Meaningful Use, the Maine Regional Extension Center, and Critical Access Hospitals Office of Rural Health and Primary Care CAH CEO Meeting October 6, 2010 Shaun Alfreds – HealthInfoNet & Maine Regional Extension Center

HealthInfoNet: Maine’s Health Information Exchange Organization Our mission is to 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 Independent 501(c)(3) Tax Exempt Public-Private Partnership Multi-stakeholder “private/public” Organization Involving Consumers, Providers, Payers, Business and Government 2 2

Acronym Soup! ARRA-American Recovery and Reinvestment Act of 2009 CMS-Centers for Medicare and Medicaid Services EMR-Electronic Health Records HHS-Health and Human Services HIN-HealthInfoNet HIE-Health Information Exchange HIT-Health Information Technology IOO – Implementation Optimization Organization MEREC-Maine Regional Extension Center PPACA-Patient Protection and Affordable Care Act (sometimes also referenced as “ACA” – Affordable Care Act) ONC-Office of the National Coordinator for Health Information Technology QC-Quality Counts REC-Regional Extension Center SEMRV – Supported EMR Vendor 3

Objectives Introduce ARRA/CMS incentives for EMR adoption “Meaningful Use” – what it means for Maine CAHs MEREC core & direct services Support structure Technical assistance Next steps – input on assistance needed 4

Federal Stimulus Funding & Health Care Reform: Why? Currently US healthcare system is… Expensive: we spend more on healthcare than any other nation Ineffective: many low quality outcomes on standards comparable to other countries Fraught with high rates of medical errors Not universally accessible Structured in manner that is unsustainable with impending workforce shortages 5

Why Emphasis on HIT? HIT and EMRs have potential to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their health care Improve care coordination Protect privacy and security of personal health information Improve population and public health 6

Known Barriers to EMR Adoption 7 Cost Lack of standards (interoperability) Privacy and confidentiality concerns Resistance to change Workforce issues Complexity of the change

ARRA & HITECH Feb 17, 2009 – a day that changed everything! ARRA - $19B for adoption of health IT $17B in incentives for EMR adoption - starting 2011 Penalties for non-EMR use by 2015 Supported by subsequent federal healthcare reform (PPACA) with increased focus on transparency, payment reform, accountability for outcomes (For light-hearted look, see “H ITECH: An Interoperetta in Three Acts”: 8

A Busy Year… ARRA HITECH Act David Blumenthal Named National Coordinator FOA Release for RECs ONC Reorganized; Interim Meaningful Use Rule Cycle 2: MEREC Awarded Meaningful Use Final Rule Cycle 1 RECs Awarded Feb ‘09Aug ‘09Feb ‘10Mar ‘10Jul ‘10Apr ‘09May ‘10Dec ‘09 EMR Certification Rule Jun ‘10 Healthcare Reform 9

Bending the Curve Towards Transformed Health Achieving Meaningful Use of Health Data Data capture and sharing Advanced clinical processes Improved outcomes

11 Quality reporting Clinical Decision Support Improving care coordination Engaging patients Managing Population Health Meaningful Use Quality Improvement Technology Practice Redesign Exchange Meaningful Use = Health Care Transformation

How Does a Provider/Hospital Achieve Meaningful Use? Use of a “Certified EMR” in a meaningful manner –Certification Commission for HIT (CCHIT) –Drummond Group Inc. (DGI) –InfoGard Laboratories Inc. Electronically exchange health information (between unaffiliated organizations) to improve the quality of care –Connect to HealthInfoNet –Connect directly (point-to-point) Report on clinical quality measures 12

Meaningful Use – Who is Eligible? Eligible Providers - MedicareEligible Providers - Medicaid Eligible Professionals (EPs)*Eligible Professionals (EPs) Doctor of Medicine or OsteopathyPhysicians (Pediatricians have special eligibility & payment rules) Doctor of Dental Surgery or Dental MedicineNurse Practitioners (NPs) Doctor of Podiatric MedicineCertified Nurse-Midwives (CNMs) Doctor of OptometryDentists ChiropractorPhysician Assistants (PAs) who lead a FQHC) or rural health clinic Eligible Hospitals*Eligible Hospitals Acute Care HospitalsAcute Care Hospitals, Critical Access Hospitals Critical Access Hospitals (CAHs)Children’s Hospitals * Hospital-based professionals excluded from incentives

What is “Meaningful Use” of EMR for CAHs? Core Objectives (14 of 14) –Certified Provider Order Entry (CPOE) –Maintain Active Problem Lists –Reporting on Clinical Quality Measures (CQMs) (15 of 15 CQMs) Menu Set Objectives (5 of 10) –Generate lists of patients by specific conditions –Capture clinical lab results in structured format –Implement drug formulary checks 14

Medicare Incentives for CAHs Reasonable costs incurred for: –Purchase of depreciable assets (hardware / software) necessary to administer a certified EMR during the reporting period –Any similar incurred costs from previous cost reporting periods to the extent they have not been fully depreciated –CAHs Medicare Share = Medicare Share for Eligible Hospitals including charity care + 20 percentage points (used instead of the 101% typically applied to reasonable costs) 15

