1. What is the Meaning of “Meaningful Use” of EHR PMI January 21, 2010 Scarborough, ME

2. Presentation Overview Introduction to HealthInfoNet and The Maine Approach to Health Information Exchange Organizing a Complex Inter-Organization Project Setting The Stage for ARRA and HITEH “Meaningful Use” and All That Jazz Moving Forward to Realize the Vision

3. Connecting the Information Silos- Bridging The Information Handoffs Physician Office Hospital Health Clinic Consumer Free Standing Diagnostic Center Reference Laboratory Reference Lab Pharmacy Information known but not shared Unnecessary duplication Of service Contraindicated Therapy HealthInfoNet

4. What Is HealthInfoNet 501(c)(3) Tax Exempt Public-Private Partnership Stake Holder Organization Involving Consumers, Providers, Payers, Business and Government An Organization Focused on Supporting Collaboration and Innovation

5. The Mission of HealthInfoNet Develop, promote and sustain an integrated, secure and reliable regional information network dedicated to delivering authorized, rapid access to person- specific healthcare data across points of care that will support Improved patient safety Enhanced quality of clinical care Increased clinical and administrative efficiency Reduced duplication of services Enhanced identification of threats to public health Expanded consumers access to their own personal health care information

6. Primary Functions of The Health Exchange Person-Centric Clinical Content Aggregation Across Points of Care Delivery Data Standardization Workflow Integration Workflow Optimization

7. 24-Month Demonstration Phase Participating Organizations Central Maine HealthCare Eastern Maine Healthcare Systems Franklin Memorial Hospital MaineGeneral Health MaineHealth Martin’s Point Health Care Maine CDC

8. Status of 24-Month Statewide HIE Demonstration Phase Impact of 6 Provider Organizations Participating  52% of annual inpatient discharges  50% of annual Emergency Department visits  42% of annual ambulatory visits Engagement with Maine Center for Disease Control and Prevention (Maine CDC)  Automated laboratory reporting to support mandated disease reporting  Reporting targeted for 30 of 72 mandated diseases

9. 24 Month Demonstration Phase Scope Release 1, (Month 8) featuring:  Patient Identifier and Demographics  Encounter History  Laboratory Results  Radiology Reports  Patient Consent Management Release 2, (month 12) featuring :  Adverse Reactions/Allergies  Medication History  Diagnosis/Conditions/Problems  Dictated/Transcribed Documents  Parameter-based Launch

10. The Demonstration Phase Exchange Technical Model

11. Current Exchange Volume & Activity Statistics as of 01-19-10 Total Lives In Master Person Index- 648,938 Total Out of State Lives in MPI- 31,483 Total Individuals Opted Out- 4,520 (<0.7%) Total Individuals With Registration Events in Two or More Participating Organizations- 80,024 (12.15%) Current Number of Registered Users- 689

12. Foundation of Organizing A Complex Collaborative Community Project Vision Governance Founding Principles/Mission Goals Valuation

13. The Project Management Challenges Confronting HealthInfoNet Large Number of Unaligned Project Participants Geographic Spread Competing Organization Priorities and Practices x 7 Blending Project Management Methodologies Stakeholder Inter-Organization Politics

14. Building the Infrastructure to Support A Complex Collaborative Community Project Developing a Modified/Collaborative Project Methodology Defining a Virtual, Shared Work Space Maintaining a Strategy for Inter- Organization Prioritization Management and Change Control Redefining the Concept of “Enterprise”

15. Setting The Stage for ARRA/HITECH As The Health Reform Game Changer An Interesting Approach to Stimulus Funding is Incentive for Change Not A Blank Check to Pay For Investment Focus on Transforming the Information Technology of Health Care is Really The Foundation for Transforming Health Care Its About Comparative Measurement And Performance Reporting- Stupid

16. Current ARRA HIT Funding Opportunities Award Range Distribution Applicant/ Fiscal Agent Beacons Curriculum Development Centers Community College Consortia State HIE Coop Medicaid Incentives Regional Extension Center SHARP Program University- based Training Quarterly 2010-2014 $1M-$30M Quarterly 2010-2014 State Non-profitMedicaid Mechanism Coop Agreement TBD 2011-2016 Incentive Payments 85% net allowable costs Primary Focus TBD 2010-2012 Coop Agreement $10M-$20M TBD 2010-2012 Coop Agreement $1.82M Inst. of Higher Ed. C.C. Consortia TBD 2010-2012 Coop Agreement $6.2M- $21.15M University/R esearch Institution TBD 2010-2014 Coop Agreement $10M-$18M University TBD 2010-2013 Grant Up to $4M HIE Capacity HIT Adoption Meaningful Use Quality and Value Demonstration Curriculum Develop. Academic Program Creation Breakthrough Advances Academic Program Creation $4-40 M Proposal Due Date 10-16-09 1-29-10 3-18-10 Funding Award Date 2-1-10 1-14-101-22-10 1-25-10 1-15-10 3-31-10 1-2011 3-2010 TBD 3-15-10 3-18-10 Community Competency Exam 1-25-10 3-18-10 $6 million Coop Agreement Inst. of Higher Ed. Competency Test Dev. TBD 2010-2012 Red: State Government Applicant / Fiscal Agent Green: Non-governmental Applicant / Fiscal Agent 16

