“MUving” to Meaningful Use Last Updated: June 13, 2011

“MUving” to Meaningful Use Last Updated: June 13, 2011

Year 1, Stage 1 MU Information contained in this presentation pertains only to Year 1, Stage 1 of Meaningful Use Information was obtained from the CMS website and the IHS website All information is based on the Final Rule. (

Today’s Objectives ARRA Across Indian Country What is Meaningful Use
Eligibility Requirements Patient Volumes Incentives/Penalties Performance Measures Next Steps: Timelines, Registration, Reports and Contacts and Resources State Specific Information (if applicable) 3

Electronic Health Record (EHR) Incentive Program Overview

What is Meaningful Use? Meaningful Use is using certified EHR technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their health care Improve care coordination Improve population and public health All the while maintaining privacy and security CMS provides incentive payments to promote adoption and meaningful use of a certified EHR The ultimate objective of Meaningful Use is to improve patient care. The CMS Final Rule released on July 28th identified five broad priorities – listed on this slide -- for making these improvements. Each priority concentrates on an aspect of patient care. Every aspect of Meaningful Use is focused on fulfilling 1 or more of these 5 priorities. 5

What are the Components of Meaningful Use?
ARRA specifies the following 3 components of Meaningful Use: Use of certified EHR in a meaningful manner (e.g., e-prescribing) Use of certified EHR technology for electronic exchange of health information to improve quality of health care Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary 6

What are the Stages of Meaningful Use?
Requirements will increase over time…more work lies ahead Stage 1 Stage 2 Stage 3 2015+ This image shows a conceptual graphic of the advancements of meaningful use. After the rule making period which led to the Final Rule that is now published in the Federal Register, 3 stages of meaningful use were established. Stage 1 which takes place in 2011 and 2012 is aimed at data capture and sharing. Stage 2 which takes place in 2013 and 2014 is aimed at advanced clinical processes and Stage 3 which is slated for 2015 targets improved outcomes. 7

What is Certified EHR? Life before Certified EHR
Life after Certified EHR

What is Meaningful Use?

Eligible professionals

Eligible Professionals: Overview
Must choose the Medicare OR Medicaid incentive program; not eligible for both Payments for Eligible Professionals are based on a calendar year Medicare reporting period is based on 90-day consecutive period during a calendar year Incentives are based on the individual, not the practice Hospital-based EPs are NOT eligible for incentives Eligibility determined by law EPs may switch between the two programs anytime prior to first payment; after that, may only switch once before As I mentioned earlier, an eligible professional must designate which program they are going to participate in. You can’t do both. You are able to make a one-time switch, but I believe you have to do it by 2015. If you are a hospital-based EP you are NOT eligible for incentives. The law defines hospital-based as an EP with 90% or more of their covered professional services taking place in either an inpatient or emergency room of a hospital (that’s Place of Service codes 21 or 23). Also provider incentives are based on the individual, not the practice. Eligible Provider is a term that has also been defined by law and the definitions differ between the Medicare and Medicaid programs. 11

Eligible Professionals: Medicare & Medicaid Comparison
EHR Incentive Program MEDICAID Implemented by the Federal Government and started January 3, 2011 Voluntary for States to implement - Most are expected to start by late summer 2011 Program ends in 2016; must initiate participation by Must participate by 2012 to receive the maximum incentive payment Program ends in 2021; must initiate participation by 2016 and still receive maximum incentive payment Can register now Can register once state offers the program (check with your state for expected launch date) Medicare payment reductions begin in 2015 for EPs who cannot demonstrate MU of certified EHR technology No Medicaid payment reductions Must demonstrate MU in Year 1 over a consecutive 90-day report period A/I/U option for Year 1

Eligible Professionals: Definition of A/I/U
Adopt: Acquire, purchase, or secure access to certified EHR technology. Implement: Install or commence utilization of certified EHR technology capable or meeting MU requirements. Upgrade: Expand the available functionality of certified EHR technology capable of meeting MU requirements at the practice site, including staffing, maintenance, and training or upgrade from existing EHR technology to certified EHR technology per the ONC EHR certification criteria.

Eligibility For professionals

Eligible Professionals: Medicare & Medicaid Eligibility Comparison
Eligible Professionals under the Medicare Incentive program include: Doctor of Medicine or Osteopathy Doctor of Oral Surgery or Dental Medicine Doctor of Podiatric Medicine Doctor of Optometry Chiropractor Specialties are eligible if they meet one of the above criteria Eligible Professionals under the Medicaid Incentive Program include: Physician Dentist Certified Nurse-Midwife Nurse Practitioner Physician Assistant practicing in a Federally Qualified Health Center (FQHC) or Rural Health Center led by a Physician Assistant **Hospital-based EPs are NOT eligible for incentives DEFINITION: 90% or more of their covered professional services in either an inpatient or emergency room (Place of Service codes 21 or 23) of a hospital

Eligible Professionals: Patient Volume Requirement
Medicare Medicaid For Medicare, there is not a Patient Volume requirement For Medicaid, an Eligible Professional must meet a minimum Patient Volume threshold

Eligible Professionals: Medicaid Patient Volume Threshold
Eligible Professional (EP) If EP does not practice predominantly at FQHC/RHC: Minimum Medicaid patient volume thresholds If EP does practice predominantly at FQHC/RHC: Minimum needy individual patient volume thresholds Physicians 30% - Pediatricians 20% Dentists Certified Nurse-Midwives NPs PAs when practicing at an FQHC/RHC that is so led by a PA N/A What does it mean to practice at an FQHC or RHC?

