1. “Preserve and Improve the Health Status of all Californians” Medi-Cal Electronic Health Records (EHR) Incentive Program Medi-Cal Electronic Health Records (EHR) Incentive Program Larry Dickey, MD, MPH Medical Director Office of Health Information Technology California Department of Health Care Services

2. “Preserve and Improve the Health Status of all Californians” Medi-Cal EHR Incentive Program Program Overview History-Where have we been? Current Activities-Where are we going? Forward-Ongoing Activities

3. “Preserve and Improve the Health Status of all Californians” Medi-Cal EHR Incentive Program –Cornerstone of ARRA Hi-Tech Program –Companion to the Medicare EHR Incentive Program administered by CMS –Medi-Cal EHR Incentive Program administered by DHCS with CMS funding –$1.4 billion dollars to California providers (practitioners and hospitals) over 10 year period beginning in 2011. Currently have paid 750 million to over 13,000 providers and 388 hospitals. –EHR Incentive programs complement health information exchange (HIE) and regional extension center (REC) programs funded by federal DHHS.

4. “Preserve and Improve the Health Status of all Californians” Medi-Cal EHR Incentive Program –Purpose : to encourage providers to: Adopt, install, or upgrade high quality EHRs certified by the Office of the National Coordinator Use EHRs to meaningfully improve clinical practice and public health Ensure quality and continuity of care Permit greater access to care Reduce costs

5. “Preserve and Improve the Health Status of all Californians” Medi-Cal EHR Incentive Program Practitioner Eligibility Who are eligible providers Physicians Dentists Nurse Practitioners Midwifes Physician assistants practicing in a PA-led Federal Qualified Health Center (FQHC) or Rural Health Clinic (RHC) Optometrists

6. “Preserve and Improve the Health Status of all Californians” Medi-Cal EHR Incentive Program Practitioner Eligibility Patient Volume Requirement –30% Medi-Cal patient volume, except for pediatricians who can qualify with 20% but receive 2/3 of incentive payments –Providers in groups all qualify if the group as a whole qualifies. 75% of participants currently. –Practitioners in FQHCs or RHCs are eligible with 30% “needy” volume: Medi-Cal + Healthy Families, uninsured and partial-pay patients –Most Indian health centers in California are Tribal Health Program (THP) Clinics, not FQHCs. Many will not qualify for incentive payments unless able to count “needy” patients.

7. “Preserve and Improve the Health Status of all Californians” Medicaid Eligible Hospitals Hospitals eligible for incentive under Medicare and Medicaid may receive both payments. Final Rule added all Critical Access Hospitals (CAHs) by definition to be eligible under Medicaid. Acute care hospital (includes CAHs) > 10% Medicaid share, Avg length of stay < 25 days, Last 4-digits of Medicare CCN = 0001-0879 and 1300-1399 Children’s hospital All

8. “Preserve and Improve the Health Status of all Californians” Medi-Cal EHR Incentive Program –Incentives : (carrots) Practitioners: $63,750 over 6 years Hospitals: $2-6 million over 4 years –Withholds: (stick) Beginning in 2015 Medicare withholds (1% to 5% progressive) for providers not attaining meaningful use. –Timeline: Enrollment: October 2011 Program ends: December 2021

9. “Preserve and Improve the Health Status of all Californians” Potential Medicaid Provider Incentives Year 1 payment for adoption, implementation, or upgrade of certified EHR technology. Purchase not necessary. Some are free. Year 2-6 payments contingent on provider demonstrating “meaningful use” of the EHR -- Does not need to be consecutive years Year 1 payment does not need to be in 2011, but cannot be later than 2016. One time switch to Medicare incentive program if before CY2015. No penalties for failure to actually use the certified EHRs. *available to each eligible provider Year 1:*$21,250 Year 2:*$8,500 Year 3:*$8,500 Year 4:*$8,500 Year 5:*$8,500 Year 6:*$8,500 Total:$63,750

10. “Preserve and Improve the Health Status of all Californians” What is a Certified EHR? –Certified by the Office of the National Coordinator for Health Information Technology –Must meet national standards for content, functionality and interoperability. All certified EHRs should be able to attain meaningful use. –Certified separately for Stage 1 (2011-2013) and Stage 2 (2014-2016) meaningful use. Stage 3 is being planned.

