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Do we need Telehealth Programsin a World of Interoperability and
Quality Payment Programs?
Stewart Ferguson, PhDChief Technology Officer (CTO)
Alaska Native Tribal Health Consortium
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2
TOPICS
1. Telehealth … Filling the Gaps
2. What’s Changed?
3. What’s going to change?
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TELEHEALH … FILLING THE GAPS
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Alaska Native Tribal Health Consortium
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
CHUGACH. (5)
EKLUTNA (1)
EAT (8)
APIA (4)
KENAITZE (1)
MSTC (1)
SEARHC (20)
KANA (7)
ANTHC & SCF (ANMC,PCC, …)
CRNA (5)
NSHC (15)
EYAK (1)
YAKUTAT (1)
SMC (1)
MANIILAQ (12) AICS
KETCHIKAN (1)
OPEN
ASNA (1)Anchor Tenant
Live
In Build
Planned
Quoting
EHR ExpansionOrganizations (# Sites)
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Alaska Native Tribal Health Consortium
Provider Comments
“Honestly, the shared domain is huge for me, especially around medically complex kids. In my opinion, [kids on the shared domain] get better, more comprehensive, and more complete care…”
“It’s like night and day. Seamless care, fewer mistakes, less guessing with shared domain. Gives the patients confidence too, that their providers know what is going on with them.”
“… the shared domain makes it much easier and predictable for getting information back to the referring provider. Given the choice, I don’t know why you would not choose a shared domain. Seriously, it’s not even close.”
5
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Alaska Native Tribal Health Consortium
Alternative comments …
“Honestly, [telehealth] is huge for me, especially around medically complex kids. In my opinion, [kids on telehealth] get better, more comprehensive, and more complete care…”
“It’s like night and day. Seamless care, fewer mistakes, less guessing with [telehealth]. Gives the patients confidence too, that their providers know what is going on with them.”
“… [telehealth] makes it much easier and predictable for getting information back to the referring provider. Given the choice, I don’t know why you would not choose [telehealth]. Seriously, it’s not even close.”
6
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Alaska Native Tribal Health Consortium
We allow …
We allow “doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient's vital medical information electronically—improving the speed, quality, safety and cost of patient care”
Definition of “Health Information Exchange” from Healthit.gov, May 12, 2014
https://www.healthit.gov/providers.../health-information-exchange/what-hie
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Alaska Native Tribal Health Consortium
We provide …
We “provide new opportunities to improve care delivery by supporting and rewarding clinicians as they find new ways to engage patients, families and caregivers and to improve care coordination and population health management.”
Objectives of the Quality Payment Program, 2016https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf
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Alaska Native Tribal Health Consortium
We have a vision …
We are “devoted to the simple vision that health data should be available to individuals and providers regardless of where care occurs. Additionally, provider access to this data must be built-in health IT at a reasonable cost for use by a broad range of health care providers and the people they serve.”
CommonWell Visionhttp://www.commonwellalliance.org/about/
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Alaska Native Tribal Health Consortium
We have a vision …
Our vision “is to make the right health information accessible at the right place and time to improve the health and welfare of all Americans.”
Sequoia Project Visionhttp://sequoiaproject.org/about-us/
10
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Alaska Native Tribal Health Consortium
Gaps we filled
• Sharing of Patient Data: “HIE” the verb
• Interoperability between and across health care systems
• Multimedia data sharing and presentation before EHR’s could support this capability
• Live audio / video even before technology evolved and matured (H.264, desktop video)
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Physical Network
Hardware
Software
Training
Workflows
Business / Finance
Outcomes
Sequence of Telemedicine Program Implementations
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We led the race …
We pushed the issues of technology, payment, strategy, and workflows.
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… and now we might become
irrelevant.
Now we may lag in the issues of technology,
payment, strategy, and workflows.