17. “Meaningful Use”- Noun, Verb or Expletive Sets the Bar for Demonstrating “Optimum” Use of EMR To Be Defined Over Three Phases- Phase One Rules Issued on 12-30-09 Each Phase will “Raise the Bar” for Minimum Standards Does “Meaningful Use” = “Meaningful Outcome”

18. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 1. CPOE is used for at least 80% of all orders 2. Medication interaction checks (drug-drug, drug-allergy, drug- formulary) functionality must be enabled. 3. Maintain an up-to-date problem list for 80% of patients seen 1. Include current and active diagnoses 2. Based on ICD-9-CM or SNOMED 4. Use e-prescribing (eRx) for at least 75% of prescriptions.

19. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 5. Maintain an active medication list for at least 80% of patients. 6. Maintain an active medication allergy list for at least 80% of patients. 7. Record demographics information (as structured data) for at least 80% of patients. 8. Record and chart changes in vital signs for at least 80% of patients age 2 and over.  Blood Pressure  BMI  Growth Chart (for children age 2 to 20)

20. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 9. Record smoking status for at least 80% of patients 13 years old or older 10. Incorporate clinical lab-test results into EHR as structured data for at least 50% of all clinical lab results ordered. 11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach (at least one report must be generated listing patients with a specific condition). 12. Report ambulatory quality measures to CMS or the States (can be manually submitted in 2011, and must be electronically submitted in 2012).

21. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 13. Send patient reminders for preventive/ follow-up care for at least 50% of patients age 50 and over. 14. Implement five clinical decision support rules relevant to specific clinical quality metrics 13. Must be relevant to specialty or high clinical priority, including ordering of diagnostic tests 14. Must have the ability to track compliance with these rules 15. Electronic insurance eligibility checking (from public and private payers) for at least 80% of patients. 16. Electronic claims submission (to public and private payers) for at least 80% of claims.

22. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 17. Provide patients with an electronic copy of their health information within 48 hours (including diagnostic test results, problem list, medication lists, and allergies) for at least 80% of patients requesting electronic copies. 18. Provide patients with electronic access to their health information (including lab results, problem list, medication lists, allergies) for at least 10% of patients. 19. Provide clinical summaries to patients for at least 80% of all office visits. 20. Demonstrate the capability to electronically exchange clinical information (problem list, medication list, allergies, diagnostic test results, etc.) by performing at least one test of transmission.

23. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 21. Perform medication reconciliation at relevant encounters and each transition of care for at least 80% of relevant encounters. 22. Provide a summary care record for each transition of care and referral for at least 80% of transitions and referrals. 23. Demonstrate the capability to submit electronic data to immunization registries and actual submission where required and accepted, by performing at least one test of transmission to immunization registries.

24. “Meaningful Use” Rules For Providers- 25 Keys to CMS Incentive Payments 24. Demonstrate the capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice, by performing at least one test of transmission to public health agencies. 25. Protect & ensure the security of electronic health information by implementing appropriate technical capabilities, and conducting a security risk analysis, and implementing security updates as necessary.

25. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 1. CPOE is used for at least 10% of all orders 2. Medication interaction checks (drug-drug, drug-allergy, drug- formulary) functionality must be enabled. 3. Maintain an up-to-date problem list for 80% of patients admitted  Include current and active diagnoses  Based on ICD-9-CM or SNOMED 4. Maintain an active medication list for at least 80% of patients admitted. 5. Maintain an active medication allergy list for at least 80% of patients admitted.

26. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 6. Record demographics information (as structured data) for at least 80% of patients admitted. 7. Record and chart changes in vital signs for at least 80% of patients admitted age 2 and over.  Blood Pressure  BMI  Growth Chart (for children age 2 to 20) 8. Record smoking status for at least 80% of patients admitted 13 years old or older. 9. Incorporate clinical lab-test results into EHR as structured data for at least 50% of all clinical lab results ordered.

27. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 10. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach (at least one report must be generated listing patients with a specific condition). 11. Report hospital quality measures to CMS or the States (can be manually submitted in 2011, and must be electronically submitted in 2012). 12. Implement five clinical decision support rules relevant to specific clinical quality metrics  Must be relevant to specialty or high clinical priority, including ordering of diagnostic tests  Must have the ability to track compliance with these rules

28. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 13. Electronic insurance eligibility checking (from public and private payers) for at least 80% of patients admitted. 14. Electronic claims submission (to public and private payers) for at least 80% of claims. 15. Provide patients with an electronic copy of their health information within 48 hours (including diagnostic test results, problem list, medication lists, and allergies) for at least 80% of patients requesting electronic copies.

29. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 16. Provide patients with an electronic copy of their discharge instructions and procedures at the time of discharge, for at least 80% of patients requesting electronic copies. 17. Demonstrate the capability to electronically exchange clinical information (discharge summary, procedures, problem list, medication list, allergies, diagnostic test results, etc.) by performing at least one test of transmission. 18. Perform medication reconciliation at relevant encounters and each transition of care for at least 80% of relevant encounters. 19. Provide a summary care record for each transition of care and referral for at least 80% of transitions and referrals.

30. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 20. Demonstrate the capability to submit electronic data to immunization registries and actual submission where required and accepted, by performing at least one test of transmission to immunization registries. 21. Demonstrate the capability to provide electronic submission of reportable lab results to public health agencies, and actual submission where it can be received, by performing at least one test of transmission to public health agencies.

31. “Meaningful Use” for Hospitals- 22 Requirements for CMS Incentive Payments 22. Demonstrate the capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice, by performing at least one test of transmission to public health agencies.  Protect & ensure the security of electronic health information by implementing appropriate technical capabilities, and conducting a security risk analysis, and implementing security updates as necessary.

32. REC Core and Direct Services Core Services Practice HIT Stage Assessment Vendor Selection and Group Purchase Outreach and Education National Learning Consortium Functional Interoperability HIE Privacy and Security Practices Quality Measurement, Reporting, and Improvement Local Workforce Development Direct Services Practice Workflow Redesign EMR Implementation HIE Interface Support eRx Implementation Support “Meaningful Use” Compliance 32 REC Services Divided into 2 Programs 1.Support providers with NO EMR 2.Support providers with EMR

33. REC Performance Milestones Milestones Signed contracts with financial commitments by priority primary-care providers. Number of priority primary-care providers that are actively using an EHR, including active use of electronic prescribing. Utilization of EHRs and promoting features essential for meaningful use. Helping priority primary-care providers to understand, and implement technology and process changes needed to attain, and demonstrate attainment of, meaningful use requirements 33

34. Proposed MEREC Structure HealthInfoNet (Prime Contractor) HealthInfoNet (Prime Contractor) MEREC Controller Office Direct Brokerage for REC Direct Services Request for Proposal (RFP) Process for all Direct REC Services Vendor Neutral Contracting Processes Builds off Wholesale and Retail Marketplace Needs Direct Brokerage for REC Direct Services Request for Proposal (RFP) Process for all Direct REC Services Vendor Neutral Contracting Processes Builds off Wholesale and Retail Marketplace Needs Direct Services Practice Workflow Redesign EMR Implementation HIE Interface Support eRx Implementation Support Meaningful Use Compliance Direct Services Practice Workflow Redesign EMR Implementation HIE Interface Support eRx Implementation Support Meaningful Use Compliance REC Contracts Core Services (HIN and Partners) Provider Education and Outreach Project Management Workforce Integration National Learning Consortium Functional Interoperability Privacy and Security Group purchasing Quality Improvement Core Services (HIN and Partners) Provider Education and Outreach Project Management Workforce Integration National Learning Consortium Functional Interoperability Privacy and Security Group purchasing Quality Improvement Unaffiliated Practices (Retail Marketplace) Private Practices Small-Med Groups Independent Clinics / Hospitals Unaffiliated Practices (Retail Marketplace) Private Practices Small-Med Groups Independent Clinics / Hospitals Affiliated Practices (Wholesale Marketplace) Eastern Maine Maine General Central Maine Maine Health Maine PCA Others Affiliated Practices (Wholesale Marketplace) Eastern Maine Maine General Central Maine Maine Health Maine PCA Others 34

35. Proposed MEREC Technical Assistance Program 35

36. Some Closing Thoughts on ARRA/HITEC At $42 Billion and Five Years It Is Too Little Money and Too Little Time– But What An Opportunity? Are The Incentives Large Enough To Drive Meaningful Adoption? Is The HIT Work Force Available to Make This Happen or Can It Be Grown Fast Enough To Make It Happen? Meaningful Use is About Process, Meaningful Change Is Quite Another Matter Mixed Messages-Mixed Results What Happened to The Patient as the Central Objective?