Medicare Incentives for CAHs Must achieve MU by 2013 to receive full incentive Only consecutive annual payments available Payment duration – (4 yrs) Reductions in reimbursement if not a meaningful user in FY 2015 –FY2015: 101% of reasonable costs to % –FY2016: to % –FY2017 and Subsequent Years: 100% Exemptions and appeals allowed 16

Medicaid Incentives for CAHs 1 st Year Alternative for Meaningful Use –Adopt, implement or upgrade –Certified EMR by ONC (see above) –Qualifies for 1 st year payment Reports on Clinical Quality Measures –1 st year by self attestation –Report numerator, denominator, and exclusion data –Subsequent years – electronic submission $2M base year plus $ per discharge Non-consecutive payments available MaineCare currently developing strategy 17

Stage 1 Meaningful Use Criteria for EHs Core (all 14) 1. CPOE 2. Drug-drug / drug-allergy 3. Demographics 4. One CDSS rule implemented 5. Up to date problem list 6. Active medication list 7. Active medication/allergy list 8. Record and chart vital signs 9. Smoking status (13 and older) 10. Hospital CQMs 11. Patient e-copy of records 12. Patient e-copy of discharge instructions 13. Health Information Exchange 14. Protection of Privacy Menu (select any 5) 1. Drug formulary checks 2. Record advance directives 3. Incorporate lab results as structured data 4. Generate lists of patients by specific conditions 5. Patient specific education provisions through EMR 6. Medication reconciliation 7. Summary of care record for each care transition 8. Capability to submit data to immunization registries 9. Capability to submit lab results to public agencies 10. Capability to submit syndromic surveillance to public agencies 18

Stage 1 Meaningful Use Criteria for EPs Core (all 15) 1. Patient demographics 2. Vital signs 3. Problem list 4. Medication list 5. Allergy list 6. Smoking status 7. Clinical summaries 8. E-copy of health information 9. E-RX 10. CPOE 11. Drug-drug-allergy check 12. E-information exchange 13. Clinical decision support rule 14. Protection of Privacy 15. Clinical Quality Measures Menu (select any 5) 1. Drug formulary checks 2. Incorporate structured lab data 3. Generate patient lists for QI etc. 4. Indentify pt specific education material 5. Medication reconciliation 6. Summary of care in transitions 7. E-submission of immunizations 8. E-submission of surveillance data 9. Patient reminders 10. Electronic patient portal 19

Clinical Quality Measures: Eligible Hospitals and CAHs 1. Emergency Department Throughput – admitted patients median time from ED arrival to ED departure for admitted patients 2. Emergency Department Throughput – admitted patients – Admission decision time to ED departure time for admitted patients 3. Ischemic stroke – Discharge on anti-thrombotics 4. Ischemic stroke – Anticoagulation for A-fib/flutter 5. Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset 6. Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 7. Ischemic stroke – Discharge on statins 8. Ischemic or hemorrhagic stroke – Stroke education 9. Ischemic or hemorrhagic stroke – Rehabilitation assessment 10. VTE prophylaxis within 24 hours of arrival 11. Intensive Care Unit VTE prophylaxis 12. Anticoagulation overlap therapy 13. Platelet monitoring on unfractionated heparin 14. VTE discharge instructions 15. Incidence of potentially preventable VTE 20

Framework for The Regional Extension Center (REC) Based on Agricultural Extension Service Model Organized out of the Office of National Coordinator (ONC) - HIN was awarded to service the State of Maine Total grant award =$4.7 Million over $1 Million committed to “core service” requirements $3.7 Million paid to EMR vendors/suppliers for “direct services” for 1002 “Priority Primary Care Providers” $264K for Critical Access Hospitals (CAH) Focused on optimizing EMR adoption and utilization by PCPs and CAHs REC gets 90/10 federal match years 1 & 2 21

Framework for The Regional Extension Center (REC) Cont. REC supports to be delivered to Primary Care Providers and CAHs. Primary care providers include: Licensed doctors of medicine or osteopathy in: Family practice, Obstetrics and gynecology, General internal or pediatric medicine, PAs, NPs in these specialties. To qualify, practitioners must also treat patients in: Individual and small group practices that are predominantly focused on primary care Outpatient clinics associated with public and non-profit CAHs Community Health Centers and Rural Health Clinics Other settings that primarily serve uninsured, underinsured, and medically underserved populations 22

The Maine Regional Extension Center (MEREC) Mission: Over the next 2 years HealthInfoNet, the Maine REC will manage a process of group purchasing, service contracting and support services targeted at implementing and optimizing the use of EMRs in Maine. The objectives are to: Drive down the cost of investment in interoperable EMRs Help providers and CAHs successfully implement and optimize the use of EMRs in conjunction with “meaningful use” criteria Deliver interoperability between individual EMR implementations and the Health Information Exchange to Better coordinate care, Improve patient safety, Improve quality outcomes, and Manage reductions in duplicate testing and other areas of cost. 23