11. “Preserve and Improve the Health Status of all Californians” Steps for Meaningful Use When providers use CEHRT in a meaningful way, it builds a broader HIT infrastructure to help reform and improve the healthcare system by ensuring quality, efficiency, and patient safety. The MU criteria are being implemented in three stages and will continue to evolve over the next five years. Stage 1 Data Capture and Information Sharing FFY 2011 - 2012 Stage 2 Advanced Clinical Practices (Clinical Decision Support) FFY 2014 Stage 3 Improved Outcomes through HIE (2017-?) The requirements for each stage become progressively more demanding

12. “Preserve and Improve the Health Status of all Californians” Stage 1 MU Requirements There are different MU objectives (core and menu) for eligible professionals (EPs) and eligible hospitals (EHs). EPs must meet 20 out of 25 objectives to qualify (15 core + 5 menu objectives). EHs must meet 19 out of 24 objectives to qualify (14 core + 5 menu objectives). Both EPs and EHs must meet all core objectives and select five out of ten menu objectives. Providers must attest at the state website www.medi-cal.ehr.ca.gov and receive verification that they met the MU objectives and measures.www.medi-cal.ehr.ca.gov

13. “Preserve and Improve the Health Status of all Californians” Stage 1 Meaningful Use: Core Objectives for EPs Eligible Professionals – 15 Core Objectives (EPs must meet all core objectives.) 1Use a computerized physician order entry (CPOE) for medication orders. 2Implement drug-drug and drug-allergy interaction checks. 3Maintain an up-to-date problem list of current and active diagnoses. 4Generate and transmit permissible prescriptions electronically (e-prescribing [eRx]). 5Maintain an active medication list. 6Maintain an active medication allergy list. 7Record demographics (e.g., preferred language, gender, race, ethnicity, and date of birth). 8Record and chart changes in vital signs (e.g., height, weight, blood pressure, body mass index, and growth charts). 9Record smoking status for patients 13 years old or older. 10Report ambulatory Clinical Quality Measures (CQM) to CMS or the States. 11Implement one clinical decision support rule. 12Provide patients with an electronic copy of their health information, upon request. 13Provide clinical summaries for patients for each office visit. 14Exchange key electronic clinical information among providers of care and patient-authorized entities. 15Protect electronic health information.

14. “Preserve and Improve the Health Status of all Californians” Stage 1 of Meaningful Use: Menu Objectives for EPs Eligible Professionals – 10 Menu Objectives (EPs must meet 5 of 10 menu objectives.) 1Implement drug formulary checks. 2Incorporate clinical lab test results as structured data. 3Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. 4Send patient reminders per patient preference for preventive/follow-up care. 5Provide patients with timely electronic access to their health information. 6Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient, if appropriate. 7Perform medication reconciliation (coordination of medications between levels of care and providers). 8Provide a summary of care record for each transition of care or referral. 9Submit electronic data to immunization registries or immunization information systems.* 10Submit electronic syndromic surveillance data to public health agencies.* * Public health objective: At least one public health objective must be selected by the provider.

15. “Preserve and Improve the Health Status of all Californians” Clinical Quality Measures 3 Core CQMs –Adult weight screening and follow-up –Blood pressure measurement 18 and over –Tobacco assessment and intervention 3 Alternate Core (if exclude any core) –Childhood immunization status –Weight assessment and counseling (children and adolescents) –Influenza immunization (50 and older)

16. “Preserve and Improve the Health Status of all Californians” Clinical Quality Measures (Stage 1) 3 of 39 Additional Measures –MCAH Related –Strep throat testing and treatment 2-18 years –Drug and alcohol intervention—adolescents and adults –Asthma assessment –Asthma medications –HIV screening (prenatal) –Anti-D Immune Globulin at 26-30 weeks –Chlamydia screening

17. “Preserve and Improve the Health Status of all Californians” Clinical Quality Measures (beginning in 2014) Report 9 of 64 in 3 of 6 domains –Patient and Family Engagement –Patient Safety –Care Coordination –Population/Public Health –Efficient Use of Healthcare Resources –Clinical Process/Effectiveness

18. “Preserve and Improve the Health Status of all Californians” Clinical Quality Measures (beginning in 2014) Report 9 in 3 of 6 domains –Patient and Family Engagement –Patient Safety –Care Coordination –Population/Public Health –Efficient Use of Healthcare Resources –Clinical Process/Effectiveness

19. “Preserve and Improve the Health Status of all Californians” Clinical Quality Measures (beginning in 2014) MCAH Related Same as previous but have added: –URI treatment –ADHD follow-up care –Depression screening (12 and over) –HBsAg prenatal testing –Maternal depression screening –Dental decay

20. “Preserve and Improve the Health Status of all Californians” A California Certified EHR? Several California state programs require retention of forms in medical records—such as CPSP For state to promote EHRs while continuing to require paper forms is contradictory Programs and provider groups have requested these forms be incorporated into EHRs DHCS Director’s Office very supportive of this

21. “Preserve and Improve the Health Status of all Californians” A California Certified EHR? First steps: –A survey has been sent out to all DHCS programs as well as to CHHS departments. Results pending –A meeting of concerned programs will be convened based on the survey. Will forms simply be scanned into the EHRs? Will it be possible to use data entered elsewhere in the EHR? Will vendors be willing to adopt standards? Will programs be willing to review vendor products for compliance?