hot topics in meaningful use: the current & future hie ...€¦ · day 1 - session 3: hot...

Day 1 - Session 3: Hot Topics in Meaningful Use

Hot Topics in Meaningful Use: The Current & Future

HIE Landscape

Thomas Novak,

ONC Office of Policy

CMS Division of State Systems

Day 1 - Session 3: Hot Topics in Meaningful Use 2


CMS HIE Funding Guidance

90/10 funding is available for HIE activities provided that: o Funds are used for time-limited Design Development and Implementation

Activities

o States leverage efficiencies with other Federal HIE funding

o HIE costs are divided equitably across other payers based on the “fair share” principle and are appropriately allocated.

SMD Letter-Use of Administrative Funds to Support HIE

FAQs

SMD Letter-Federal Funding for Medicaid HIT Activities

3

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD11004.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/FAQ-09-10-2013.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD10016.pdf


HIE IAPD Template

HIE funding requests follow the HITECH IAPD templateo Requests can be incorporated into an existing Health Information

Technology (HIT) IAPD-Update (IAPD-U), or submitted as a standalone IAPD.

o Information specific to the HIE request should be included in all relevant IAPD sections.

o Appendix D of the IAPD template is specific to HIE. All questions outlined in Appendix D should be answered in detail.

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Use of Medicaid HITECH Funding to Support State HIE Functions

5

0

2

4

6

8

10

12

14

16

OnboardingProviders

Public Health HIEInfrastructure

HIE Services Planning

16

10

12

10

8

Number of States


Examples of Onboarding Activities*

Hospitals first

Federally Qualified Health Centers (FQHCs) first

Eligible professionals (EPs)

Targeted # of Hospitals & EPs

By region

Mix of providers

By function (e.g. Immunizations, Lab Reporting)

6

*Onboarding includes a wide range of activities, such as provider outreach, contracting, implementation planning, project sizing, security analyses, interface testing, training, production rollout, etc.)


Examples of Public Health Activities*Cancer Registries

Immunization Registries

Syndromic Surveillance

Lab Reporting

Childhood Lead Poisoning

Opioid Treatment Program

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*Includes range of activities such as replacement, requirements analysis, design, configuration, testing, user training, data migration, etc.


Examples of HIE Infrastructure Activities

Creating Charter

Service Access Layer

Trust Broker

Master Facility Index

Master Clinical Index

Patient Matching

Single Sign On

Security Services

Data Loading

8


Examples of HIE Services

Electronic Clinical Quality Measure (eCQM) Collection

Direct Messaging

Query Based Exchanges

Event Notification

Image Exchange

9


Examples of Planning (Other)

Preplanning Analysis

Planning

Post Implementation Evaluation

10


Exchange with outside ambulatory care providers

and outside hospitals is increasing.

11

41 45* 44

50*

58* 62*

76*

0

20

40

60

80

100

2008 2009 2010 2011 2012 2013 2014

Pe

rce

nt

of

Ho

spit

als


Limited capability of exchange partners to receive information electronically a top barrier.

12

Technical

Barriers

Financial

Barriers

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement.

59

58

45

24

16

10

30

26

10

25

0 10 20 30 40 50 60 70 80 90 100

Exchange partner lacks EHR or other system to receive data

Exchange partners' EHR system lacks capability to receivedata

Difficult to find provider address

Difficult to match or idenitfy patients

Lack capability to electronically receive data from outsidesources

Lack capability to electronically send data to outside sources

Cumbersome workflow to send from EHR system

Many recipients report summary of care record sent notuseful

Don't typically share patient data with outside providers

Additional costs to exchange with outside providers/settings

Percent of Hospitals

Operational

Barriers


One-quarter of hospitals nationwide are finding, sending, receiving AND using data electronically.

13

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement NOTES: “Find” is only interoperable exchange activity not specific to summary of care records. Find refers to query. “Send” and “Receive” include routine exchange using secure messaging using an EHR, using a provider portal, OR via health information exchange organization or other third party. “Use” requires that the records are integrated into the hospital’s EHR system without the need for manual entry.

