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2009 Annual Meeting
Stewardship and Service
ARRA & HIT: What Do They
Mean to You?
An Update on the EHR
Incentives
November 8, 2009
Ivy Baer, J.D., M.P.H.
Director & Regulatory Counsel
Lori Mihalich-Levin, J.D.
Senior Policy Analyst
2009 Annual Meeting
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•Review the timeline for future rulemaking and other activities
•Explain the ARRA Medicare and Medicaid incentives for EHR adoption for hospitals and physicians
•Discuss what we know about meaningful use,
•Take questions; try to provide some answers
Today’s Goals:
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The Two Major Players
in HHS:
• ONC (Office of the National Coordinator of Health Information Technology; formerly known as ONCHIT)
– David Blumenthal (National Coordinator)
– HIT Policy Committee & HIT Standards
Committee
• CMS – Office of e-Health Standards and Services
– Tony Trenkle (Director)
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3 Regulations,
Likely by Dec. 31
•HHS/ONC interim final rule re: standards, implementation specifications, certification criteria
•HHS/ONC proposed rule on certification
•CMS proposed rule on EHR incentives
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Regulatory Timeline (cont.)
October 2010: Earliest CMS will start paying Medicare incentives to hospitals
January 2011: Earliest CMS will start paying Medicaid incentives to hospitals and Medicare and Medicaid incentives to physicians
2015: Medicare penalties begin for hospitals and “eligible professionals” failing to meet definition of “meaningful use”
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Where Are We with EHR Use
Right Now?
Hospitals:
• < 2% have fully implemented comprehensive EHRs in all units
• < 8% have basic EHRs
• <17% have CPOE fully implemented
• 75% have electronic lab/image reports
(Source: Blumenthal, NEJM, April 16, 2009)
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Where Are We with EHR Use
Right Now?
Ambulatory Settings:
• 4% of physicians have fully-functional EHR
• 13% have basic EHRs
• 16% purchased but not implemented
• 26% plan to purchase within 2 years
(Source: Blumenthal, NEJM, June 18, 2008)
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Physicians
•Medicare or Medicaid or E-prescribing
•Incentives for max of 5 years
•CBO estimates 2009-2019:
• Bonuses: $15.2 b
• Penalties: $1.3 b
Hospitals
•Medicare and Medicaid
•Incentives for max of 4years
•CBO estimates 2009-
2019:
• Bonuses: $8.7 b
• Penalties: $2.6 b
$20 Billion in Incentives
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• Medicare maximum (for early adopters; 2011-2012): $44,000
• $18,000; $12,000; $8,000; $4,000; $2,000
• 10% increase if in health professional shortage area
• Amount is a cap--75% of allowed charges for all covered services furnished by the EP during the year
Where’s the money? (EPs)
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• Medicaid maximum: $63,750
• E-prescribing bonus (MIPAA, not ARRA):
• 2010: 2% Part B allowable charges
• 2011: 1% Part B allowable charges
• 2012: 0.5% Part B allowable charges
Where’s the money?
(EPs cont.)
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• The floor:
Using EHR technology in a meaningful manner, including e-prescribing
Exchanging health information electronically to improve quality of care
Reporting on clinical quality measures
• Measures of meaningful use are to be more stringent over time
Meaningful User:
EPs/Medicare
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Hospital-based professionals (pathologist, anesthesiologist, emergency physician)
• Generally expected to use EHR system of the hospital
• Based on site of service
• Not disqualified merely on the basis of some association or business relationship with the hospital
• “Good news”: no penalties
Who’s ineligible
for incentives?
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Letter from Reps. Eshoo and Speir to Sec. Sebelius:
Also letters from Exe. Stabenow & Rougel
“We are concerned that this provision will also exclude physicians who are practicing in ambulatory clinics owned by hospitals. We believe the Conference Report is clear when it states that the legislation does not disqualify otherwise eligible professionals merely on the basis of some association or business relationship with a hospital [such as] professionals who are employed by a hospital to work in an ambulatory care clinic . . .”
July 7, 2009
Hospital-Based: Take 3
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Selection of quality measures:
• Look to proposed PFS „10: preference for measures endorsed by an entity with a contract with the Secretary: NQF
More on MU:
Quality Measures
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“PQRI could potentially provide invaluable experience and serve as a foundation for establishing the capacity for eligible professionals to send, and for CMS to receive, data on quality measures via EHRs.”
