1. Meaningful What? AAP Child Health Informatics Center Update on EHRs and related issues

2. Six years ago…. “…Within 10 years, every American must have a personal electronic medical record. That's a good goal for the country to achieve. The federal government has got to take the lead in order to make this happen.” George W. Bush, April 26, 2004

3. ARRA Legislation “Meaningful Use” criteria release July 13, 2010 Passed on Feb. 13, 2009. President signed Feb. 17, 2009. Included Health Information Technology for Economic and Clinical Health Act (HITECH)

4. “The meaningful use framework will be about the goals of care, not the technology.” “The HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.” David Blumenthal, MD National Coordinator for Health Information Technology US Department of Health and Human Services

5. Improve quality, safety, efficiency and reduce disparities Engage patients Improve coordination of care Ensure privacy and security of PHI Improve population health and interact with public health programs Meaningful Use - Objectives

6. What is MU and who determines it? There are three base requirements for “meaningful use” identified in the new law, including:  Use of certified or qualified EHR technology.  Electronic exchange of health information  Use of EHR in reporting on clinical and other quality measures Medicare & Medicaid (limited)

7. Eligibility Under Medicaid Any Provider with a unique National Provider Identifier (NPI)  who over a continuous, representative 90-day period in the calendar year prior to reporting has at least 30% of all patient encounters at least 20% of all patient encounters AND is a PEDIATRICAN  Challenges for Pediatricians in some states

8. Eligibility Under Medicaid Any Provider for whom at least 50% of patient encounters over a 6-month period occur in a  Federally-Qualified Health Center (FQHC) or  Rural Health Center (RHC)  with at least 30% of patient encounters from individuals who: Receive medical assistance from Medicaid or CHIP; Are furnished uncompensated care by the provider; Are furnished services at no cost or reduced cost according to a sliding-scale determined by the individual’s ability to pay.

9. Medicaid Providers Users of Certified EHR Technology in 2011  Do NOT need to demonstrate – Adopt, Implement, or Upgrade ONLY! Earliest Payment:  Register – January 2011  Attest – April 2011  Payment – May 2011

10. What are the Penalties for not adopting MU? Medicaid – none Medicare  Physicians who have not adopted an EHR  1% payment reduction in 2015  2% in 2016  3% in 2017

11. StageFocusDate Range Stage 1Electronic data capture, track & communicate key conditions, CDS, quality measure & public health data reporting Starting in 2011 Stage 2expands on stage 1, covers disease management dimensions, information exchange in the most structured format possible (CPOE and Diagnostic Study results like Labs & Rads) Starting in 2013 Stage 3promotes improvements in quality, safety & efficiency as well as population health, focuses on CDS for national high priority conditions & patient self management tools Starting in 2015

12. Medicaid Providers Year 1 and 2 – Stage 1 only  Year 3 – MUST meet criteria in effect If 2012 is Year 1  providers will have to jump to Stage 2 in 2014  providers will have to jump to Stage 3 in 2015 If 2013 is Year 1  providers will have to jump to Stage 3 in 2015 States cannot leverage penalties Start Date as late as 2016 (Medicare starts penalties in 2015)

13. Payment Amount for Medicaid Professionals Cap on Net Average Allowable Costs (HITECH Act) Up to 85 percent For Eligible Professionals Max Cumulative Incentive over 6- years $25,000 in Year 1 for most professionals$21,250 $63,750 $10,000 in Years 2-6 for most professionals$8,500 $16,667 in Year 1 for pediatricians (> 20 percent and <30% Medicaid patient volume) $14,167 $42,500 $6,667 in Years 2-6 for pediatricians (> 20 percent and <30% Medicaid patient volume) $5,667

14. Medicaid Incentive Program Enrollment NPI (National Provider Identifier) Business address and phone Taxpayer Identification Number  SSN (payment to individual)  EIN (payment to practice) Decision on participation through Medicare or Medicaid  If Medicaid – State selected (choose ONE state if participating in more than one Medicaid program – can change state selection once)

15. Stage 1: Goals for Meaningful Use Provide access to comprehensive patient health data for patient’s healthcare team. Use evidence-based order sets and computerized provider order entry (CPOE). Apply clinical decision support at the point of care. Generate lists of patients who need care and use them to reach out to those patients. Report information for quality improvement and public reporting.

