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Office of E-Health Standards and Services Centers for Medicare & Medicaid Services
HITECH Legislation: Purpose
Improve outcomes, facilitate access, simplify care and reduce costs by providing:
• Major financial support to providers and States • Learning opportunities created and leveraged through TA from CMS and others • Far-reaching frameworks are being established that will orchestrate federal, State and local, public and private health care resources for generations to come
American Recovery & Reinvestment Act (Recovery Act) – February 2009 Electronic Health Record (EHR) Incentive Notice of Proposed Rulemaking (NPRM) on Display – December 30, 2009; published January 13, 2010 NPRM Comment Period Closes – March 15, 2010
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Definition of Meaningful Use (MU) Definition of Eligible Professional (EP) and Eligible Hospital/Critical Access Hospital (CAH) Definition of Hospital-Based Eligible Professional Medicare Fee-for-service (FFS) EHR Incentive Program Medicare Advantage (MA) EHR Incentive Program Medicaid EHR Incentive Program Collection of Information Analysis (Paperwork Reduction Act) Regulatory Impact Analysis
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Information about applying for grants Changes to HIPAA Office of the National Coordinator (ONC) Interim Final Rule (IFR) – Health Information Technology (HIT): Initial Set of Standards, Implementation Specifications, and Certification Criteria for EHR Technology EHR certification requirements ONC NPRM - Establishment of Certification Programs for Health Information Technology Procedures to become a certifying body
Harmonizes MU criteria across CMS programs as much as possible Closely links with the ONC certification and standards IFR Builds on the recommendations of the HIT Policy Committee and external stakeholders Coordinates with the existing CMS quality initiatives Provides a platform that allows for a staged implementation over time
Medicare Advantage (MA) Medicaid
◦ Eligible professionals (EPs) ◦ Eligible hospitals and critical access hospitals (CAHs) ◦ MA EPs ◦ MA-affiliated eligible hospital ◦ EPs ◦ Eligible hospitals
Eligible Providers in Medicare
Doctor of Medicine or Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Chiropractor Acute Care Hospitals
Eligible Professionals (EPs)
Doctor of Dental Surgery or Dental Medicine
Critical Access Hospitals (CAHs)
*Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC (including Maryland hospitals)
Eligible Providers in Medicare Advantage (MA)
Must furnish, on average, at least 20 hours/week of patient-care services and be employed by the qualifying MA organization -orMust be employed by, or be a partner of, an entity that through contract with the qualifying MA organization furnishes at least 80 percent of the entity’s Medicare patient care services to enrollees of the qualifying MA organization Will be paid under the Medicare Fee-for-service EHR incentive program
MA Eligible Professionals (EPs)
Qualifying MA-Affiliated Eligible Hospitals
Eligible Providers in Medicaid
Physicians (Pediatricians have special eligibility & payment rules) Nurse Practitioners (NPs) Certified Nurse-Midwives (CNMs) Dentists Physician Assistants (PAs) who lead a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is directed by a PA Acute Care Hospitals Children’s Hospitals
Eligible Professionals (EPs)
Hospital-based EPs do not qualify for Medicare EHR incentive payments Most hospital-based EPs will not qualify for Medicaid EHR incentive payments Defined as an EP who furnishes 90% or more of their services in a hospital setting (inpatient, outpatient, or emergency room)
Entity Physicians - Pediatricians Dentists CNMs PAs when practicing at an FQHC/RHC that is so led by a PA NPs Acute care hospitals Children’s hospitals
Minimum Medicaid patient volume threshold 30% 20% 30% 30% 30% 30% 10% No requirement
practices predominantly in an
FQHC or RHC—30%
Or the Medicaid EP
patient volume threshold
Not an option for hospitals
EP is also eligible when practicing predominantly in FQHC/RHC providing care to needy individuals Proposes practicing predominantly is when FQHC/RHC is the clinical location for over 50% of total encounters over a period of 6 months in the most recent calendar year Needy individuals (specified in statute) include:
◦ Medicaid or CHIP enrollees; ◦ Patients furnished uncompensated care by the provider; or ◦ furnished services at either no cost or on a sliding scale.