Eligible Professionals: Medicaid Patient Volume Calculation
3 main options for calculating patient volume Individual EP Calculation (Patient Encounter) Group Practice Patient panel* State picks from these or proposes new method for review and approval If CMS approves a method for one state, it may be considered an option for all states *Will NOT be included in the first release of the RPMS Third Party Billing patient volume report.

Eligible Professionals: Medicaid Encounter
For calculating Medicaid patient volume, a “Medicaid encounter” means services rendered to an individual on any one day where Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for all or part of: The service; or Their premiums, co-payments, and/or cost-sharing Can be calculated for the GROUP or the individual EP

Eligible Professionals: Medicaid Individual EP Calculation
Individual EP Calculation: Medicaid Total Medicaid patient encounters for the EP in any representative continuous 90-day period in the preceding calendar year Total patient encounters for the EP in that same 90-day period *100 We propose this flexible patient volume methodology in order to capture the highest number of true Medicaid practitioners potentially eligible for the EHR incentive program. We believe Congress set the high patient volume thresholds in order to offer these incentives to the practitioners whose practices are open and accessible to Medicaid beneficiaries. We noted that many Medicaid eligible individuals, such as children, may seek care at specified times of the year, such as the beginning of the school-year for required immunizations. Since there are five different types of providers, varying from specialty to primary care, we thought the flexibility would capture any seasonal encounter adjustments in the year, while still honoring Congress' intent to reward higher-volume Medicaid practitioners. We demonstrate our proposed calculation for Medicaid patient volume here, which is the total Medicaid patient encounters in a 90-day period in the preceding calendar year representing the numerator and the same provider’s total patient encounters in that same 90-day period in the denominator, then multiplied by 100 for a percentage. For the needy individual patient volume, the threshold is calculated in the same manner, but with the numerator equal to the EP’s total number of needy individual patient encounters in any 90 day period in the preceding calendar year. Medicaid EPs and eligible hospitals would be required to annually re-attest to patient volume thresholds to continue to qualify for Medicaid incentive payments. If a State has an alternative approach to the established timeframe for measuring patient volume, it may propose it to us for review through the State Medicaid HIT Plan (discussed later) and we would make a determination of whether it is an acceptable alternative. To be considered for approval, the alternative approach would require a verifiable data source and justification. In defining the way in which patient volume is established, we provide for a consistent methodology per the statute, but also allow for the possibility that States may propose acceptable alternatives that synchronize with existing data sources, which could decrease State data burdens. This alternative approach must provide an auditable record (that is, a record of how the professional demonstrated patient volume) for CMS to monitor the States’ oversight of the Medicaid incentive payment program implementation. 20

Eligible Professionals: Medicaid Group Practice Calculation
Group Practice Calculation: Medicaid Total Medicaid patient encounters for the entire clinic/group practice in any representative continuous 90-day period in the preceding calendar year Total patient encounters for the entire clinic/group practice in that same 90-day period *100 NOTE: To use the Group Practice calculation: The Group Practice patient volume must be appropriate for the EP (e.g., if an EP ONLY sees Medicare, commercial or self-pay patients, this is not an appropriate calculation). There is an auditable data source to support the clinic’s patient volume determination. The practice and EPs must use one methodology in each year (i.e. clinics could not have some EPs using individual patient volume while others use the group practice volume). The clinic/group practice uses the entire practice or clinic’s patient volume and does not limit it in any way. If EP works inside & outside of the clinic/practice, only those encounters associated with the clinic/practice are included, not the EP’s outside encounters. 21

Eligible Professionals: Medicaid Patient Panel Calculation
Patient Panel Calculation (Managed Care/Medical Home Approach): Medicaid [Total Medicaid patients assigned to the EP’s panel in any representative continuous 90-day period in the preceding calendar year when at least one Medicaid encounter took place with the Medicaid patient in the year prior to the 90-day period] + [Unduplicated Medicaid encounters in the same 90-day period] *100 [Total patients assigned to the provider in the same 90-day with at least one encounter taking place with the patient during the year prior to the 90-day period] + [All unduplicated encounters in the same 90-day period] 22

Eligible Professionals: Medicaid Needy Patient Encounter
For calculating needy individual patient volume, a “needy patient encounter” means services rendered to an individual on any one day where: Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid for all or part of: The service; or Their premiums, co-payments, and/or cost-sharing; or The services were furnished at no cost; or The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay Can be calculated for the GROUP or the individual EP