16. Meaningful Use Criteria Stage 1  Core set (15) Providers must meet ALL criteria in the core set  Menu Set (10) Providers must meet 5 of the menu set  States may modify criteria ONLY related to Public health Registries

17. Core Set Electronic Prescribing  Medication list and Medical Allergy list  Drug-drug and drug-allergy checks.  Generate and transmit permissible prescriptions electronically. (Faxes do not count!)

18. Core Set Record Demographics: Preferred Language, Gender, Race, Ethnicity, Date of Birth Up to date Problem List Recording of Vital Signs  Height, weight, blood pressure, body mass index  EHR is required to generate growth charts.

19. Core Set Recording of Smoking Status (for patients at least 13 years old) Implement 1 Clinical Decision Support Rule Report Clinical Quality Measures  2011 – attestation  2012 – electronic submission

20. Core Set Provide Electronic Copy of Patient Health Information within 3 business days (on request) Provide patients with a clinical summary for each visit Perform at least 1 test of EHR’s capacity to exchange key clinical information electronically Protect EHR information – Comply with HIPAA!

21. Menu Set - select 5 1. Implement drug-formulary checks 2. Incorporate Lab results 3. Generate a List of Patients by Condition 4. Patient Reminders for Preventive/Follow-Up Care 5. Provide Patients Timely Electronic Access  >10% of unique patients are provided electronic access to health information within 4 business days

22. Menu Set - select 5 6. Patient Specific Education Resources 7. Medication Reconciliation 8. Summary of Care Document 9. Data Transmission to Immunization Registries/Information Systems 10. Data Transmission of Syndromic Surveillance Data to Public Health Agencies

23. MU Measurement Even though incentives are paid by Medicare or Medicaid, the requirements for MU apply to ALL patients. MU measurements are based on a percentage of ALL patients

24. Clinical Quality Measure Reporting Pediatricians required to report  3 “core” measures OR  3 “alternate core” measures  If the denominator is 0 for any core measure -> replace with alternate core measures  If the denominator is 0 for all core and alternate core measures -> report on 3 of the “additional” measures

25. Core Measures % of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded. % of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods or strategies. % of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.

26. Alternate Core Measures % of patients 2-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year. % of children 2 years of age who had, by their 2 nd birthday:  4 DTaP  1 VZV  3 IPV  4 PCV  1 MMR  2 Hep A  2 HiB  2 or 3 RV  3 Hep B  2 flu vaccines The measure calculates a rate for each vaccine and 9 separate combination rates. % of patients aged 50 years and older who received an influenza immunization during the flu season (September through February).

27. Additional Measures % of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long- term control medication (inhaled corticosteroid) or an acceptable alternative treatment. % of patients aged 5 through 40 years with a diagnosis of asthma and who have been seen for at least 2 office visits, who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms. % of children 2-18 years of age, who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. The % of adolescent and adult patients with a new episode of alcohol and other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and who initiated treatment and who had 2 or more additional services with an AOD diagnosis within 30 days of the initiation visit.

28. Additional Measures % of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit. % of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26- 30 weeks gestation. % of women 15- 24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. % of patients 5 - 50 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement year. Report 3 age stratifications (5- 11 years, 12-50 years, and total).

29. So – what to do? Certified EHR – talk to your vendor! National Provider Identifier Choose Medicaid Program AAP is monitoring resources for YOU!  ONC  RECs  Local & State  www.aap.org/ehr www.aap.org/ehr

30. Regional Extension Centers $ 650 million under the HITECH Act Creation of a network of up to 70 Regional Health Information Technology Extension Centers  focusing initially on primary care providers in small practices  offer advice on which EHR systems to purchase  assist physicians and hospitals in becoming meaningful EHR users

31. Thank you! Beki Marshall Manager, Health Information Technology Education and Implementation American Academy of Pediatrics bmarshall@aap.org