48

78

56

40

23

0

10

20

30

40

50

60

70

80

90

Find Send Receive Use Conduct All 4Interoperable

Exchange Activities

Perc

en

t o

f H

osp

itals

Health Info from

outside sources

Patient Summary Care Record


Nearly all hospitals have the infrastructure

to enable exchange.

14

71.9

85.2*

94.0* 96.9

9.412.2

15.6

27.6*

44.4*

59.4*

75.5*

0

10

20

30

40

50

60

70

80

90

100

2008 2009 2010 2011 2012 2013 2014

Pe

rce

nt

of

Ho

spit

als

Certified EHR Basic EHR System

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement.


One-quarter of hospitals nationwide are finding, sending, receiving AND using data electronically.

15

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement NOTES: “Find” is only interoperable exchange activity not specific to summary of care records. Find refers to query. “Send” and “Receive” include routine exchange using secure messaging using an EHR, using a provider portal, OR via health information exchange organization or other third party. “Use” requires that the records are integrated into the hospital’s EHR system without the need for manual entry.

48

78

56

40

23

0

10

20

30

40

50

60

70

80

90

Find Send Receive Use Conduct All 4Interoperable

Exchange Activities

Perc

en

t o

f H

osp

itals

Health Info from

outside sources

Patient Summary Care Record


What’s Next?

o Provider Directories

MMIS funded

Bi-directional public health interface

Secure Messaging

Care Plan exchange

ADT Alerting

o CQM

Pophealth

o CDW/Query

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Hot Topics in Meaningful Use: The Legal Perspective

Matthew Fisher, Esq.

Co-Chair of Health Law Group

Mirick O’Connell

Worcester, MA


Top Legal Issues in Meaningful Use

• Assignment of Benefits• How to do it• How to make it binding• Who receives the money

• Audits• How does the process work • What are your legal rights in the process

• Patient Engagement • Access concerns• Privacy & security

• Interoperability • What barriers are in place• Who owns data• What can be forced

Image from www.franklinht.com


Assignment of Benefits

What do the Meaningful Use Regulations say about assignment?

Solely a private matter between the parties

As stated by CMS in the Stage 1 final regulation (75 Fed. Reg. 44446, July 28, 2010): “[The HITECH Act] does not require reassignment to an employer or entity with which the physician has a valid contractual arrangement.”

In the same comment, parties are encouraged to review existing contracts to determine what is required, permitted or allowed.

Clearly, assignment is up to the parties.



Don’t fear, there is some guidance in the regulations

• 42 CFR 495.10(f) – sets limitations on incentive assignment• Eligible Professional can assign to employer or entity that can bill for

the EP’s Services

• Any assignment must be consistent with general Medicare (or Medicaid) requirements for assignment of benefits

• Incentive can only be assigned to one employer or entity

• Where the difficulty can arise

• What is being done to ensure limits in place

• However approach, make sure meets regulatory requirements

Image from www.franklinandfanklin.com



• Some Practical Considerations:• Where is assigned payment going

• Does it go to EP, employer, or split

• If splitting, how is it split

• What actions will be required of each party

• Specifically who will handle attestations, who will keep records, and more

• What happens when/if the physician/EP leaves the employer

• What happens to records

• How will future payments be handled

• Will information be forwarded to a new employer

• Where is the assignment language located

• Standalone agreement

• Part of an employment agreement


Audits – Everyone’s Fear

• Conducted by Figliozzi and Company (for Medicare), up to each state for Medicaid

• Typically receive a letter asking for information about attestation

• Notice tied to attesting individual or facility

• Can be stressful• Ask for a lot of information

• Don’t receive much time to respond

• Can happen before or after payment of incentive• If after, can be up to 6 years later