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Physical Network
Hardware
Software
Training
Workflows
Business / Finance
Outcomes
What is about to change …
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WHAT’S CHANGED
1. Everyone got an EHR
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Alaska Native Tribal Health Consortium 17
Percent of non-Federal acute care hospitals with adoption of at least a Basic EHR with notes system and possession of a certified EHR: 2008-2015
Source: http://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php
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Alaska Native Tribal Health Consortium 18
Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system by hospital type
Source: http://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php
At least 8 out of 10 small, rural, and
Critical Access hospitals adopted a Basic EHR
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Alaska Native Tribal Health Consortium 19
Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system at the State-Level for years 2008, 2011, and 2015
For all states, at
least 6 in 10
hospitals adopted a Basic EHR
Source: http://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php
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WHAT’S CHANGED
1. Everyone got an EHR
2. Those EHRs started to communicate
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Alaska Native Tribal Health Consortium
What’s Changed in your EHR?
• Meaningful Use
– Stage 1, 2, 3
– EP, EH
– Medicaid, Medicare
• Health Information Exchange
• Patient Portals, Patient Engagement
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Alaska Native Tribal Health Consortium
Data is Suddenly Portable
• Direct Secure Messaging
– Adoption of Messaging Formats
• CommonWell
• Sequoia Project
22
Source: www.hl7.org
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WHAT’S CHANGED
1. Everyone got an EHR
2. Those EHRs started to communicate
3. Those EHRs can do telehealth … better
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EHR Vendor: “Types of Telemedicine”Low
-Tech
Hig
h-T
ech
eVisits
Video
Conferencing
Remote
Monitoring
Phone
Remote
Surveillance
Paper
Online
Chat
Available
Pilot
Future
Secure
Messaging
Prescribed
Education
Supervised
Self-Mgmt
Asynchronous Synchronous
VtC, S&F, RPM, eVisits … will all be integrated into the EHR very soon.
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Member Portal (HealtheLife)
25
Members can:
• Access health records
• Access patient education
• Schedule appointments
• Secure messaging
• Pay bills online
• Receive personal health
reminders
• Transmit summary of care
• Rx refill & renewal requests
• Complete surveys and e-Visits
• Integrate devices
Providers can:
• Personalize and update content
• Increase patient touch points
and satisfaction
• Reduce overhead related to
faxing, calling, printing, etc.
Source: Cerner.com
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Alaska Native Tribal Health Consortium
Behavioral Health: Mood Trek
See your patient’s
journey through
simple tracking
tools…
This is part of a solution used by more than 270 organizations.
Source: Cerner.com
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Alaska Native Tribal Health Consortium
Video Visits
Patient Provider
HealtheLife
Patient Portal
HealtheLife App
PowerChart
PowerChart Touch App
Web-Based Video
OR OR
This is part of a solution used by more than 270 organizations.
Source: Cerner.com
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Alaska Native Tribal Health Consortium
How important is telehealth to us [Cerner]?
Source: Cerner.com
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Alaska Native Tribal Health Consortium
The relentless innovation in information technology
Delivering telehealth
Securing the enterprise
Leveraging “big data” and advanced analytics
The evolution of the Chief Information Officer role
Source: Cerner.com
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Alaska Native Tribal Health Consortium 30
High-Risk
Patients
Rising-Risk Patients
Low-Risk Patients
5% of patients.
Usually with complex disease(s), comorbidities.
15% - 35% of patients.
May have conditions not under control.
60% - 80% of patients.
Any minor conditionsare easily managed.
Trade high-cost
services for low-cost management.
Avoid unnecessary
higher-acuity, higher-cost spending.
Keep patient healthy,
loyal to the system.