The Recovery Act specifies the following 3 components of Meaningful Use:
Use of certified EHR in a meaningful manner (ex: 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 and other measures
Process of defining
o o o o o
To be determined by Secretary Must include quality reporting, electronic prescribing, information exchange NCVHS hearings HIT Policy Committee (HITPC) recommendations Listening Sessions with providers/organizations Public comments on HITPC recommendations Comments received from the Department and the Office of Management and Budget (OMB)
Data capture and sharing
Advanced clinical processes
Meaningful Use will be defined in 3 stages through rulemaking
◦ Stage 1 – 2011 ◦ Stage 2 – 2013* ◦ Stage 3 – 2015*
*Stages 2 and 3 will be defined in future CMS rulemaking.
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Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health care Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.
Eligible Hospitals and CAHs
◦ 25 Objectives and Measures ◦ 8 Measures require ‘Yes’ or ‘No’ as structured data ◦ 17 Measures require numerator and denominator ◦ 23 Objectives and Measures ◦ 10 Measures require ‘Yes’ or ‘No’ as structured data ◦ 13 Measures require numerator and denominator
Reporting Period – 90 days for first year; one year subsequently
1. 2. 3.
4. 5. 6. 7.
Use CPOE Implement drug-drug, drug-allergy, drugformulary checks Maintain an up-to-date problem list of current and active diagnoses based on ICD9-CM or SNOMED CT® Maintain active medication list Maintain active medication allergy list Record demographics Record and chart changes in vital signs
8. 9. 10. 11. 12.
Record smoking status for patients 13 years and older Incorporate clinical 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 or the States Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules Check insurance eligibility electronically from public and private payers Submit claims electronically to public and private payers
15. 16. 17. 18. 19. 20.
Provide patients with an electronic copy of their health information upon request Capability to electronically exchange key clinical information among providers of care and patient-authorized entities Perform medication reconciliation at relevant encounters and each transition of care Provide summary care record for each transition of care and referral Capability to submit electronic data to immunization registries and actual submission where required and accepted Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities
1. 2. 3.
Generate and transmit permissible prescriptions electronically Send reminders to patients per patient preference for preventive/follow-up care Provide patients with timely electronic access to their health information within 96 hours of information being available to the EP Provide clinical summaries for patients for each office visit
Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request 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.
2011 – Providers required to submit summary quality measure data to CMS or States by attestation 2012 – Providers required to electronically submit summary quality measure data to CMS or States EPs are required to submit clinical data on the 2 measure groups: core measures and a subset of clinical measures most appropriate to the EP’s specialty Eligible hospitals are required to report summary quality measures for applicable cases
Preventive care and screening: Inquiry regarding tobacco use Blood pressure management Drugs to be avoided by the elderly:
Patients who receive at least one drug to be avoided Patients who receive at least two different drugs to be avoided
EPs will need to select one of the following specialties Cardiology Pulmonology Endocrinology Oncology Proceduralist/Surgery Primary Care Pediatrics Nephrology Obstetrics and Gynecology Neurology Psychiatry Ophthalmology Podiatry Radiology Gastroenterology
Hospitals are required to report summary data to CMS or States on 35 clinical quality measures For the Medicaid program incentive, hospitals have the option to select 8 alternative Medicaid clinical quality measures to meet the requirements for reporting if the 35 measures do not apply to their patient population Hospitals only eligible for Medicaid will report directly to the States
Adopt, implement, upgrade (AIU) Meaningful use (MU)
◦ First participation year only ◦ Successive participation years; and ◦ Proposed option for early adopters in year 1
States may propose to CMS for approval limited additional criteria for MU, beyond the NPRM Prioritizing coordination between:
◦ CHIPRA and HITECH ◦ NPRM is the MU base-level requirement
Adopt: Acquired and installed
Implement: Commenced utilization
- e.g., evidence of acquisition, installation etc. - e.g., staff training, data entry of patient demographic information into EHR, data use agreements
Upgrade: Version 2.0; expanded functionality
- e.g., ONC EHR certification (short-term) or additional functionality such as clinical support or HIE capacity (longer-term)
Eligible hospitals, unlike EPs, may receive incentives from Medicare and Medicaid
◦ Subsection(d) hospitals, also acute care
Hospitals meeting Medicare MU requirements may be deemed for Medicaid , even if the State has an expanded (approved) definition of meaningful use
There is a deliberate overlap between the CHIPRA core measures and the Stage 1 measures for MU.
