1. PR’s Journey Towards Electronic Health Records Adoption & Meaningful Use PRESENTATION TO PR HIT SUMMIT Antonio Fernandez Regional Extension Center for PR and USVI

2. 2 HITECH: How the Pieces Fit Together Medicare and Medicaid EHR Incentive Programs Health IT Practice Research Improved Individual & Population Health Outcomes Increased Transparency & Efficiency Improved Ability to Study & Improve Care Delivery ADOPTION EXCHANGE State Grants for Health Information Exchange Medicaid Administrative Funding for HIE Standards & Certification Framework Privacy & Security Framework Regional Extension Centers Medicaid EHR Program 1 st Year Incentive Workforce Training MEANINGFUL USE 2

3. Program Timeline

4. 4 EHR ADOPTION PROGRESS IN PR Physicians who have selected a Certified EHR 3,900 Installations in Physician Practices 2,512 Meaningful Users 325 Dentists in Process of Adoption 197 FQHC’s in EHR Adoption Process 49 Hospitals Having Attested under Medicaid AIU 21 Number of eRx’s during Month of May 451,110 Pharmacies Dispensing e-Rx’s in May 1,012 Active E-Prescribers during month of May 1,854

5. Physician Adoption by Health Region

6. Hospitals Attesting under AIU for 2012 Medicaid Incentives

7. FQHC’s in Process of Certified HER Adoption

10. Puerto Rico Monthly ePrescriptions

11. 11 Stage 1 Data capture and sharing Stage 1 Data capture and sharing Stage 2 Advanced clinical processes Stage 2 Advanced clinical processes Stage 3 Improved outcomes Stage 3 Improved outcomes Ascending Meaningful Use Stages For more information on meaningful use of EHRs, visit: http://www.cms.gov/EHRIncentivePrograms/35_Meaningful_Use.asp  Better clinical outcomes  Improved population health outcomes  Increased transparency and efficiency  Empowered individuals  More robust research data on health system Improved quality of patient care

13. 13 Meaningful Use: Changes from Stage 1 to Stage 2 Eligible Professionals 15 core objectives 5 of 10 menu objectives 20 total objectives Eligible Professionals 17 core objectives 3 of 6 menu objectives 20 total objectives Eligible Hospitals & CAHs 14 core objectives 5 of 10 menu objectives 19 total objectives Eligible Hospitals & CAHs 16 core objectives 3 of 6 menu objectives 19 total objectives Stage 2 Stage 1

16. 16 EPs must meet all 17 core objectives: Core ObjectiveMeasure 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. E-Rx E-Rx for more than 50% 3. Demographics Record demographics for more than 80% 4. Vital Signs Record vital signs for more than 80% 5. Smoking Status Record smoking status for more than 80% 6. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 7. Labs Incorporate lab results for more than 55% 8. Patient List Generate patient list by specific condition 9. Preventive Reminders Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years Stage 2 EP Core Objectives

17. 17 EPs must meet all 17 core objectives: Core ObjectiveMeasure 10. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing 11. Visit Summaries Provide office visit summaries for more than 50% of office visits 12. Education Resources Use EHR to identify and provide education resources more than 10% 13. Secure Messages More than 5% of patients send secure messages to their EP 14. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care 15. Summary of Care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 16. Immunizations Successful ongoing transmission of immunization data 17. Security Analysis Conduct or review security analysis and incorporate in risk management process Stage 2 EP Core Objectives

18. 18 EPs must select 3 out of the 6: Menu ObjectiveMeasure 1. Imaging Results More than 10% of imaging results are accessible through Certified EHR Technology 2. Family History Record family health history for more than 20% 3. Syndromic Surveillance Successful ongoing transmission of syndromic surveillance data 4. Cancer Successful ongoing transmission of cancer case information 5. Specialized Registry Successful ongoing transmission of data to a specialized registry 6. Progress Notes Enter an electronic progress note for more than 30% of unique patients Stage 2 EP Menu Objectives

19. 19 Eligible hospitals must meet all 16 core objectives: Core ObjectiveMeasure 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. Demographics Record demographics for more than 80% 3. Vital Signs Record vital signs for more than 80% 4. Smoking Status Record smoking status for more than 80% 5. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 6. Labs Incorporate lab results for more than 55% 7. Patient List Generate patient list by specific condition 8. eMAR eMAR is implemented and used for more than 10% of medication orders Stage 2 Hospital Core Objectives

20. 20 Eligible hospitals must meet all 16 core objectives: Core ObjectiveMeasure 9. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing 10. Education Resources Use EHR to identify and provide education resources more than 10% 11. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care 12. Summary of Care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 13. Immunizations Successful ongoing transmission of immunization data 14. Labs Successful ongoing submission of reportable laboratory results 15. Syndromic Surveillance Successful ongoing submission of electronic syndromic surveillance data 16. Security Analysis Conduct or review security analysis and incorporate in risk management process Stage 2 Hospital Core Objectives

21. 21 Eligible Hospitals must select 3 out of the 6: Menu ObjectiveMeasure 1. Progress Notes Enter an electronic progress note for more than 30% of unique patients 2. E-Rx More than 10% electronic prescribing (eRx) of discharge medication orders 3. Imaging Results More than 10% of imaging results are accessible through Certified EHR Technology 4. Family History Record family health history for more than 20% 5. Advanced Directives Record advanced directives for more than 50% of patients 65 years or older 6. Labs Provide structured electronic lab results to EPs for more than 20% Stage 2 Hospital Menu Objectives