Federal Register Display Copy, Proposed Rule, Physician Fee Schedule for CY 2010, p. 212
Proposed PFS 2010
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Calls for development of a plan to integrate clinical reporting on quality measures with reporting requirements related to meaningful use of electronic health records. The measures would demonstrate:
Meaningful use of an electronic health record and
Clinical quality of care furnished to an individual
House Bill
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•How is the money paid?
• Consolidated payment or periodic installments
• Rules to be promulgated to coordinate incentives for an eligible professional furnishing services in more than one practice; cannot be paid more than the capped amount for any payment year
Suppose MU has
been achieved…
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•Attestation
•Submission of claims with appropriate coding
•Survey response
•Reporting
•Other
How will the government
know you’ve achieved MU?
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•Fee schedule reductions for eligible professionals who do not achieve meaningful use:
• 2015: 1%
• 2016: 2%
• 2017 and after: 3%
• 2018 and after: if less than 75% of eligible professionals are meaningful users, further reductions possible, but cannot be less than 95%
• Significant hardship on case-by-case basis if practice in rural area without sufficient internet access
What happens 2015 and after?
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Website posting of individuals and groups receiving incentive payments
Other details:
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• Not hospital-based
• At least 30% of patient volume attributable to Medicaid beneficiaries; or
• A pediatrician who has at least 20% of patient volume attributable to Medicaid beneficiaries; and
• Practices predominantly in a FQHC or rural health clinical and has at least 30% patient volume attributable to “needy individuals”
Medicaid Incentives:
Eligibility
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•1st year: demonstrate that are engaged in efforts to adopt, implement, or upgrade certified HER technology
•Subsequent years: demonstrate meaningful use through a means approved by the state and HHS
Medicaid MU
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Medicare Payments
to Hospitals
Key Points:
Hospitals are eligible for both Medicare and Medicaid incentives (because based on inpatient discharges)
Must be an “eligible hospital”
Must use “certified” EHR technology
Status as “meaningful user” will be posted on internet
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Medicare Payments
to Hospitals
What is the payment formula?
[[(Base amount + Discharge related amount) x Medicare share] x Transition factor
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Medicare payments to hospitals (continued)
Base Amount:
$2 million
Discharge Related Amount:
$200 for each hospital discharge between 1,150 and 23,000 within 12 month period
Medicare Payments
to Hospitals
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Medicare Payments to Hospitals
Medicare Share:
• Numerator: total Part A and C inpatient days.
• Denominator: total inpatient days adjusted to exclude any charges attributable to charity care
• Note: if no data available on charity care, uncompensated care will be used as proxy and adjusted downward to eliminate bad debt data.
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Medicare Payments
to Hospitals
Transition Factor
First payment year: 100%
Second payment year: 75%
Third payment year: 50%
Forth payment year: 25%
Any succeeding payment year: 0
If a hospital adopts an EHR after 2015, the transition factor is 0.
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Medicare Payments
to Hospitals
What are the payment penalties?
75% of inpatient payment update at risk.
2015: 1/3 reduction (i.e. 25% of update)
2016: 2/3 reduction (i.e. 50% of update)
2017 on: full reduction (i.e. 75% of update)
(Note: Remaining 25% of update based on successful quality reporting)
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Payment Year
Year of
AdoptionFY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017
2011 100% 75% 50% 25%
2012 100% 75% 50% 25%
2013 100% 75% 50% 25%
2014 75% 50% 25%
2015 50% 25%
No adoption
by 2015
¾* of
percentage
increase in
market-basket
reduced by 33
1/3%
¾* of
percentage
increase in
market-basket
reduced by 66
2/3%
¾* of
percentage
increase in
market-basket
reduced by
100%
Hospital Incentive Payment
and Penalty Timeline
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EXAMPLE
Assume:
•20,000 discharges; 50,000 A & C days; 100,000 total days
•Charity care charges as 20% of total charges
•Year 1 of implementation is 2012
Base amount = $2 million + (20,000 x $200) = $6 million
Medicare Share = 50,000/(100,000 x 80%) = 50,000/80,000 = .625
Transition Factor = 1
Total = $6 million x .625 x 1 = $3.75 million
________________________________________________________________
Now assume same facts except with charity care charges as 10% of total charges:
Medicare share = 50,000/(100,000x90%) = 50.000/90,000 = .56
Total = $6 million x .56 x 1 = $3.36 million
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Medicare Payments
to Hospitals
What are the open issues?