Segment Care Management Models Based on Patient Care Needs
Source: Playbook for Population Health, © The Advisory Board Company 2013
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Alaska Native Tribal Health Consortium 31
Prioritize Investments by Patient Population
Source: Playbook for Population Health, © The Advisory Board Company 2013
High-RiskPatients
Rising-Risk Patients
Low-Risk Patients
IT• HIE• Data warehouse• Home Monitoring
• Analytics• Disease registry
• Patient Portal• Telemedicine• Call center• Text-based
communication
Network Development
• High-risk clinics• Home care• Post-acute care• Community
resources
• Medical home implementation
• Post-dischargeclinics
• Retail clinics• Urgent care centers• Worksite clinics
Workforce• High-risk care
managers
• Patient navigators• Health coaches• Physician extenders
• Call center staff• E-visit providers
Increasing number of patients
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Alaska Native Tribal Health Consortium 32Source: Cerner.com
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WHAT’S CHANGED
1. Everyone got an EHR2. Those EHRs started to communicate3. Those EHRs can do telehealth better4. More need/want to do telehealth
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Alaska Native Tribal Health Consortium
Interest and Support
34
A majority of respondents already offer remote monitoring (64%), store and forward technology (54%), and real-time interaction capabilities (52%). Additionally, 39 percent say they have services that qualify as mHealth —patient-driven apps and online portals. (Nathaniel Lacktman, Esq. Healthcare Partner, Foley & Lardner)
90% of healthcare executives reported that their organizations have implemented or are working on a telehealth program (Foley 2014 Telemedicine Survey).
35% of employers with on-site health facilities offer telemedicine services and another 12% plan to do it within the next two years. About 70% of employers plan to offer telemedicine services as an employee benefit by 2017 (Towers Watson 2015 Employer-Sponsored Health Care Center Survey).
http://chironhealth.com/blog/telemedicine-gaining-traction-patient-attraction-growing-heres-data/
64% of Americans would attend a doctor’s appointment via video (American Well 2015 Telehealth Survey)
57% of primary care physicians are open to holding appointments with patients remotely (American Well 2015 Telehealth Survey).
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Alaska Native Tribal Health Consortium
Interest and Support … But …
“Telemedicine reimbursement poses the primary obstacle to success, but EMR-related challenges are persistent and widely noted in the survey,” said McGraw. “There is clearly a high demand in the industry for EMR integration, specifically the two-way flow of individual data elements between telemedicine platforms and EMR systems.”
http://www.clinical-innovation.com/topics/mobile-telehealth/survey-shows-growing-interest-telemedicine
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Alaska Native Tribal Health Consortium
Comparing Providers (2011)
36
High User
Medium User
Low User
500 or more cases
100-499 cases
10-99 cases
Initiator (22)
Consultant (49)
Initiator (120)
Consultant (112)
Initiator (222)
Consultant (159)
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Alaska Native Tribal Health Consortium
Rate the importance of EHR Integration
37
Listing patients from your EHR database (so you can select a name to start a telemed case).
4.0
Providing a patient health summary obtained from the EHR with every telemed case.
4.0
Receiving hospital discharge summaries, sent to you as a telemed case.
3.7
Providing a text summary of the telehealth case in your EHR.
4.1
Providing a link in your EHR that would open the telehealth case.
4.2
Providing the complete telehealth case with text, images and other attachments, in your EHR.
4.1
1Very unimportant
2Somewhat unimportant
3Somewhat important
4Very important
5Extremely important
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WHAT’S GOING TO CHANGE
1. Federal regulations are going to drive dramatic changes.
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Regulatory Changes
Medicare Access and CHIP Reauthorization Act (MACRA)Merit-Based Incentive Payment System (MIPS)
Quality Payment Program (QPP)
Certified Electronic Health Record Technology (CEHRT)
Meaningful Use Stage 3
39
Quality
Cost
Volume-Driven Healthcare
Value-Driven Healthcare
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Alaska Native Tribal Health Consortium
MACRA
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114 10, enacted April 16, 2015), amended title XVIII of the Social Security Act (the Act) to repeal the Medicare Sustainable Growth Rate, to reauthorize the Children’s Health Insurance Program, and to strengthen Medicare access by improving physician and other clinician payments and making other improvements.