◦ BMI 2-18 yrs old ◦ Annual hemoglobin A1C testing (all children and adolescents diagnosed with diabetes) ◦ Pharyngitis - appropriate testing 2-18 yrs old ◦ Follow-up care for children prescribed attentiondeficit/hyperactivity disorder (ADHD) medication
The Medicaid EHR Incentive Program starts in 2011 and ends in 2021 The latest that a Medicaid provider can initiate the program is 2016 A Medicaid provider can initiate the program under the Adopt, Implement and Upgrade bar but in their 2nd and subsequent years, they must meet MU at the stage that is in place, per rule-making (Stage 3 by 2015).
Eligible Hospitals and CAHs
◦ Medicare FFS ◦ Medicare Advantage ◦ Medicaid
◦ Medicare FFS ◦ Medicare Advantage (paid under Medicare FFS) ◦ Medicaid
Eligible professionals (EPs)
Calendar Year 2011-2016 (Medicare) – Up to $44,000 over 5 years if “meaningful EHR user” 2011-2021 (Medicaid) – Up to $63,750 over 6 years – Adopt/Implement/Upgrade or meaningful use in Year 1, MU Years 2-6 2015 and later – If not “meaningful EHR user” up to 3% payment adjustment in Medicare reimbursement We propose that after the initial designation, EPs be allowed to change their program selection only once during payment years 2012 through 2014
First Calendar Year in which the EP receives an Incentive Payment Calendar Year 2011 2012 2013 2014 2015 2016 TOTAL $44,000 CY 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 $15,000 $12,000 $8,000 $4,000 $39,000 $12,000 $8,000 $4,000 $24,000 $0 $0 $0 CY 2012 CY 2013 CY 2014 CY 2015 and later
First Calendar Year in which the EP receives an Incentive Payment Calendar Year 2011 2012 2013 2014 2015 2016 TOTAL $4,400 CY 2011 $1,800 $1,200 $800 $400 $200 $1,800 $1,200 $800 $400 $200 $4,400 $1,500 $1,200 $800 $400 $3,900 $1,200 $800 $400 $2,400 $0 $0 $0 CY 2012 CY 2013 CY 2014 CY 2015 and later
First Calendar Year in which the EP receives an Incentive Payment Calendar CY 2011 Year $21,250 2011 2012 $8,500 2013 2014 2015 2017 2018 2019 2020 2021 TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 2016 $8,500 $8,500 $8,500 $8,500 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016
$21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750
◦ Federal Fiscal Year ◦ $2M base + per discharge amount (based on Medicare/Medicaid share) ◦ Hospitals meeting Medicare MU requirements may be deemed eligible for Medicaid payments ◦ Payment adjustments for Medicare after 2015 ◦ Medicare hospitals cannot receive payments after 2016. For Medicaid, hospitals cannot initiate payments after 2016 but can receive payments if they initiated the program before 2016 ◦ No penalties for Medicaid ◦ NPRM has narrative and sample calculation
Medicare can pay incentives to EPs no sooner than January 2011 Medicare can pay eligible hospitals and CAHs no sooner than October 2010 Medicaid EPs can potentially receive payments as early as 2010 for adopting, implementing or upgrading
Prior approval for reasonable administrative expenses (P-APD, I-APD) Establish a State Medicaid HIT Plan (SMHP) State may receive 90% FFP and 100% FFP for the payments themselves NPRM defines numerous previously undefined terms in CFR
◦ Medicaid Management Information Systems (MMIS) ◦ Medicaid IT Architecture (MITA)
Statutory Conditions of Use of the HITECH Admin Funds: 1. Administration of incentives, including tracking of meaningful use by Medicaid EPs and eligible hospitals;
2. Oversight, including routine tracking of meaningful use attestations and reporting mechanisms; and 3. Pursuing initiatives to encourage the adoption of certified EHR technology for the promotion of health care quality and the exchange of health care information.