Definition of “meaningful EHR user”
Definition of “certified EHR technologies”
Multi-campus providers
Interaction between meaningful EHR use and quality programs, ICD-10 adoption
EHR reporting period
Definition of “charity care”
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Medicaid Payments
to Hospitals
• Hospital Medicaid payments are in addition to hospital Medicare payments.
• 10% Medicaid Volume Requirement
– Except Children‟s Hospitals, which are eligible regardless of Medicaid volume
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Medicaid Payments
to Hospitals
What is the payment formula?
[(Base amount + Discharge related amount) x Medicaid share] x Transition factor
(i.e. same as Medicare formula but with “Medicaid Share”)
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Medicaid Payments
to Hospitals
Limits :
• 6 year limit on payments
• 2016 deadline
• No more than 50% of the total payments may be made in one year or 90% in two consecutive years
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“The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.”
-HIT Policy Committee, “Meaningful Use. A Definition,”Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee, June 16, 2009
HIT Policy Committee’s
“Ultimate Goal”
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What is the HIT Policy
Committee?
• Advisory Committee established by ARRA, holds monthly public meetings.
• Goals:
Policy framework for development of nationwide HIT infrastructure
Identify areas where standards, implementation specifications, and certification criteria are needed (in order of priority)
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HIT Policy Committee (cont.)
• Required to make recommendations to National Coordinator in 8 areas, including:
Privacy and security
Utilization of a certified EHR for everyone in the US by 2014
Use of certified EHR to improve quality
• Chair: David Blumenthal
• Vice Chair: Paul Tang
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What is the HIT Standards
Committee?
• Advisory Committee established by ARRA, holds monthly public meetings
• HIT Policy Committee Sets Standards Committee‟s Priorities
• Goal: recommend standards, implementation specifications, and certification criteria to National Coordinator
• Chair: Jonathan Perlin
• Vice Chair: John Halamka
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Helpful HIT Web Resources:
• ONC: www.hit.hhs.gov
• CMS: http://www.cms.hhs.gov/Recovery/11_HealthIT.asp
• AAMC: http://aamc.org/hit
• (for an HIT laugh) http://rossmartinmd.com/f/blog.htm
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• Meeting with David Blumenthal and CMS
• Providing written comments on proposals
• Keeping members informed of all activities through a list serve
• Tracking ONC and CMS developments
• Attending all Advisory Committee meetings
• Keeping the AAMC HIT webpage current
• Coordinating efforts with other associations
The AAMC is:
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Join our Health IT list serv by sending a blank email (leave the subject line and body blank) to [email protected]
(You will receive a confirmation e-mail to confirm your subscription; please respond to this e-mail as instructed in the message or your subscription will not be complete.)
Interested in more frequent
updates?
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2009 Annual Meeting
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*- The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. Prepared by Will Dardani 7/23/09
Health Outcomes
Priority Policy
Care Goals 2011 Objectives* for Eligible Providers
Goal is to electronically capture in coded format and to report health information and
to use that information to track key clinical conditions
2011 Measures* for Eligible Providers
Improve quality, safety,
efficiency, and reduce health
disparities
Provide access to
comprehensive patient health
data for patient’s health care
team
Use evidence-based order sets
and CPOE
Apply clinical decision support
at the point of care
Generate lists of patients who
need care and use them to
reach out to patients (e.g.,
reminders, care instructions,
etc.)
Report to patient registries for
quality improvement, public
reporting, etc.