Eligible Professionals: Medicaid Needy Individual EP Calculation
Individual EP Calculation: Needy Individual Total Needy Individual patient encounters for the EP in any continuous 90-day period in the preceding calendar year Total patient encounters for the EP in that same 90-day period *100 NOTE: “Needy individuals” means individuals that meet one of the following: Received medical assistance from Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act). Furnished uncompensated care by the provider. Furnished services at either no cost or reduced cost based on a sliding scale determined by the individuals’ ability to pay. 24

Eligible Professionals: Medicaid Needy Group Practice Calculation
Group Practice Calculations: Needy Individual Total Needy Individual patient encounters for the entire clinic/group practice in any continuous 90-day period in the preceding calendar year *100 Total patient encounters in that same 90-day period NOTE: See notes on slides 22 and 23 25

Eligible Professionals: Medicaid Needy Patient Panel Calculation
Patient Panel Calculation (Managed Care/Medical Home Approach): Needy Individual [Total Needy Individual patients assigned to the EP’s panel in any representative continuous 90-day period in the preceding calendar year when at least one Needy Individual encounter took place with the Needy Individual in the year prior to the 90-day period] + [Unduplicated Needy Individual encounters in the same 90-day period] *100 [Total patients assigned to the provider in the same 90-day with at least one encounter taking place with the patient during the year prior to the 90-day period] + [All unduplicated encounters in the same 90-day period] 26

Eligible Professionals Incentives

Eligible Professionals: Medicare Incentive Payments
Incentive amounts based on 75% Fee-for-Service allowable charges Maximum incentives are $44,000 over 5 years Extra 10% bonus amount available for practicing predominantly in a Health Professional Shortage Area (HPSA) (identifies, by zip code or county, areas lacking sufficient clinicians to meet primary care needs) Incentives decrease if starting after 2012 Must begin by 2014 to receive incentive payments Last payment year is 2016 Receive one (1) incentive payment per year 28

Eligible Professionals: Medicare Incentive Payment Example
Amount of Payment Each Year of Participation Calendar Year EP Receives a Payment CY 2011 CY 2012 CY 2013 CY2014 CY 2015 and later $18,000 $12,000 $8,000 $15,000 CY 2014 $4,000 CY 2015 $2,000 $0 CY 2016 TOTAL $44,000 $39,000 $24,000 Chart showing annual payments based on the first year an EP qualifies for an incentive payment. If the EP qualifies for their first incentive payment in either calendar year 2011 or calendar year 2012, their incentive payments would be: year 1: $18,000, year 2: $12,000, year 3: $8,000, year 4: $4,000, year 5: $2,000. This would total $44,000 over the course of 5 years participating in the program. If the EP qualifies for their first incentive payment in calendar year 2013, their incentive payments would be: year 1: $15,000, year 2: $12,000, year 3: $8,000, year 4: $4,000. This would total $39,000 over the course of 4 years participating in the program. If the EP qualifies for their first incentive payment in calendar year 2014, their incentive payments would be: year 1: $12,000, year 2: $8,000, year 3: $4,000. this would total $24,000 over the course of 3 years participating in the program. There are no incentive payments for an EP who begins demonstrating meaningful use starting in calendar year 2015 or later. The last payment year for the incentives is 2016. 29

Eligible Professionals: Medicaid Incentive Payments
Incentive amounts based on 85% EHR Cost Maximum incentives are $63,750 over 6 years The first year payment is $21,250 No extra bonus for health professional shortage areas available Incentives are same regardless of start year Must begin by 2016 to receive incentive payments Incentives available through 2021 Receive one (1) incentive payment per year 30

Eligible Professionals: Medicaid Incentive Payment Example
Amount of Payment Each Year if Continues Meeting Requirements 1st Calendar Year EP Receives a Payment CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016 $21,250 $8,500 CY 2017 CY 2018 CY 2019 CY 2020 CY 2021 TOTAL $63,750 Chart showing annual payments based on first year EP qualifies for an incentive payment in the Medicaid EHR incentive program. If you start participating anytime between 2011 and 2016, your first year payment would be $21,250. Subsequent payments for the remaining 6 years that an EP can participate would be $8,500 each year they qualify. At the end of the 6 years, if you continue to meet the program requirements to qualify for payment, your total incentive payments would be $63,750. 31

Eligible Professionals: Summary of Medicare & Medicaid Incentives
Start CY 2011 End CY 2016 (max. 5 years, must start by 2014) 2021 (max. 6 years, must start by 2016) Incentive Amount Up to $44,000 total per provider; based on % Medicare claims (10% bonus for EP’s in HPSAs) Up to $63,750 total per provider; based on 85% of EHR costs Reimbursement Reduced CY 2015 No penalties All right, this slide highlights some of the basic differences between the Medicare and Medicaid programs. One thing I notice that we have covered here yet is the provider program is on a calendar year and the hospital program is on a federal fiscal year. For pediatricians with between 20 and 30% Medicaid, incentive amount and limit is reduced by 1/3 The first year payment can be as high as $14,167 and $5,667 for each of the following 5 years

Eligible Professionals: Incentive Payments
IHS EP’s must re-assign incentive payments to their facility; Tribal EPs should consult with their Tribal/facility leadership. EP’s who achieve MU by combining services from multiple sites or states, may only assign their payment to one entity in one state. In the first year of demonstrating MU under Medicare, a payment will be made when the EP reaches his/her minimum allowable charges or the end of the year, whichever comes first.

Eligible Professionals Performance Measures & Clinical Quality Measures

Eligible Professionals: Meaningful Use Requirements
STAGE 1: Meaningful Use Requirements 15 core performance measures* 5 performance measures out of 10 from menu set* 6 total Clinical Quality Measures 3 core or alternate core 3 out of 38 from menu set * Most measures require achievement of a performance target 35

Eligible Professionals 15 Core Performance Measures
>30%: Computerized physician order entry (CPOE): Unique patients w/at least 1 medication on medication list have at least 1 medication ordered w/CPOE >40%: E-Prescribing (eRx) Yes/No: Report ambulatory clinical quality measures to CMS/States Yes/No: Implement one clinical decision support rule >50%: Provide patients with an electronic copy of their health information, upon request >50%: Provide clinical summaries for patients for each office visit Yes/No: Implement drug-drug and drug-allergy interaction checks during the entire EHR reporting period >50%: Record demographics >80%: Maintain an up-to-date problem list of current and active diagnoses >80%: Maintain active medication list >80%: Maintain active medication allergy list >50%: Record and chart changes in vital signs >50%: Record smoking status for patients 13 years or older Test Performed (Yes/No): Capability to exchange key clinical information among providers of care and patient-authorized entities electronically Yes/No: Conduct or review a security risk analysis per CFR (a)(1) and implement security updates as necessary & correct deficiencies

Eligible Professionals 10 Menu Set Performance Measures (Choose 5)
Yes/No: Implement drug-formulary checks for entire EHR reporting period >40%: Incorporate clinical lab test results as structured data Yes/No: Generate lists of patients by specific conditions >10%: Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate >50%: Medication reconciliation at transitions of care >50%: Summary of care record for each transition of care/referrals Performed Test (Yes/No): Capability to submit electronic data to immunization registries/systems* Performed Test (Yes/No): Capability to provide electronic syndromic surveillance data to public health agencies* >20%: Send reminders to patients per patient preference for preventive/follow up care >10%: Provide patients with timely electronic access to their health information (within 4 business days) *At least 1 public health measure must be selected NOTE: States have the option to require one or more of the items shown in italic font as core measures

Eligible Professionals: Clinical Quality Measures
Core Set: If denominator = 0, must report on the Alternate Core measures NQF Measure Number & PQRI Implementation Number Clinical Quality Measure Title NQF 0013 Hypertension: Blood Pressure Measurement NQF 0028 Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention NQF 0421 PQRI 128 Adult Weight Screening and Follow-up Alternate Core Set Chart showing the core set of clinical quality measures. The left column is the NQF Measures Number and PQRI Implementation Number. The right column is the Clinical Quality Measure Title. 1. NQF 0013 = Hypertension: Blood Pressure Measurement. 2. NQF 0028 = Preventive Care and Screening Measure Pair: a.) Tobacco Use Assessment, b.) Tobacco Cessation Intervention. 3. NQF 0241 and PQRI 128 = Adult Weight Screening and Follow-Up. NQF Measure Number & PQRI Implementation Number Clinical Quality Measure Title NQF 0024 Weight Assessment and Counseling for Children and Adolescents NQF 0041 PQRI 110 Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older NQF 0038 Childhood Immunization Status 38

Eligible Professionals: 38 Additional Clinical Quality Measures (Choose 3)
Diabetes: Hemoglobin A1c Poor Control Diabetes: Low Density Lipoprotein (LDL) Management and Control Diabetes: Blood Pressure Management Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Pneumonia Vaccination Status for Older Adults Breast Cancer Screening Colorectal Cancer Screening Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 39

Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Asthma Pharmacologic Therapy Asthma Assessment Appropriate Testing for Children with Pharyngitis Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients 40

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies Diabetes: Eye Exam Diabetes: Urine Screening Diabetes: Foot Exam Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation Ischemic Vascular Disease (IVD): Blood Pressure Management 41

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) Prenatal Care: Anti-D Immune Globulin Controlling High Blood Pressure Cervical Cancer Screening Chlamydia Screening for Women Use of Appropriate Medications for Asthma Low Back Pain: Use of Imaging Studies Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control Diabetes: Hemoglobin A1c Control (<8.0%) 42

Eligible Professionals: Clinical Quality Measures Release Date
1st Release 9 EP measures (3 core/3 alternate core/3 menu set (breast cancer screening, cervical cancer screening, and colorectal cancer screening) CRS v11.0 Patch 2 2nd Release All 15 hospital measures CRS v11.0 Patch 3, est. release of May 27, 2011 3rd Release Remaining EP menu set measures identified as priority for Stage 1 development CRS v11.1. est. June 30, 2011 43

Eligible Professionals: Meaningful Use Summary
Medicare Medicaid Demonstrate MU of a certified EHR in all participation years First Year of participation, demonstrate MU for a 90 day consecutive period. In the first year of Stage 1, adopt, implement, or upgrade (AIU) to a certified EHR. After the first year, demonstrate MU of a certified EHR as noted in the next three rows. For Stage 1, report on 15 core measures and five measures from menu set of 10. Meet performance targets on most measures. For Stage 1, report on a total of 6 clinical quality measures (3 core, 3 menu set). If the denominator for any of the 3 measures is zero, must report on the 3 alternate core measures. If all 6 of the measures have a denominator of zero, the eligible professional must still report on any 3 menu set measures shown in the menu set. Note: There are no performance targets.

Eligible Hospitals

Eligible Hospital: Overview
IHS hospitals are eligible to participate in both the Medicare and Medicaid incentive programs Eligible IHS Hospitals include: Subsection-D/Acute Care Hospitals Critical Access Hospitals For Medicaid, must meet a 10% Medicaid patient volume requirement; no patient volume requirement for Medicare Eligible reporting period based on consecutive 90-day period during a fiscal year (Medicare) CMS recommends hospitals register for both programs, even if you don’t know yet if you meet the Medicaid patient volume requirements. Who is eligible to participate? (Read bullets on slide) PPS = Prospective Payment System. 46

Eligible Hospital: Medicare & Medicaid Comparison
EHR Incentive Program MEDICAID Implemented by the Federal Government and started January 3, 2011 Voluntary for States to implement - Most are expected to start by late summer 2011 Program ends in 2016; must initiate participation by Must participate by 2012 to receive the maximum incentive payment Program ends in 2021; must initiate participation by 2016 and still receive maximum incentive payment Can register now Can register once state offers the program (check with your state for expected launch date) Medicare payment reductions begin in 2015 for EHs who cannot demonstrate MU of certified EHR technology No Medicaid payment reductions Must demonstrate MU in Year 1 over a consecutive 90-day report period A/I/U option for Year 1

Eligibility for Hospitals

Eligible Hospitals: Medicare & Medicaid Eligibility Comparison
Eligible Hospitals under the Medicare Incentive program include: Subsection D Hospitals Critical Access Hospitals Eligible Hospitals under the Medicaid Incentive Program include: Acute Care Hospitals Children’s Hospitals

Eligible Hospital: Medicaid Patient Volume Requirement
Eligible Hospitals Minimum Medicaid patient volume threshold Acute care hospitals, including Critical Access Hospitals 10%

Eligible Hospital: Medicaid Patient Volume Calculation
1 main option for calculating patient volume Medicaid Encounters State picks can use this method or propose a new method for review and approval If CMS approves a method for one state, it may be considered an option for all states

Eligible Hospital: Medicaid Encounter Definition
For calculating Medicaid patient volume, a “Medicaid encounter” means services rendered to an individual where Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of: Service per inpatient discharges, Premiums, co-payments, and/or cost-sharing per inpatient discharge Service in an emergency department* on any one day, or, Their premiums, co-payments, and/or cost sharing in an emergency department* on any one day. *An emergency department must be part of the hospital under the qualifying CCN.

Eligible Hospital: Medicaid Patient Volume Calculation
Total Medicaid encounters in any representative continuous 90-day period in the preceding fiscal year Total encounters in the same 90-day period *100 We propose this flexible patient volume methodology in order to capture the highest number of true Medicaid practitioners potentially eligible for the EHR incentive program. We believe Congress set the high patient volume thresholds in order to offer these incentives to the practitioners whose practices are open and accessible to Medicaid beneficiaries. We noted that many Medicaid eligible individuals, such as children, may seek care at specified times of the year, such as the beginning of the school-year for required immunizations. Since there are five different types of providers, varying from specialty to primary care, we thought the flexibility would capture any seasonal encounter adjustments in the year, while still honoring Congress' intent to reward higher-volume Medicaid practitioners. We demonstrate our proposed calculation for Medicaid patient volume here, which is the total Medicaid patient encounters in a 90-day period in the preceding calendar year representing the numerator and the same provider’s total patient encounters in that same 90-day period in the denominator, then multiplied by 100 for a percentage. For the needy individual patient volume, the threshold is calculated in the same manner, but with the numerator equal to the EP’s total number of needy individual patient encounters in any 90 day period in the preceding calendar year. Medicaid EPs and eligible hospitals would be required to annually re-attest to patient volume thresholds to continue to qualify for Medicaid incentive payments. If a State has an alternative approach to the established timeframe for measuring patient volume, it may propose it to us for review through the State Medicaid HIT Plan (discussed later) and we would make a determination of whether it is an acceptable alternative. To be considered for approval, the alternative approach would require a verifiable data source and justification. In defining the way in which patient volume is established, we provide for a consistent methodology per the statute, but also allow for the possibility that States may propose acceptable alternatives that synchronize with existing data sources, which could decrease State data burdens. This alternative approach must provide an auditable record (that is, a record of how the professional demonstrated patient volume) for CMS to monitor the States’ oversight of the Medicaid incentive payment program implementation. 53

Hospital Incentives

Eligible Hospital: Medicare & Medicaid Incentive Summary
Start FY 2011 End FY 2016 (max. 4 years, must start by 2015) 2021 (max. 6 years, must start by 2016) Incentive Amount Varies, depending on % Medicare inpatient bed days. CAHs paid based on EHR costs and % Medicare inpatient bed days. Varies, depending on % Medicaid inpatient bed days. Reimbursement Reduced FY 2015 No penalties All right, this slide highlights some of the basic differences between the Medicare and Medicaid programs. One thing I notice that we have covered here yet is the provider program is on a calendar year and the hospital program is on a federal fiscal year. For pediatricians with between 20 and 30% Medicaid, incentive amount and limit is reduced by 1/3 The first year payment can be as high as $14,167 and $5,667 for each of the following 5 years

Eligible Hospitals Performance Measures & Clinical Quality measures

Eligible Hospital: Meaningful Use Requirements
STAGE 1: Meaningful Use Requirements 14 core performance measures* 5 performance measures out of 10 from menu set* 15 total Clinical Quality Measures * Most measures require achievement of a performance target 57

Eligible Hospital CORE Performance Measures
>30%: Computerized physician order entry (CPOE): Unique patients w/at least 1 medication on medication list have at least 1 medication ordered w/CPOE Yes/No: Report hospital clinical quality measures to CMS or States Yes/No: Implement one clinical decision support rule >50%: Provide patients with an electronic copy of their health information, upon request >50%: Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request Yes/No: Implement drug-drug and drug-allergy interaction checks during the entire EHR reporting period >50%: Record demographics >80%: Maintain an up-to-date problem list of current and active diagnoses >80%: Maintain active medication list >80%: Maintain active medication allergy list >50%: Record and chart changes in vital signs >50%: Record smoking status for patients 13 years or older Test Performed (Yes/No): Capability to exchange key clinical information among providers of care and patient-authorized entities electronically Yes/No: Conduct or review a security risk analysis per CFR (a)(1) and implement security updates as necessary & correct deficiencies

Eligible Hospitals Menu Set Performance Measures (Choose 5)
Yes/No: Implement drug-formulary checks for entire EHR reporting period >40%: Incorporate clinical lab test results as structured data Yes/No: Generate lists of patients by specific conditions >10%: Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate >50%: Medication reconciliation at transitions of care >50%: Summary of care record for each transition of care/referrals Performed Test (Yes/No): Capability to submit electronic data to immunization registries/systems* Performed Test (Yes/No): Capability to provide electronic syndromic surveillance data to public health agencies* >50%: Record advanced directives for patients 65 years or older Performed Test (Yes/No): Capability to provide electronic submission of reportable lab results to public health agencies* *At least 1 public health measure must be selected NOTE: States have the option to require one or more of the items shown in italic font as core measures

Eligible Hospital: 15 Clinical Quality Measures
Emergency Department Throughput – admitted patients Median time from ED arrival to ED departure for admitted patients Admission decision time to ED departure time for admitted patients Ischemic stroke – Discharge on anti-thrombotics Ischemic stroke – Anticoagulation for A-fib/flutter Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 Ischemic stroke – Discharge on statins 60

Eligible Hospital: 15 Clinical Quality Measures
Ischemic or hemorrhagic stroke – Rehabilitation assessment VTE prophylaxis within 24 hours of arrival Anticoagulation overlap therapy Ischemic or Hemorrhagic stroke – Stroke Education Intensive Care Unit VTE prophylaxis Platelet monitoring on unfractionated heparin VTE discharge instructions Incidence of potentially preventable VTE 61

Eligible Hospital: Clinical Quality Measures Release Date
1st Release 9 EP measures (3 core/3 alternate core/3 menu set (breast cancer screening, cervical cancer screening, and colorectal cancer screening) CRS v11.0 Patch 2 2nd Release All 15 hospital measures CRS v11.0 Patch 3, est. release of May 27, 2011 3rd Release Remaining EP menu set measures identified as priority for Stage 1 development CRS v11.1. est. June 30, 2011

Eligible Hospitals: Meaningful Use Summary
Medicare Medicaid Demonstrate MU of a certified EHR in all participation years. Year One for 90 consecutive days All Subsequent Years-Hospitals will have to demonstrate MU for the entire reporting year In the first year of Stage 1, adopt, implement, or upgrade (AIU) to a certified EHR. After the first year, demonstrate MU of a certified EHR as noted in the next three rows. For Stage 1, report on 14 core measures and 5 measures from a menu set of 10. Meet performance targets on most measures. For Stage 1, report on all 15 hospital clinical quality measures. Note: There are no performance targets.

Next Steps: Timeline, Toolkit, Reports, Registration, and Resources

CMS EHR Incentive Program Timeline
Jan. 1, 2011 Reporting year begins for EPs Jan. 3, 2011 Registration begins for the Medicare Incentive Program Registration begins for 11 State Medicaid Incentive Programs April 2011 Attestation for the Medicare EHR Incentive Program begins. Spring-Summer 2011 Registration begins for additional states July 3, 2011 Eligible Hospitals LAST day to begin their 90-day reporting period for the Medicare Incentive Program. Sept.30, 2011 Last day of the federal fiscal year & Reporting year for Eligible Hospitals Oct. 1, 2011 Eligible Professionals LAST day to begin their 90-day reporting period for the Medicare Incentive Program. Nov. 30, 2011 Eligible Hospitals LAST day to register and attest to receive an Incentive Payment for fiscal year 2011. Dec. 31, 2011 Last day of calendar year & reporting year for Eligible Professionals. Feb. 29, 2012 Eligible Professionals LAST day to register and attest to receive an Incentive Payment for calendar year 2011. October 1, 2010 – Reporting year begins for eligible hospitals and CAHs.

RPMS Certification Status

ONC EHR Certification Number*
Ambulatory: EJKDEAI Inpatient: ELL6EAI *Entered during CMS registration and attestation

Certified RPMS EHR: Release Dates
Upcoming releases Certified EHR patch 8 - May 2011 Reporting Tools-May and June 2011

Certified EHR: Key Points
A certified EHR is required to demonstrate meaningful use EHR Certification demonstrates that the EHR is standardized and interoperable RPMS-EHR was certified by InfoGard on April 1, 2011 The CMS certification number can be obtained at: The certified version RPMS-EHR will be released by the end of May 2011 Further enhancements ongoing.

Meaningful Use Resources

Meaningful Use: Tools and Resources
MU Tool Kit EHR MU Guide Reports EHR Costs Guidance

Meaningful Use: Tool Kit
MU Readiness Assessment Tool Post-EHR deployment MU status for use by MU Coordinators, MU Consultants, and/or RPMS Deployment Team Based on a State assessment tool MU Action Plan MU Checklist EPs Eligible Hospitals Certified RPMS Report Automated tool Compares a list of RPMS applications installed at a facility with the official certified RPMS list Determines which versions/patches are needed

Meaningful Use: EHR MU Cheat Sheets & Guide
EPs Eligible Hospitals Release: May 2011 EHR MU Guide Developed by RPMS EHR Deployment Team and MU Team Detailed guide showing steps for setting up RPMS and entering MU information that is needed to demonstrate MU Release: May 16, 2011

MU Website

Meaningful use Reports

Meaningful Use Reports: EP & EH Performance Report
Shows performance on all MU measures that calculate a rate, e.g., CPOE rate, demographic rate, e-prescribing rate, etc. May also include measures that require a yes/no answer, e.g., performance of a test of facility’s ability to electronically exchange key clinical information Includes a summary that provides information needed to attest with CMS or the respective State to receive incentive payment Included in PCC Management Reports initially and subsequently added to a new MU tab in iCare Two releases of the Stage 1 report: 1st release: All measures; some yes/no measures need to be answered by person running report (May 20, 2011 release) 2nd release: All measures; yes/no measures answered automatically by report, where applicable (TBD)

Meaningful Use Reports: Clinical Quality Measure Report
2 new reports added to the RPMS Clinical Reporting System (CRS) (EP and Hospital Report) & new MU tab in iCare Release Plan 1st Release 9 EP measures (3 core/3 alternate core/3 menu set - Breast Cancer Screening, Colorectal Cancer Screening, Cervical Cancer Screening) CRS v11.0 Patch 2, est. April 27, 2011 2nd Release All 15 hospital measures CRS v11.0 Patch 3, est. May 27, 2011 3rd Release Remaining EP menu set measures identified as priority for Stage 1 development CRS v11.1. est. June 30, 2011 Certification and Meaningful Use are two different things. An EHR has been certified when it is proven to be capable of providing mandated functionality. IHS is going to provide a certified EHR to its providers and hospitals. Meaningful Use, on the other hand, cannot be provided to you. It is how you choose to use the certified technology. IHS has an EHR Deployment Team that will implement the technology at sites that do not have it. However, responsibility falls to the facility staff to know and use the Meaningful Use requirements.

Meaningful Use Reports: Patient Volume Report
Developing software requirements/program logic Anticipate late July release Calculates EP Medicaid patient volume rates EP Needy Individual patient volume rates Group practice rates (Medicaid and Needy Individual) in lieu of calculating the rate for each individual EP Hospital Medicaid patient volume rates Will be added to RPMS Third Party Billing (TPB) Relies on information stored in RPMS TPB; sites using a COTS TPB will not be able to run this report

Meaningful Use Report: Cost Reports
MU Team investigating as to whether or not a formula to estimate EHR costs for EPs is still needed for the Medicaid EP incentives MU Team developing formula/calculation for critical access hospitals to determine their EHR costs Release: TBD

Regional Extension Centers (REC’s)

Regional Extension Center
Sign-up with a Regional Extension Center (REC) is critical to REC funding release and on-set of facility support All federal sites must register with the National Indian Health Board’s National REC (NIHB National REC) Registration occurring now via NIHB website Tribal sites may register with an REC of their choice, including the NIHB National REC ONC list of RECs The most recent information we have from CMS regarding dual eligible hospitals indicates that there could possibly be payment delays due to administrative processes if a hospital signs up for the Medicare program and subsequently changes to dual. Hospitals should keep this in mind and decide whether they want to wait until their state is ready to begin registration for the Medicaid program or proceed and risk a payment delay from Medicare. 84

Registration for EHR incentive Programs

CMS Incentive Program Registration
First register on the CMS website, then with your respective State, if applying for Medicaid incentives. Registration open now - Alaska - Mississippi - Oklahoma - Iowa - North Carolina - Texas - Kentucky - South Carolina - Michigan - Louisiana - Tennessee - Alabama - Missouri Registration for other states will launch during spring and summer 2011 States will pay no later than 5 months after you register; most sooner The most recent information we have from CMS regarding dual eligible hospitals indicates that there could possibly be payment delays due to administrative processes if a hospital signs up for the Medicare program and subsequently changes to dual. Hospitals should keep this in mind and decide whether they want to wait until their state is ready to begin registration for the Medicaid program or proceed and risk a payment delay from Medicare. 86

Eligible Hospital Checklist
National Provider Identifier (NPI) An enrollment record in Provider Enrollment, Chain and Ownership System (PECOS). Note: If you do not have an enrollment record in PECOS, you should still register for the Medicare and Medicaid EHR incentive programs. CMS Identity and Access Management (I & A) User ID and Password. CMS Certification Number (CCN). Hospital Tax ID Number Address from IRS form CP-575 and copy of form Eligible Professional Checklist National Provider Identifier (NPI) An enrollment record in Provider Enrollment, Chain and Ownership System (PECOS) if you are a Medicare eligible professional. National Plan and Provider Enumeration System (NPPES) User and ID and Password. Payee Tax Identification Number (for reassignment of individual provider benefits to facility) Payee National Provider Identifier (NPI) (for reassignment of individual provider benefits to facility) Confirmed facility tax ID number (TIN) for incentive benefit reassignment by IHS eligible professionals in group practices Address from IRS form CP-575 and copy of form

Providers will use the NPPES/NPI web user account user name & password

Medicaid EPs &hospitals must continue with the State’s site to verify additional info.
Providers will not receive confirmations at this point in the program. It is important that providers print this page or record the information in another way.

Area MU Coordinators Area MU Coordinator
Contact Information Aberdeen CAPT Scott Anderson (605) Alaska Richard Hall Kimi Gosney Erika Wolter (907) (907) (907) Albuquerque TBA Bemidji Jason Douglas Alan Fogarty (218) (218) Billings CAPT James Sabatinos (406) California Marilyn Freeman (916) , ext. 362 Nashville Robin Bartlett (615) Navajo LCDR Andrea Scott (928) Oklahoma Amy Rubin (405) Phoenix CAPT Lee Stern (602) Portland CAPT Leslie Dye Donnie Lee, MD (503) (503) Tucson Scott Hamstra, MD (520)

Area MU Consultants(contractors)
Contact Information Team Lead (ABQ) JoAnne Hawkins (505) Regional Consultant #1 Donna Nicholls (505) Ext 1545 Regional Consultant #2 TBD Aberdeen Carol Smith (605) Alaska Karen Sidell Rochelle (Rocky) Plotnick (907) (907) Albuquerque Malissa Lyons (505) Bemidji Billings Jeremy Lougee (406) California Tim Campbell (707) Nashville Robin Kitzmiller (615) Navajo Harvey Frank Hulse (505) Oklahoma Ursula Hill (405) Phoenix Rick Bowman (interim) (520) Portland Angela Boechler (971) Tucson Rick Bowman 91

IHS Meaningful Use: Contact Information Theresa Cullen, MD, MS Rear Admiral, USPHS IHS Chief Information Officer (301) Chris Lamer, Meaningful Use Project Lead, IHS (615) Cathy Whaley, Acting Meaningful Use Project Manager, DNC (520) JoAnne Hawkins, Meaningful Use Team Lead, DNC (505)

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“MUving” to Meaningful Use Last Updated: June 13, 2011

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“MUving” to Meaningful Use Last Updated: June 13, 2011

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