Image from www.kentuckrec.com


Audits – How to Prepare

• Begin preparing for an audit as you make each attestation

• Develop and implement a plan• Identify what information needed for attestation

• Identify key personnel who will help with attestations

• Document, document, document• Document support for attestation as it is done

• Keep documentation

• Counterintuitive, but documentation needed to support electronic activities

• Mock Audits• Help preparation

• Can be done with an attorney, which can mean attorney-client privilege


Audits and Appeals

• Not happy without outcome from audit, submit an appeal

• Told to submit appeal within 30 days when get audit determination back

• Appeal process itself very opaque

• To file appeal, CMS instructs filling out provided form and submitting all supporting information

• 5 categories identified for appeals:• Failed audit

• Failed reporting

• Clinical quality measures e-reporting requirement appeal

• Eligibility

• Other, which requires explanation


Appeals – What to Expect

• Not clear given lack of guidance and firsthand experience

• Be proactive and do not try to hold any information back

• Prepare in advance

• Seek assistance

Image from www.goldinglawyers.com


Patient Engagement

• Patient engagement long been a core measure for Meaningful use

• New and updated patient focused measures in Stage 3• 80% of patients must be able to access records through

view/download/transmit function or through a certified Application Program Interface (API)

• Provide 35% of patients access to patient-specific educational resources• 25% of patients must access records through API or

view/download/transmit• 35% of patients must receive clinically-relevant secure message• Incorporate information from patients or non-clinical settings for 15% of

patients

• Keys measures to watch• API• Secure messaging • Incorporation of patient information


Patient Engagement

• Overarching concerns• Maintaining privacy and security

• Increased access and output points

• More vulnerabilities

• HIPAA risk analysis and Meaningful Use Risk assessment be key

• Need to stay on top of regulatory requirements

• Ties to maintaining privacy and security

• Contracting with outside vendors

• Can needed tools to hit targets be done internally

• What resources or support from outside are needed

• How to set standards and enforce expectations

Image from www.intehealth.com


Patient Engagement

• Specific Concerns• API or patient portal redesigned

• How will information be used

• How encourage or direct patients to utilize

• If take outside EMR, how ensure interaction with EMR

• Secure Messaging

• Major HIPAA risk

• Messaging clearly allowed, but need to consider how implemented

• Be sure to pay attention to specific Meaningful Use requirements

• Incorporating patient information

• May require interaction with big companies – think Apple Watch

• What is needed to enable information to be received

• How reliable is the information


Interoperability

• A focus of both the industry and outside players

• What does interoperability really mean?• Meaningful Use sets out expectations in Stage 3 Proposed Rule:

• Health information exchange• Send electronic summary for 50% of transfers of care (TOC) and

referrals• Get electronic summary for 40% of TOCs and referrals• Perform medication/allergy/problem reconciliation for80% of

TOCs and referrals• Public health and clinical data registry reporting

• Immunizations• Syndromic surveillance• Reportable conditions case reporting• Public health registries• Non-public health registries• Electronic lab reporting


Interoperability

• Meaningful Use focuses on particular uses

• A little narrower than more generalized discussion of interoperability and data movement

• However, interactions between systems still necessary

• For TOCs and referrals, information will likely need to flow from one EMR to another

• Also need to worry about plugging into a state or private created exchange

• Meeting requirements may be out of hands of EP/EH


Interoperability

• Exchange of information may hinge on ability of systems to work together

• What can providers, hospitals, others do?• Push for change

• Lawsuit could be in the future

• Information blocking put under the lights

• Challenge thrown down to vendors


Summary

• Meaningful Use presents many legal challenges, opportunities, and questions

• Resolving issues will take all in healthcare working together• Means providers, vendors, consultants, government, and others

• Key Takeaways:• Pay attention to contracts

• Keep HIPAA, privacy, and security foremost in mind

• Think about consequences and try to plan ahead


Contact Information

Matthew Fisher, Esq.• Email: [email protected]

• Phone: 508-929-1648

• Twitter: matt_r_fisher

• LinkedIn: https://www.linkedin.com/in/matthewreidfisher

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