What you need to know: MACRA created MIPS/APMS and Quality Payment Programs.
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Alaska Native Tribal Health Consortium
PATHS TO PAYMENT
41
MACRA presents two alternative paths to payment
The Merit-based Incentive Payment
System (MIPS)
Advanced Alternative Payment Models (Advanced
APMs)
Shared Savings Program (Tracks 2 and 3)
Next Generation ACO Model Comprehensive ESRD Care (CEC) Comprehensive Primary Care
Plus (CPC+) Oncology Care Model (OCM)
Physicians (MD/DO and DMD/DDS) Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse
Anesthetists
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MIPS Weighted Categories & Financial Impact
42
ADVANCING CARE INFORMATION (ACI)
Previously MU
CLINICAL PRACTICE IMPROVEMENT ACTIVITIES
(CPIAs)
QUALITYPreviously PQRS & MU CQM
RESOURCE USEPreviously VM
25%
15%
60%
25%
15%
50%
10%
25%
15%
30%
30%
25%
15%
30%
30%
2017+/- 4% in 2019
2018+/- 5% in 2020
2019+/- 7% in 2021
2020+/- 9% in 2022
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Alaska Native Tribal Health Consortium
ADVANCING CARE INFORMATION (ACI)
43
Formerly Meaningful Use (MU). Now 8 measures.
Patient Access0-10 Points
View/Download/Transmit (VDT)
0-10 Points
Patient-Specific Education
0-10 Points
Secure Messaging0-10 Points
Health Information Exchange (Summary
of Care)*0-10 Points
Patient Generated Health Data0-10 Points
Request/Accept Patient Care Record
0-10 Points
Clinical Information Reconciliation
0-10 Points
Maximum of 80 points towards total ACI score
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Clinical Practice Improvement Activities (CPIA)
Expanded Practice Access
Population Management
Care Coordination
BeneficiaryEngagement
Patient Safety Practice
Assessment
AlternativePayment Models
Same day appointments for urgent needs
After hours clinician advice
Monitoring health conditions & providing timely intervention
Participation in a Qualified Clinical Data Registry (QCDR)
Timely communication on test results
Timely exchange of clinical information with patients and providers
Use of remote monitoring
Use of telehealth
Establishing care plans for complexpatients
Beneficiaryself-management assessment and training
Employing shared decision making
Use of clinical checklists
Use of surgical checklists
Assessments related to maintaining of certification
Participation in an APM will also count for CPIA
CMS proposes more than 90 activities
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Resource Use
45
Highest Points = Most Efficient Resource Use
CMS calculates scores based on Medicare claims
No additional reporting 40+ Episode-specific measures Measures worth 10 points each
The Resource Use performance category values clinicians delivering more efficient, high quality care…
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Composite Performance Score
46
MIPS performance category points are added up to create the Composite Performance Score…
Performance Category Max. Points % MIPS Score
Advancing Care Information 100 Points 25%
Quality 80 to 90 Points 50%
Resource UseAverage score of all cost measures that can be attributed
10%
CPIAs 60 Points 15%
…which is compared to the “MIPS Performance Threshold” to determine the adjustment % the eligible clinician will receive
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Financial Impact
47
Payment adjustments will take place 2 years following the performance year …
Payment Adjustment
+4% +5%
MAXIMUM +/- ADJUSTMENT
+7% +9%-9% -7% -5% -4%
…plus potential bonuses x3 for top performers
2019
2020
2021
2022
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2017 Reporting Options“Pick Your Pace”
No Submission Test ProgramPartial/Full Submission
APM Participant
Non-Participant in MIPS
Testing MIPS Reporting MIPS Advanced APM Participant
Does not report on any measures for at least 90 days.
Receives a negative 4% payment adjustment in 2019.
Only reports onemeasure in one category.
Avoids Negative Payment Adjustment
Testing ACI = all base measures
Either a Full or Partial (90 days or more) reporting period.