Use CPOE for all orders1
Implement drug-drug, drug-allergy, drug-formulary checks
Maintain an up-to-date problem list of current and active diagnoses based on
ICD-9 or SNOMED
Generate and transmit permissible prescriptions electronically (eRx)
Maintain active medication list
Maintain active medication allergy list
Record demographics:
o Preferred language
o Insurance type
o Gender
o Race2
o Ethnicity
Record advance directives
Record vital signs:
o Height
o Weight
o Blood pressure
Calculate and display:
o BMI
Record smoking status
Incorporate lab-test results into EHR as structured data
Generate lists of patients by specific conditions to use for quality
improvement, reduction of disparities, and outreach
Report ambulatory quality measures to CMS
Send reminders to patients per patient preference for preventive/follow up
care
Implement one clinical decision rule relevant to specialty or high clinical
priority
Document a progress note for each encounter
Check insurance eligibility electronically from public and private payers,
where possible
Submit claims electronically to public and private payers
Report quality measures to CMS including:
o % diabetics with A1c under control
o % hypertensive patients with BP under control
o % of patients with LDL under control
o % of smokers offered smoking cessation counseling
% of patients with recorded BMI
% of orders (for medications, lab tests, procedures, radiology, and
referrals) entered directly by physicians through CPOE
Use of high-risk medications (Re: Beers criteria) in the elderly
% of patients over 50 with annual colorectal cancer screenings
% of females over 50 receiving annual mammogram
% of patients at high-risk for cardiac events on aspirin prophylaxis
% of patients who received flu vaccine
% of lab results incorporated into EHR in coded format
Stratify reports by gender, insurance type, primary language, race,
ethnicity
% of all medications entered into EHR as generic, when generic
options exist in the relevant drug class
% of orders for high-cost imaging services with specific structured
indications recorded
% of claims submitted electronically to all payers
% patient encounters with insurance eligibility confirmed
1 - CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic
interfaces to receiving entities are not required in 20112 - Race and ethnicity codes should follow federal guidelines (see Census Bureau)
2009 Annual Meeting
Stewardship and Service
Health Outcomes
Priority Policy
Care Goals 2011 Objectives* for Eligible ProvidersGoal is to electronically capture in coded format and to report health information
and to use that information to track key clinical conditions
2011 Measures* for Eligible Providers
Engage patients and
families
Provide patients and
families with timely
access to data,
knowledge, and tools to
make informed decisions
and to manage their
health
Provide patients with an electronic copy of their health
information (including lab results, problem list, medication
lists, allergies) upon request3
Provide patients with timely electronic access to their health
information (including lab results, problem list, medication
lists, allergies)3
Provide access to patient-specific education resources
Provide clinical summaries for patients for each encounter
% of all patients with access to personal health information
electronically
% of all patients with access to patient-specific educational
resources
% of encounters for which clinical summaries were
provided
Improve Care
Coordination
Exchange meaningful
clinical information
among professional
health care team
Capability to exchange key clinical information (e.g., problem
list, medication list, allergies, test results), among providers of
care and patient authorized entities electronically4
Perform medication reconciliation at relevant encounters and
each transition of care5
% of encounters where med reconciliation was performed
Implemented ability to exchange health information with
external clinical entity (specifically labs, care summary and
medication lists)
% of transitions in care for which summary care record is
shared (e.g., electronic, paper, e-Fax)
Improve populations
and public health
Communicate with
public health agencies
Capability to submit electronic data to immunization registries
and actual submission where required and accepted6
Capability to provide electronic syndromic surveillance data to
public health agencies and actual transmission according to
public law
Report up-to-date status for childhood immunizations6
Ensure adequate
privacy and security
protections for
personal health
information
Ensure privacy and
security protections for
confidential information
through operating
policies, procedures, and
technologies and
compliance with
applicable law
Provide transparency of
data sharing to patient
Compliance with HIPAA Privacy and Security Rules7,8
Compliance with fair data sharing practices set forth in the
Nationwide Privacy and Security Framework
Full Compliance with HIPAA Privacy and Security Rules
Conduct or update a security risk assessment and implement
security updates as necessary
*- The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. Prepared by Will Dardani 7/23/09
3 - Electronic access to and copies of may be provided by a number of electronic methods (e.g., PHR, patient portal, CD, USB Drive)4 – Health information exchange capability and demonstrated exchange to be specified by Health Information Exchange Work Group of HIT Policy Committee5 – Transition of care defined as moving from one health care setting or provider to another6 – Applicability to Medicare versus Medicaid meaningful use is to be determined7 – The HIT Policy Committee recommends that CMS withhold meaningful use payment for any entity until confirmed HIPAA privacy or security violation has been resolved8 - The HIT Policy Committee recommends that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or security violation has been resolved
2009 Annual Meeting
Stewardship and Service
Health
Outcomes
Policy
Priority
Care Goals 2011* Hospital ObjectivesGoal is to electronically capture in coded format and to report health
information and to use that information to track key clinical conditions
2011* Hospital Measures
Improve quality,
safety,
efficiency, and
reduce health
disparities
Provide access to
comprehensive patient
health data for patient’s
health care team
Use evidence-based
order sets and CPOE
Apply clinical decision
support at the point of
care
Generate lists of
patients who need care
and use them to reach
out to patients (e.g.,
reminders, care
instructions, etc.)
Report to patient
registries for quality
improvement, public
reporting, etc.