3 Key Elements: What is the current HIT landscape? What is the State’s Vision for the next 5 years? How will they implement and oversee a successful EHR Incentive Program? NPRM proposes States uses MITA principles in developing SMHP SMHP will include State’s methodologies for verifying eligibility; disbursing payments; coordinating with stakeholders; contracting; privacy & security; curtailing fraud & abuse; and other activities
States and CMS must assure there is no duplication of payments to providers (between States and between States and Medicare) States are required to seek recoupment of erroneous payments and have an appeals process CMS/Medicaid has oversight/auditing role including how States implement the EHR Incentive Program (90% FFP) and how they make correct payments to the right providers for the right criteria (100% FFP).
Other Medicare Incentive Program Medicare Physician Quality Reporting Initiative (PQRI) Medicare Electronic Health Records Demonstration (EHR Demo) Medicare Care Management Performance Demonstration (MCMP) Electronic Prescribing Incentive Program (eRx)
Eligible for HITECH? Yes, if the PQRI incentive is extended in its current format beyond 2010, EPs can participate in both if they are eligible Yes, if the EP is eligible
Yes, if the practice is eligible. The MCMP demo will end before EHR incentive payments are available If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously
Feds will implement (will be an option nationally) Fee schedule reductions begin in 2015 for providers that are not Meaningful Users Must be a meaningful user in Year 1 Maximum incentive is $44,000 for EPs MU definition will be common for Medicare Medicare Advantage EPs have special eligibility accommodations Last year an EP may initiate program is 2014; Last payment in program is 2016; Payment adjustments begin in 2015 Only physicians, subsection (d) hospitals and CAHs
Voluntary for States to implement (may not be an option in every State) No Medicaid fee schedule reductions A/I/U option for 1st participation year Maximum incentive is $63,750 for EPs States can adopt a more rigorous definition (based on common definition) Medicaid managed care providers must meet regular eligibility requirements Last year an EP may initiate program is 2016; Last payment in program is 2021 5 types of EPs, 3 types of hospitals
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Public comment period ends March 15, 2010 CMS review of comments Draft final regulation CMS/HHS/OMB clearance Final rule publication - Spring 2010 CMS On-going review of States’ Planning APDs CMS to issue additional guidance on Medicaid 90/10 Implementation funding On-Going Federal HIT Coordination (ONC, AHRQ, HRSA, IHS, FCC, etc)
Comments are due March 15, 2010 at 5 p.m.
Document type: Proposed Rule Keyword or ID: CMS-2009-0117-0002
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A/I/U – Adopt, implement or upgrade CAH – Critical Access Hospital CCN – CMS Certification Number CDS – Clinical Decision Support CMS – Centers for Medicare & Medicaid Services CY – Calendar Year EHR – Electronic Health Record EP – Eligible Professional eRx – E-Prescribing FFS – Fee-for-service FY – Federal Fiscal Year HHS – U.S. Department of Health and Human Services HIT – Health Information Technology HITECH Act – Health Information Technology for Electronic and Clinical Health Act HITPC – Health Information Technology Policy Committee HIPAA – Health Insurance Portability and
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Accountability Act of 1996 HPSA – Health Professional Shortage Area IFR – Interim Final Rule MA – Medicare Advantage MCMP – Medicare Care Management Performance Demonstration MITA- Medicaid Information Technology Architecture MU – Meaningful Use NPI – National Provider Identifier NPRM – Notice of Proposed Rulemaking OMB – Office of Management and Budget ONC – Office of the National Coordinator of Health Information Technology PQRI – Medicare Physician Quality Reporting Initiative Recovery Act – American Reinvestment & Recovery Act of 2009 TIN – Taxpayer Identification Number