Report all requiredmeasures across all categories.
Achieves QP Status(receives a 5% incentive payment in 2019)- or –
Achieves Partial QP Status (can elect to participate or not in MIPS)
- 4% 0% 0% to +4% +5%
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Alaska Native Tribal Health Consortium
CEHRT, MIPS & MU Sequence
Calendar Year
(EH & EP)
Eligible Hospitals (EH) and Critical Access Hospitals
(CAH)
EligibleProfessionals (EP)
(Medicaid)
Eligible Clinicians (EC)
(Medicare)
2014 Stage 1 or Stage 2 Stage 1 or Stage 2 Stage 1 or Stage 2
2015 Modified Stage 2 Modified Stage 2 Modified Stage 2
2016 Modified Stage 2 Modified Stage 2 Modified Stage 2
2017Modified Stage 2 or
Stage 3 (90 Days)Modified Stage 2 or
Stage 3 (90 Days)MIPS
(90 Days-ACI)
2018 Stage 3 (Full Year) Stage 3 (Full Year)MIPS
(90 Days-ACI)
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2014 Certified EHR
2014 or 2015 Certified EHR
2015 Certified EHR
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Alaska Native Tribal Health Consortium
Meaningful Use (MU)
Meaningful Use is at the core of the EHR Incentive Payment Programs.
Previous rulemaking established three stages of Meaningful Use:
STAGE 1 - Data Capture and Information Sharing STAGE 2 - Advanced Clinical Processes STAGE 3 – Improved Outcomes
50
Meaningful Use Stage 3 is about provider behavior.
2015 Certification Rule is about the technology to support that behavior.
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Alaska Native Tribal Health Consortium
EHR Incentive Programs Stage 3 Meaningful Use Objectives
Objective 1: Protect Patient Health InformationObjective 2: Electronic PrescribingObjective 3: Clinical Decision SupportObjective 4: Computerized Provider Order EntryObjective 5: Patient Electronic Access to Health
InformationObjective 6: Coordination of Care through Patient
EngagementObjective 7: Health Information ExchangeObjective 8: Public Health and Clinical Data
Registry Reporting51
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52https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medicaid_Stage3.pdf
80% OF PATIENTS WILL BE ON A PORTAL
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53https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medicaid_Stage3.pdf
25% OF PATIENTS WILL MESSAGE TO A PROVIDER
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54https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medicaid_Stage3.pdf
50% OF TRANSFEROF CARE WILL OCCUR VIA DSM AND CCDA
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Alaska Native Tribal Health Consortium
QPP in the words of CMS
The Quality Payment Program provides new opportunities to improve care delivery by supporting and rewarding clinicians as they find new ways to engage patients, families and caregivers and to improve care coordination and population health management.
https://qpp.cms.gov/docs/QPP_Key_Objectives.pdf
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WHAT’S GOING TO CHANGE
1. Federal regulations are going to drive dramatic changes.
2. Telehealth can integrate with EHRs.
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2015 Edition Final Rule Health IT Goals
57
Improve Interoperability Facilitate Data Access and Exchange
Use the ONC Health IT Certification Program to
Support the Care Continuum
Support Stage 3 of the EHR Incentive Programs
Improve Patient Safety
Reduce Health Disparities
Ensure Privacy and Security
Capabilities
Improve the Reliability and Transparency of Certified Health IT
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2015 Base EHR Definition
58
Base EHR Capabilities Certification Criteria
Includes patient demographic and
clinical health information, such as
medical history and problem lists
Demographics § 170.315(a)(5)
Problem List § 170.315(a)(6)
Medication List § 170.315(a)(7)
Medication Allergy List § 170.315(a)(8)
Smoking Status § 170.315(a)(11)
Implantable Device List § 170.315(a)(14)
Capacity to provide clinical
decision supportClinical Decision Support § 170.315(a)(9)
Capacity to support physician
order entry
Computerized Provider Order Entry (medications, laboratory, or
diagnostic imaging) § 170.315(a)(1), (2) or (3)
Capacity to capture and query
information relevant to health
care quality
Clinical Quality Measures – Record and Export § 170.315(c)(1)
Capacity to exchange electronic
health information with, and
integrate such information from
other sources
Transitions of Care § 170.315(b)(1)
Data Export § 170.315(b)(6)
Application Access – Patient Selection § 170.315(g)(7)Application Access – Data Category Request § 170.315(g)(8)
Application Access – All Data Request § 170.315(g)(9)
Direct Project § 170.315(h)(1) or Direct Project, Edge Protocol, and
XDR/XDM § 170.315(h)(2)
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Application Programming Interface (API)
59Source: Cerner Corporation
APIs enable apps for providers and consumers. This meets the needs of the government and people who want more choices.