10% of all orders (any type) directly entered by authorizing
provider (e.g., MD, DO, RN, PA, NP) through CPOE1
Implement drug-drug, drug-allergy, drug-formulary checks
Maintain an up-to-date problem list of current and active
diagnoses based on ICD-9 or SNOMED
Maintain active medication list
Maintain active medication allergy list
Record demographics:
o Preferred language
o Insurance type
o Gender
o Race2
o Ethnicity
Record advance directives
Record vital signs:
o Height
o Weight
o Blood pressure
Calculate and display:
o BMI
Record smoking status
Incorporate lab-test results into EHR as structured data
Generate lists of patients by specific conditions
Report hospital quality measures to CMS
Implement one clinical decision rule related to a high priority
hospital condition
Check insurance eligibility electronically from public and
private payers, where possible
Submit claims electronically to public and private payers
Report quality measures to CMS
including:
o % of smokers offered smoking cessation
counseling
% of eligible surgical patients who
receive VTE prophylaxis
% of orders (for medications, lab tests,
procedures, radiology, and referrals)
entered directly by physicians through
CPOE
Use of high-risk medications (Re: Beers
criteria) in the elderly
% of lab results incorporated into EHR in
coded format
Stratify reports by gender, insurance
type, primary language, race, ethnicity
% of all medications entered into EHR as
generic, when generic options exist in the
relevant drug class
% of orders for high-cost imaging
services with specific structured
indications recorded
% of claims submitted electronically to
all payers
% patient encounters with insurance
eligibility confirmed
*- The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. Prepared by Will Dardani 7/23/09
1 - CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic interfaces to receiving entities are not
required in 20112 - Race and ethnicity codes should follow federal guidelines (see Census Bureau)
2009 Annual Meeting
Stewardship and Service
Health Outcomes
Policy Priority
Care Goals 2011* Hospital ObjectivesGoal is to electronically capture in coded format and to report health information and to use that information to track key
clinical conditions
2011* Hospital Measures
Engage patients and
families
Provide patients and
families with timely
access to data,
knowledge, and tools to
make informed
decisions and to manage
their health
Provide patients with an electronic copy their health information (including lab results,
problem list, medication lists, allergies, discharge summary, procedures) upon request3
Provide patients with an electronic copy of their discharge instructions and procedures at time
of discharge, upon request3
Provide access to patient-specific education resources
% of all patients with access to personal health
information electronically
% of all patients with access to patient-specific
educational resources
Improve Care
Coordination
Exchange meaningful
clinical information
among professional
health care team
Capability to exchange key clinical information (e.g., discharge summary, procedures,
problem list, medication list, allergies, test results), among providers of care and patient
authorized entities electronically4
Perform medication reconciliation at relevant encounters and each transition of care5
Report 30-day readmission rate
% of encounters where med reconciliation was
performed
Implemented ability to exchange health information
with external clinical entity (specifically labs, care
summary and medication lists)
% of transitions in care for which summary care
record is shared (e.g., electronic, paper, e-Fax)
Improve populations and
public health
Communicate with
public health agencies
Capability to submit electronic data to immunization registries and actual submission where
required and accepted6
Capability to provide electronic submission of reportable data to public health agencies and
actual transmission where it can be received
Capability to provide electronic syndromic surveillance data to public health agencies and
actual transmission according to applicable law and practice
% reportable lab results submitted electronically
Ensure adequate privacy
and security protections for
personal health
information
Ensure privacy and
security protections for
confidential information
through operating
policies, procedures, and
technologies and
compliance with
applicable law
Provide transparency of
data sharing to patient
Compliance with HIPAA Privacy and Security Rules7,8
Compliance with fair data sharing practices set forth in the Nationwide Privacy and Security
Framework
Full Compliance with HIPAA Privacy and Security
Rules
Conduct or update a security risk assessment and
implement security updates as necessary
3 - Electronic access to and copies of may be provided by a number of electronic methods (e.g., PHR, patient portal, CD, USB Drive)4 – Health information exchange capability and demonstrated exchange to be specified by Health Information Exchange Work Group of HIT Policy Committee5 – Transition of care defined as moving from one health care setting or provider to another6 – Applicability to Medicare versus Medicaid meaningful use is to be determined7 – The HIT Policy Committee recommends that CMS withhold meaningful use payment for any entity until confirmed HIPAA privacy or security violation has been resolved8 - The HIT Policy Committee recommends that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or security violation has been resolved
*- The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. Prepared by Will Dardani 7/23/09