase Payment is either single consolidated payment or periodic installment payments

Meaningful Use Incentives by Adoption Year 13 Meaningful User Total Incentive 2011$ 18,000 $ 12,000 $ 8,000 $ 4,000$ 2,000 $ 44, ,000 $ 12,000 $ 8,000$ 4,000$ 2,000 $ 44, ,000 $ 12,000$ 8,000$ 4,000 $39, ,000 $ 8,000$ 4,000 $ 24, $ Penalties

Medicaid Payments Maximum incentive is $63,750 First Payment Year is $21,250 Must begin by 2016 No bonus for HPSA Incentives available through 2021 Paid Once per Year

Eligible Provider Payments Eligible Professionals may participate in only one program and must designate the program. There will be a Registration Process to seek EHR incentives. Eligible Providers may change their program selection once before Payment will be made through a single payment to the TIN number

Hospital Payments Hospital Specific Calculation:  [$2Million + (0 x ( discharges) +(200 x (23, discharges) + [Medicare Share] x [Transition Factor].  If the adoption is after 2013 the payment will reduce based upon modified Transition Factor Critical Access Hospital: reasonable costs incurred for the purchase of depreciable assets like computers, hardware and software (excluding depreciation and interest) multiplied by Medicare share percentage  Paid through prompt interim payment– cost reporting period  No payment after 2015 and no payments for more than 4 consecutive years

Development of Meaningful Use ARRA –February 17, 2009 Meaningful Use Proposed Definition –Health IT Policy Committee-Provided a Matrix to Define Terms Final Matrix Approved August 14, 2009 Proposed Rule Published January 13, 2010 Final Rule Published July 28, 2010

Ultimate Goal of HIT Policy Committee The ultimate goal of meaningful use of an Electronic Health Record is to enable significant and measurable improvements in population health through a transformed health care delivery system. The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.

Health Outcome Policy Priorities Improve Quality, Safety, Efficiencies and Reduce Health Disparities Engage Patients and Families Improve Care Coordination Improve Population and Public Health Ensure Adequate Privacy and Security Protections for Personal Health Information

Meaningful Use under ARRA Use of E-prescribing Use Certified EHR to report on clinical quality measures selected by DHHS DHHS may set alternative requirements for a group practice DHHS shall seek to improve the use of electronic health records and health care quality over time by requiring more stringent measures of meaningful use EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination.

Meaningful User --Medicare Eligible Professional/Eligible Hospital is a meaningful user during the payment year if: 1.Demonstrates use of a certified EHR technology in a meaningful manner; 2.Demonstrates to the satisfaction of the Secretary that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care such as promoting care coordination, in accordance with all laws and standards applicable to the exchange of information; and 3.Using certified EHR technology to submit to DHHS in a manner the clinical quality measures specified by DHHS

Meaningful User--Medicaid EP or Eligible Hospital may demonstrate that they have engaged in efforts to adopt implement or upgrade certified EHR technology Must demonstrate meaningful use of certified EHR technology through a means approved by the State and acceptable to the Secretary that may be based upon the federal methodologies for Medicare programs For Hospitals, if the hospital is a meaningful user under Medicare then it is a meaningful user for Medicaid One uniform definition of Meaningful Use is the minimum standard for both Medicare and Medicaid.

Meaningful Use Requirements January 13, 2010July 22, Measures for Providers 23 Measures for Hospitals Core Elements Menu Elements Administrative TasksRemoved Administrative Transactions Measures required high thresholdsMeasures require lower end of percentage thresholds Denominator calculation of each chartNo Denominator calculation on each chart Patient Education RequiredPatient education only for Hospitals

Proposed Rule /Final Rule Stage 1: Electronically capturing health information in a coded format Track key clinical conditions and communicating that information for Care Coordination Purposes Implement Clinical Decision Support tools to facilitate – disease and medication management; –reporting clinical quality measures; and –public health information

Proposed Rule Stage 2 Encourage the use of Health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using CPOE and the electronic transmission of diagnostic test results. Stage 3 Focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to comprehensive patient data and improving population health

Demonstration of Meaningful Use During the First Year Eligible Professionals and Hospitals shall file an attestation statement that they are in compliance with the meaningful use measures. During the Second Year, Eligible Professionals and Hospitals shall electronically report the information.