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WHAT’S GOING TO CHANGE
1. Federal regulations are going to drive dramatic changes.
2. Telehealth can integrate with EHRs.3. Patient data will be more portable
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Alaska Native Tribal Health Consortium
Two Workflow Methods
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CCDA Sent Directly to Provider
CCDA Queried from CommonWell
Transition of Care
Direct DSM activity.Medical records request.Provider Letters
Incorporate
CommonWell XDS document exchange
Match patient.Save message.Query & retrieve –auto or manual
Direct
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Alaska Native Tribal Health Consortium
CommonWell Live Sites
http://www.commonwellalliance.org/providers/
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Alaska Native Tribal Health Consortium
National Initiatives
CommonWell services are essential to the exchange of health data across the care continuum.
• Person Enrollment — Enable each individual to be registered and uniquely identified in the CommonWellnetwork
• Record Location — Create a “virtual table of contents” that specifies the available locations for patient information
• Patient Identification and Linking — Link each individual’s clinical records across the care continuum
• Data Query and Retrieval — Enable caregivers to search, potentially select and receive needed data across a trusted network
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http://www.commonwellalliance.org/services/
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Alaska Native Tribal Health Consortium
CommonWell and Carequality
Together, CommonWell members and Carequalityparticipants represent more than 90% of the acute EHR market and nearly 60% of the ambulatory EHR market.
Today, over 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWellnetwork. Patients and their providers at these care sites will have access to more complete health data on which to base healthcare decisions.
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WHAT’S GOING TO CHANGE
1. Federal regulations are going to drive dramatic changes.
2. Telehealth can integrate with EHRs.
3. Patient data will be more portable
4. Healthcare will become more integrated
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Alaska Native Tribal Health Consortium
The Goal …
“Our collective goal throughout the QPP is to support the vision of a simpler approach to technology for providers, focused on advancing information sharing and better outcomes for patients,” said Washington.
National Coordinator Dr. Vindell Washingtonhttp://healthitanalytics.com/news/will-macra-and-the-qpp-unlock-health-data-for-smarter-care
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BECOME ENGAGED
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Alaska Native Tribal Health Consortium
Get Involved
• It’s obvious telehealth is part of the solution.
• Not a lot of answers. Many questions.
• Stay connected to the EHR world. Cannot live in isolation in a “Telehealth world”.
• Get smart - or go home.
• Standalone telehealth systems will die.
• Engage in strategy development for QPP.
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Alaska Native Tribal Health Consortium
Get More Involved
• The opportunity is to change from checking a box (MU?) to changing health care.
– Consider the patient portal: do we just get patients to sign up? Or do we build programs to improve wellness, patient engagement, pop health.
• Look for other models of excellence, get involved early and often in EHR.
• Now more than ever, it’s all about partnerships.
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Do we need Telehealth Programsin a World of Interoperability and
Quality Payment Programs?
We need Telehealth Programs
that leverage changes and
provide leadership
Stewart Ferguson, PhDChief Technology Officer (CTO)
Alaska Native Tribal Health Consortium