Maine Regional Extension Center (MEREC) Service Area Service Area Statistics All Counties within Maine ME Congressional Districts 1 & 2 Total Population : 1.3 M 3,500 Providers 1,634 Primary Care Providers 1,002 Priority Primary Care Providers 15 CAHs Total Patients Served by HIE: 792,722 24

How Does The Money Flow? Funds awarded to Maine REC - paid to suppliers/vendors delivering EMR installation, implementation and optimization services Payments spread over three milestones: –Contract executed between provider organization & REC –Provider organization achieves use of certified EMR including use of e-prescribing & quality reporting –Provider achieves “Meaningful Use” criteria and is exchanging information with the statewide HIE REC reports achievement of milestones to ONC quarterly to release funds 25

Maine REC Services Structure HealthInfoNet (Prime Contractor) HealthInfoNet (Prime Contractor) HealthInfoNet Contract Office (REC Direct Service Brokerage) Brokerage for REC Direct Services Request for Proposal (RFP) Process for all Direct REC Services Vendor Neutral Contracting Implementation Optimization Organizations (IOOs) EMR Vendors Wholesale Providers Brokerage for REC Direct Services Request for Proposal (RFP) Process for all Direct REC Services Vendor Neutral Contracting Implementation Optimization Organizations (IOOs) EMR Vendors Wholesale Providers Direct Services Practice Workflow Redesign EMR Implementation eRx Implementation Support Meaningful Use Compliance Quality Improvement Services Direct Services Practice Workflow Redesign EMR Implementation eRx Implementation Support Meaningful Use Compliance Quality Improvement Services REC Contracts Core Services (HIN and Partners) Vendor Selection and Group Purchase Education and Outreach National Learning Consortium Functional Interoperability HIE Privacy and Security Best Practices Quality & Reporting Local Workforce Development through Partnership with OSC Core Services (HIN and Partners) Vendor Selection and Group Purchase Education and Outreach National Learning Consortium Functional Interoperability HIE Privacy and Security Best Practices Quality & Reporting Local Workforce Development through Partnership with OSC Retail (Unaffiliated Practices) Private Practices Small-Med Groups Independent Clinics / Hospitals Retail (Unaffiliated Practices) Private Practices Small-Med Groups Independent Clinics / Hospitals 26 Wholesale (Affiliated Practices) Eastern Maine MaineGeneral Central Maine Maine Health Maine PCA Nova Health Franklin Memorial Maine Coast Martin’s Point Mercy St. Joseph’s Western ME PHO CAHs

Maine REC Technical Assistance Program 27

Role of REC “Wholesale” Partners Support owned/affiliated practices EMR implementation and optimization Meaningful use Drive meaningful quality improvement across organizations through the use of HIT Optimize practice workflow and evidenced based practice Drive quality by having the “right” information at the “right” time leveraging HIE Meet meaningful use criteria to enable CMS incentives funding to flow Meet statewide quality improvement guidelines 28

Support EMR implementation for unaffiliated practices: Provide access to supported, low-cost EMR product(s) Vendor support for practice workflow redesign EMR vendors and Implementation Optimization Organization(s) (IOO) Direct assistance for EMR implementation Vendor and IOO Quality reporting Education – through core supports Maine REC Support – “Retail” Market 29

“Wholesale” + “Retail” practices - i.e. all REC Supported practices: Educational tools, resources, & information Collaborative learning opportunities Bi-annual “Learning Sessions” in 4 regions 1:1 Practice Quality Improvement Coaching Encouraged for Wholesalers, provided to Retail practices Build on existing provider/PHO QI staff Maine REC Supports – All Providers 30

MEREC Education & Outreach One goal of the MEREC is to educate providers about EMR benefits, implementation and meaningful use MEREC will host regional forums, biannually to educate and enroll providers including primary care and critical access hospitals First series late Oct – early Nov 2010 Subsequent series – Spring 2011, Fall 2011, Spring 2012, Fall

MEREC Regional Forums Offered in partnership with Quality Counts Four regional forums in Hallowell, Bangor, Houlton and Portland Audience – Primary care providers & CAH hospital staff Topic – EMR adoption and meaningful use in primary care 32

Forum Objectives Raise awareness of MEREC services Provide overview of technology and processes involved in adopting EMR systems and demonstrating meaningful use. Discuss key considerations in implementing an EMR or optimizing existing systems Explain linkage between EMR use and medical home and quality improvement initiatives and requirements. 33

Forum Details Vendor area and networking Refreshments provided 1 CME credit offered 4:00 – 8:00pm –Hallowell,10/26 –Houlton, 10/27 –Bangor, 10/28 –Portland, 11/9 RSVP to 34

THANK YOU! For More Information: HealthInfoNet: Shaun T. Alfreds, COO Todd Rogow, REC Director Web resources: CMS: