2010 ubo/ubu conference health budgets & financial policy briefing: arra arran't you going...

2010 UBO/UBU Conference

Health Budgets& Financial Policy Briefing: ARRA

ARRAn't You Going to Make Some Changes Too?

Date: 23 March 2010

Time: 1010–1100

2010 UBO/UBU ConferenceTurning Knowledge Into Action Discussion Framework

Statutory framework under ARRA– Support of EHR adoption– Requirements of federal healthcare delivery

organizations Implementing the regulations required by ARRA

– EHR standards and certification criteria (ONC)– EHR Incentive Program (CMS)– EHR certification bodies and processes (ONC)

Definition of Meaningful Use Initial set of standards, certification criteria and

implementing specifications

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2010 UBO/UBU ConferenceTurning Knowledge Into Action

Statutory Framework Under ARRASupport for EHR Adoption

The ARRA seeks to greatly accelerate the adoption of EHRs across the nation by providing substantial incentive payments for the adoption and use of EHRs.

To meet the requirements to receive these incentive payments, Eligible Professionals (EP) and Eligible Hospitals (EH) must use certified EHRs in a meaningful way.

Thus, the incentive program is dependent upon creating very objective definitions for this new entitlement program linked to the concept of “meaningful use.”

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Statutory Framework Under ARRA (2) Support for EHR Adoption

The general requirements set forth in the ARRA for meaningful use require that a provider/hospital

1.use “certified EHR technology” including “electronic prescribing,”

2.use standards-based electronic exchange of appropriate health information “to improve the quality of health care [and] care coordination,” and

3.report information on “clinical quality … and … other measures.”

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Statutory Framework Under ARRA (3) Requirements for Federal HCOs

SEC. 13111. COORDINATION OF FEDERAL ACTIVITIES WITH ADOPTED STANDARDS AND IMPLEMENTATION SPECIFICATIONS.(a) SPENDING ON HEALTH INFORMATION TECHNOLOGY SYSTEMS.— As each agency…implements, acquires, or upgrades health information technology systems used for the direct exchange of individually identifiable health information between agencies and with non-Federal entities, it shall utilize, where available, health information technology systems and products that meet standards and implementation specifications adopted under section 3004 of the Public Health Service Act, as added by section 13101.

(b) FEDERAL INFORMATION COLLECTION ACTIVITIES.—With respect to a standard or implementation specification adopted under section 3004 of the Public Health Service Act, as added by section 13101, the President shall take measures to ensure that Federal activities involving the broad collection and submission of health information are consistent with such standard or implementation specification, respectively, within three years after the date of such adoption.

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Interpretation of S13111 of the ARRA S13111 uses the same language as that previously

stated in EO 13410 EO 13410 had been interpreted to mean that while

national standards implementation did not have to be implemented internally within the departments, any information that crossed organizational boundaries (left the VA or DoD), would have to be standards compliant.

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The implications of the ARRA and prior EO assessments are clear– DoD/VA sharing should be based on national

standards– DoD/VA sharing with partners in the private or

commercial communities should be based on national standards

– As noted in the following section of this brief, new national standards are being proposed and the “old” standards are not necessarily the basis of plans moving forward

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Implementing the Regulations Required by ARRA

To support national HIE, the ARRA required three sets of rules– EHR standards and certification criteria (ONC)– EHR Incentive Program (CMS)– EHR certification bodies and processes (ONC)

The ONC-published Interim Final Rule on EHR standards and certification criteria has the most direct bearing on Federal Health Care Organizations

The CMS proposed rule on EHR incentives has strong impact on adoption of EHRs in the private sector

The ONC has yet to propose its rule regarding new certification bodies and procedures to accelerate the certification of EHRs and EHR modules

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EHR Standards, Implementation Specifications and Certification Criteria (ONC IFR) - 1

ONC published its Interim Final Rule (IFR) on 13 January 2010.

As an IFR is a “final rule,” it has the force of law and became final on 12 February 2010.

The “finality” of the rule is needed to support certification standards for EHRs in time for providers to qualify for Meaningful Use (MU) incentives by 2011.

Although the ONC IFR is a final rule, ONC has agreed to take comments from the public through 15 March and hopes to publish a final rule by year’s end.

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ONC IFR – 2Stages of Meaningful Use (MU)

The ARRA required that “…more stringent measures of meaningful use” be defined by HHS to “improve the use of electronic health records and health care quality over time”.

Three “stages” of MU were defined in the CMS NPRM and adopted in the ONC IFR:– Stage 1: Required in 2011 – Final (for EHRs on

12Feb– Stage 2: Required in 2013 – Open for comment– Stage 3: Required in 2015 – Open for comment

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ONC IFR – 3Three Components of the Rule

The title of ONC’s IFR is “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology”

As the name of the rule implies, it addresses:– Standards for EHR Technology– Implementation Specifications for EHR Technology– Certification Criteria for EHR Technology

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ONC IFRImplementation Specifications (IS) – 1

The IFR defines IS as “specific requirements or instructions for implementing a standard.” Many IS have been developed by HITSP.

While the IFR states, “We expect that in determining whether to recognize harmonized or updated standards from other entities, the HIT Standards Committee will look to entities such as HITSP…,” it goes on to state that “HITSP… developed implementation specifications… which …resulted in varying degrees of interoperability…. and resulted in a narrow and unique set of implementation specifications, designed for a specific architecture and well-defined exchange…. We do not believe, with the exception of the few mentioned below, that there are mature implementation specifications ready to adopt to support meaningful use Stage 1.”