22. 22 Stage 2 focuses on actual use cases of electronic information exchange: Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals. The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals. At least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR. Closer Look at Stage 2: Electronic Exchange

23. 23 Changes to Stage 1: E-Copy & Online Access Current Stage 1 Objective Objective= Provide patients with e-copy of health information upon request Provide electronic access to health information Provide patients with e-copy of health information upon request Provide electronic access to health information New Stage 1 Objective 23 Objective= Provide patients the ability to view online, download and transmit their health information The measure of the new objective is 50% of patients are provided access to their information; there is no requirement that 5% of patients do access their information for Stage 1. The change in objective takes effect in 2014 to coincide with the 2014 certification and standards criteria

24. 24 Patient engagement – engagement is an important focus of Stage 2. EXCULSIONS – CMS is introducing exclusions based on broadband availability in the provider’s county. Requirements for Patient Action: More than 5% of patients must send secure messages to their EP More than 5% of patients must access their health information online Closer Look at Stage 2: Patient Engagement

25. 25 CQM Selection and HHS Priorities All providers must select CQMs from at least 3 of the 6 HHS National Quality Strategy domains:  Patient and Family Engagement  Patient Safety  Care Coordination  Population and Public Health  Efficient Use of Healthcare Resources  Clinical Processes/Effectiveness

26. 26 CMS’s commitment to alignment includes finalizing the same CQMs used in multiple quality reporting programs for reporting beginning in 2014 Other programs include Hospital IQR Program, PQRS, CHIPRA, and Medicare SSP and Pioneer ACOs, and Patient-Centered Medical Homes Hospital Inpatient Quality Reporting Program Physician Quality Reporting System Children’s Health Insurance Program Reauthorization Act Medicare Shared Savings Program and Pioneer ACOs Aligning CQMs Across Programs

27. 27 Patient-Centered Medical Homes Model for care provided by physician practices that seeks to strengthen the physician-patient relationship and replaces episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship. It is a Model of care where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. The physician- led care team is responsible for providing all the patient’s health care needs and, when needed, arranges for appropriate care with other qualified physicians.

28. 28 Patient-Centered Medical Home Six MUST PASS elements are considered essential to the patient-centered medical home, and are required for practices at all recognition levels by NCQA. Practices must achieve a score of 50% or higher on must-pass elements: 1.PCMH 1, Element A: Access During Office Hours 2.PCMH 2, Element D: Use Data for Population Management 3.PCMH 3, Element C: Care Management 4.PCMH 4, Element A: Support Self-Care Process 5.PCMH 5, Element B: Referral Tracking and Follow-Up 6.PCMH 6, Element C: Implement Continuous Quality Improvement

29. 29 Patient-Centered Medical Home PCMH 1: Access and Continuity PCMH 2: Identify and Manage Patient Populations PCMH 3: Plan and Manage Care PCMH 4: Self- Management Support PCMH 5: Track and Coordinate Care PCMH 6: Performance Measurement and Quality Improvement Meaningful Use Criteria Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health care Improve care coordination Ensure adequate privacy and security protections for personal health information Improve population and public health

30. 30 REC 2.0 Scope of Services Medicaid/Medicare EHR Incentive Program Eligible Provider Registration & Attestation Support Outreach to Other Eligible Providers (Hospitals, Physicians Specialists & Dentists) Meaningful Use Education and Provider Support Privacy & Security Education & Risk Assessment Direct Messaging/Health Information Exchange ADT (Admissions/Discharge/Transfer) Care Transitions Coordination Accountable Care Organizations, Patient-Centered Medical Homes & Transformation Project Support Meaningful User Groups/Communities of Practice HIT Education, Training, and Workforce Development Healthcare Analytics

31. 31 AREAS OF OPPORTUNITY Specialized EHR Needs for Key specialty areas: Psychiatric/Behavioral Health Care Pediatric/Children’s HealthCare Correctional Health Care Strategies for Consumer Engagement & Mobile Health Applications for Consumers, Patients and Families Population Health Management Privacy & Security Education, Risk Assessment & Management Designing Integrated Models of Care which could be adapted to Serving Underserved Populations outside of Puerto Rico

33. 33 CMS Stage 2 Webpage: http://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/Stage_2.html Links to the Federal Register Tipsheets: – Stage 2 Overview – 2014 Clinical Quality Measures – Payment Adjustments & Hardship Exceptions (EPs & Hospitals) – Stage 1 Changes – Stage 1 vs. Stage 2 Tables (EPs & Hospitals) Stage 2 Resources

34. RECPR.ORG/BLOG

35. Other Links U.S. Department of Health & Human Services http://www.hhs.gov Welcome to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) https://pecos.cms.hhs.gov National Plan & Enumeration System https://nppes.cms.hhs.gov/NPPES/LoginPage.do?userType=PROVIDER Puerto Rico Immunization Registry https://prir.salud.gov.pr/PRIRPRD/portalInfoManager.do Puerto Rico Health Informatio Network (PRHIN) https://www.prhin.net Mi Salud http://www.salud.gov.pr/Pages/default.aspxpr/Pages/default.aspx

36. Contact Information Antonio Fernandez afernandez@psm.edu Regional Extension Center (REC) Ponce School of Medicine & Health Sciences