Reporting Period FY Day Reporting FY 2012 Entire Calendar Year FY 2013 Entire Calendar Year FY 2014 Entire Calendar Year

Medicaid Payments First participation year only for Medicaid providers Adopted –Acquired and Installed: Evidence of installation prior to incentive Implemented –Commenced Utilization of: Staff training, data entry of patient demographic information into EHR Upgraded –Expanded Upgraded to certified EHR technology or added new functionality to meet the definition of certified EHR technology Must use certified EHR technology (CMS Presentation July 20, 2010)

MU Elements Eligible Professionals have 15 Core Elements Hospitals have 14 Core Elements Menu Sets offer flexibility, but at least one Menu set must address a public objective 5 objectives out of 10 from the Menu Set 6 Total Clinical Quality measures

EP Core Elements –Computerized physician order entry (CPOE) –E-Prescribing (eRx) –Report ambulatory clinical quality measures to CMS/States –Implement one clinical decision support rule –Provide patients with an electronic copy of their health information, upon request –Provide clinical summaries for patients for each office visit –Drug-drug and drug-allergy interaction checks –Record demographics

EP Core Elements –Maintain an up-to-date problem list of current and active diagnoses –Maintain active medication list –Maintain active medication allergy list –Record and chart changes in vital signs –Record smoking status for patients 13 years or older –Capability to exchange key clinical information among providers of care and patient-authorized entities electronically –Protect electronic health information

Hospital Core Elements –CPOE –Drug-drug and drug-allergy interaction checks –Record demographics –Implement one clinical decision support rule –Maintain up-to-date problem list of current and active diagnoses –Maintain active medication list –Maintain active medication allergy list

Hospital Core Elements –Record and chart changes in vital signs –Record smoking status for patients 13 years or older –Report hospital clinical quality measures to CMS or States –Provide patients with an electronic copy of their health information, upon request –Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request –Capability to exchange key clinical information among providers of care and patient-authorized entities electronically –Protect electronic health information

Not Applicable Elements If an element is not applicable and the provider does not have any eligible patients then the measure may be excluded

Medicaid and State Public Policy For Stage 1, the States may add additional public health objectives for Medicaid Incentives: 1.Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach 1.Generate one report listing patients with a specific conditions 2.Submit electronic immunization information 1.Perform at least one test to submit immunization registry information

Medicaid State Public Policy 3. Submit electronic data on reportable lab results to public health agencies Perform at least one test of capacity to submit data on lab results to public health agencies 4. Submit electronic surveillance data to public health agencies Perform one test to submit data to public health agencies Hospitals do not have to satisfy extra requirements if “deemed” a meaningful user under Medicare

Criteria for HIT Stimulus Funding: Meaningful Use and Certification Requirements May 4, 2010 Certification A Required Element

Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Interim Final Rule issued by Office of National Coordinator Became effective 30 days after issuance Public Comment period open for 60 days after issuance Final rule to be issued in 2010

Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Certification criteria specify the capabilities and related standards that certified EHR technology must include to support the meaningful use Stage 1 requirements Adopted standards are consistent with current industry practices – no surprise Adopted standards based on standards for interoperability of health information technologies Future rules will have increased details and requirements regarding interoperability

Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Interim Final Rule – Goals of the rule in adopting the standards, implementation specifications and certification criteria: –Promote interoperability –Promote technical innovation –Encourage participation and adoption, including small businesses –Keep implementation costs as low as reasonably possible –Consider best practices –Enable mechanisms such as Nationwide Health Information network to serve as beta user for innovation and as reference for best practices Intended to be interactive and evolving

Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Certification criteria for eligible professionals and eligible hospitals may vary where proposed meaningful use Stage 1 objectives are specific to one provider or another Certain standards are floors or minimums Around 28 separate certification criteria Adopted Standards: vocabulary, content exchange, transport, privacy and security Adopted Implementations Specifications

Certification Process Adopts initial set of standards, implementation specifications an certification criteria Establishes capabilities that certified EHR technology MUST include in order to, at a minimum, support the achievement of what has been proposed for meaningful use Stage 1 by eligible professionals and eligible hospitals under the Medicare and Medicaid EHR Inventive Programs Remember: All compliance is voluntary.

Certification Process The National Coordinator authorized to establish a voluntary certification program for health information technology, (not only EHR) EHR is the first certification program Background comments indicate a desire to establish voluntary certification programs for other health information technology: personal health records health information exchanges Feasibility of such initiatives may depend on available funding as incentives for adoption

Certification Process Temporary Certification Program Provides a process for an organization to be an authorized testing and Certification Body. (ATCB) ONC will act as certifying body during this temporary period ATCB authorized to test and certify Complete EHRs and/or HER Modules Likely only a few organizations can meet the certification requirements ONC will accept applications for ATCB at any time Temporary program sunsets once the permanent program is put in place

Certification Process Permanent Certification Program The ONC will move as many certification responsibilities as possible to private entities - Authorized Certification Body (“ACB”) The ACB will be authorized to address certification The ACB must be accredited prior to submitting an application to act as a certifying entity The National Voluntary Laboratory Accreditation Program would be responsible for accrediting testing laboratories - the ONC accreditation would no longer be applicable to testing. The NVLAP solely responsible for overseeing testing The ACB renewal required every 2 years

Thank you Michele Madison Partner, Healthcare This presentation is provided as a general informational service to clients and friends of Morris, Manning & Martin LLP. It should not be construed as, and does not constitute, legal advice on any specific matter, nor does this message create an attorney-client relationship. These materials may be considered Attorney Advertising in some states. Please note, prior results discussed in the material do not guarantee similar outcomes.