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ONC IFRIS Adopted by the ONC IFR – 2

The Physician Quality Reporting Initiative (PQRI) Measure Specifications Manual for Claims and Registry

The HIPAA “IS” for eligibility for health plan transactions and health care claims

The “requirements of Phase 1 of the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)”

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ONC IFRCertification Criteria – 1

“…the Secretary has decided not to adopt previously recognized certification criteria developed in 2006 as any of the certification criteria in this interim final rule.”

The current approach is that certification criteria will be aligned with “the proposed definition of meaningful use Stage 1….”

Certification Criteria are those criteria that an EHR must be capable of supporting in order to be certified

Stage 1 certification criteria follow

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1 - Use Computerized Provider Order Entry

2 - Implement drug-drug, drug-allergy, drug-formulary checks

3 - Maintain an up-to-date problem list of current and active diagnoses based on ICD–9–CM or SNOMED CT®.

4 - Generate and transmit permissible prescriptions electronically (eRx).

5 - Maintain active medication list

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6 - Maintain active medication allergy list

7 - Record demographics (4, 5)

8 - Record and chart changes in vital signs:

• Height

• Weight

• Blood pressure

• Calculate and display: BMI

• Plot and display growth charts for children 2–20 years, including BMI

9 - Record smoking status for patients 13 years old or older.

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10 - Incorporate clinical lab-test results into EHR as structured data.

11 - Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach.

12 - Report quality measures to CMS or the States (7, 8).

13 - Send reminders to patients per patient preference for preventive/follow up care.

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14 - Implement 5 clinical decision support rules

15 - Check insurance eligibility electronically from public and private payers

16 - Submit claims electronically to public and private payers

17 - Provide patients with an electronic copy of their health information upon request

18 - Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request

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19 - Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the eligible professional

20 - Provide clinical summaries for patients for each office visit

21 - Capability to exchange key clinical information among providers of care and patient authorized entities electronically

- Provide summary care record for each transition of care and referral

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22 - Perform medication reconciliation at relevant encounters and each transition of care.

23 - Capability to submit electronic data to immunization registries and actual submission where required and accepted.

24 - Capability to provide electronic submission of reportable lab results (as required by state or local law) to public health agencies and actual submission where it can be received.

25 - Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.

26 - Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

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ONC IFRThe Standards Supporting MU – 1

The standards are organized into four categories including: Vocabulary standards: i.e., standardized

nomenclatures and code-sets used to describe clinical problems and procedures, medications, and allergies

Content exchange standards: i.e., standards used to share clinical information such as clinical summaries, prescriptions, and structured electronic documents

Transport standards: i.e., standards used to establish a common, predictable, secure communication protocol between systems

Privacy & security standards: e.g., authentication, access control, and transmission security which relate to and span across all of the other types of standards

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The intent of the initial set of standards was to focus on those that support interoperability and privacy & security.

The IFR provides the content exchange and vocabulary standards adopted as well as privacy & security standards.

This presentation focuses on the content exchange and vocabulary standards

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Purpose Cate-gory

Adopted Standard(s) to Support Meaningful Use – Stage 1

Patient Summary Record

Cx HL7 CDA R2 CCD Level 2 or ASTM CCR

Problem List V Applicable HIPAA code set required by law (i.e., ICD-9-CM); or SNOMED-CT®

Medication List V Any code set by an RxNorm drug data source provider that is identified by the United States National Library of Medicine as being a complete data set integrated within RxNorm

Medication Allergy List V No standard applicable at this time

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Purpose Cate-gory


Procedures V Applicable HIPAA code sets required by law (i.e., ICD-9-CM or CPT-4®)

Vital Signs V No standard adopted at this time

Units of Measure V No standard adopted at this time

Lab Orders and Results V LOINC® when LOINC® codes have been received from a laboratory

Drug Formulary Check Cx Applicable Part D standard required by law (i.e., NCPDP Formulary & Benefits Standard 1.0)

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Purpose Cate-gory


Electronic Prescribing

Cx Applicable Part D standard required by law (i.e., NCPDP SCRIPT 8.1) or NCPDP SCRIPT 8.1 and NCPDP SCRIPT 10.6

V Any code set by an RxNorm drug data source provider that is identified by the United States National Library of Medicine as being a complete data set integrated within RxNorm+

Administrative Transactions

Cx Applicable HIPAA transaction standards required by law

Quality Reporting Cx CMS PQRI 2008 Registry XML Specification #+

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Purpose Cate-gory


Submission of Lab Results to Public Health Agencies

Cx HL7 2.5.1

V LOINC® when LOINC® codes have been received from a laboratory

Submission to Public Health Agencies for Surveillance or Reporting (except adverse event rptg)

Cx HL7 2.3.1 or HL7 2.5.1

V According to Applicable Public Health Agency Requirements

Submission to Immunization Registries

Cx HL7 2.3.1 or HL7 2.5.1

V CVX#+

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Conclusion & Recommendations

ARRA and Implementing Regulations in the Federal Register are setting a path for Nationwide Health Information Exchange (HIE)

Federal health care organizations (HCOs) must use these standards when sharing health information “between agencies and with non-Federal entities”

Federal HCOs should consider undertaking an analysis of HIE at organizational boundaries and determine how to modernize these exchanges to meet national standards

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Questions?

2010 ubo/ubu conference health budgets & financial policy briefing: arra arran't you going...

Documents

arra ehr standards

arra s13111

arra arrant

action statutory framework

quality of health care

report information

adopted standards

adoption of ehrs