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Electronic Electronic Health Records Health Records Initiative Initiative Understanding the Understanding the American Recovery and American Recovery and Reinvestment Act Reinvestment Act and it’s Impact and it’s Impact

The Circuit EHR Presentation

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Dan Falke and Jeff Burke presented Electronic Health Records, hosted by Resovit

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Page 1: The Circuit EHR Presentation

Electronic Health Electronic Health Records Records InitiativeInitiative

Understanding the Understanding the

American Recovery and American Recovery and Reinvestment ActReinvestment Act

and it’s Impactand it’s Impact

Page 2: The Circuit EHR Presentation

OverviewOverview The ARRA recently signed into law in February The ARRA recently signed into law in February

2009 includes incentives for physician practices 2009 includes incentives for physician practices and hospitals to implement and demonstrate and hospitals to implement and demonstrate ““meaningful usemeaningful use” of a ” of a qualifiedqualified electronic health electronic health records system (EHR).records system (EHR).

ARRA provides for significant incentives for those ARRA provides for significant incentives for those physicians and hospitals that are meaningful EHR physicians and hospitals that are meaningful EHR users .users .

There are significant penalties for those physicians There are significant penalties for those physicians and hospitals that do not implement EHR prior to and hospitals that do not implement EHR prior to 2015.2015.

Practices and hospitals that already have EHR Practices and hospitals that already have EHR qualify for the incentives as long as the system qualify for the incentives as long as the system meets the “qualified” criteria and they can meets the “qualified” criteria and they can demonstrate “meaningful use”.demonstrate “meaningful use”.

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AgendaAgenda Health IT Economic & Clinical Health Act Health IT Economic & Clinical Health Act

(HITECH) provision of the American (HITECH) provision of the American Recovery and Reinvestment Act (ARRA)Recovery and Reinvestment Act (ARRA)

Qualified EHRQualified EHR Meaningful UseMeaningful Use Health Information Exchange (HIE)Health Information Exchange (HIE) EHR Meaningful Use Incentive ProgramsEHR Meaningful Use Incentive Programs OpportunitiesOpportunities HIT Extension CentersHIT Extension Centers Q & AQ & A

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ARRA and HITECHARRA and HITECHTitle XIIITitle XIII

Financial Impact of ARRAFinancial Impact of ARRA $47 billion for Health Information Technology

Expectation is that $45B will be paid to eligible professionals and hospitals in incentives

$2 billion allocated to the Office of the National Coordinator (ONC) for administration

$300,000,000 to support regional efforts toward national health information exchange (HIE) and the Regional Health Information Organizations (RHIO)

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Title IV HITECH Title IV HITECH Medicare and Medicaid Health Medicare and Medicaid Health

Information TechnologyInformation Technology Incentives are available for implementation and

“meaningful” use of qualified EHR systems. Qualified Electronic Health Record — The term

‘qualified electronic health record’ means an electronic record of health-related information on an individual includes patient demographic and clinical health

information, such as medical history and problem lists

has the capacity— to provide clinical decision support to support computerized physician order entry to capture and query information relevant to health care

quality to exchange electronic health information with, and

integrate such information from other sources

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Office of the National Office of the National Coordinator Coordinator (ONC)(ONC)

Formed under the provisions of Formed under the provisions of ARRA to further define key policies ARRA to further define key policies and regulations of the HITECH Act.and regulations of the HITECH Act. Define certification process of EHR’sDefine certification process of EHR’s Establish Meaningful Use objectives Establish Meaningful Use objectives

and measuresand measures Define incentive payment plansDefine incentive payment plans Administer HITECH ActAdminister HITECH Act

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Qualified EHRQualified EHR

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Qualified EHR Qualified EHR ApplicationApplication

Certification body and standardsCertification body and standards ONC will certify organization to qualify EHR systemsONC will certify organization to qualify EHR systems Stated goal is to have more than one certified Stated goal is to have more than one certified

organizationorganization Most recognized EHR certification body today is Most recognized EHR certification body today is

Certification Commission on Health Information Certification Commission on Health Information Technology (CCHIT)Technology (CCHIT) Established in 2004, certifying EHR systems since Established in 2004, certifying EHR systems since

20062006 Comprehensive certification processComprehensive certification process Published certification standardsPublished certification standards Endorsed by AMA and many other professional Endorsed by AMA and many other professional

organizationsorganizations

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CCHIT Certification CCHIT Certification OverviewOverview

CCHIT CCHIT Comprehensive Comprehensive CertificationCertification

CCHIT ARRA CCHIT ARRA CertificationCertification

System supports all System supports all functionality deemed functionality deemed to be necessary by to be necessary by CCHIT work groupCCHIT work group CCHIT work groups CCHIT work groups staffed by volunteer staffed by volunteer professionals from professionals from providers, vendors, providers, vendors, and industry expertsand industry experts criteria available at criteria available at www.cchit.orgwww.cchit.org

Systems meets specific Systems meets specific requirements to support requirements to support specific components of specific components of the ARRA Meaningful Use the ARRA Meaningful Use criteria.criteria. Modular certification Modular certification allows vendors to allows vendors to integrate best-of-breed integrate best-of-breed solutions to achieve a solutions to achieve a “meaningful use” “meaningful use” qualifying environment.qualifying environment. Draft criteria to be Draft criteria to be published in Oct. 2009. published in Oct. 2009. Final in April 2010Final in April 2010

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CCHIT EHR Certification CCHIT EHR Certification CategoriesCategories

AreasAreas AmbulatoryAmbulatory Emergency Emergency

DepartmentDepartment In-PatientIn-Patient Long Term and Post Long Term and Post

Acute CareAcute Care Clinical ResearchClinical Research

Behavioral HealthBehavioral Health CardiovascularCardiovascular Children’s HealthChildren’s Health DermatologyDermatology

Overall Overall FunctionalityFunctionality

Clinical Decision Clinical Decision SupportSupport

InteroperabilityInteroperability QualityQuality SecuritySecurity PrivacyPrivacy ePrescribingePrescribing Health Information Health Information

ExchangeExchange Personal Health Personal Health

RecordRecord

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Qualified EHR Qualified EHR ApplicationsApplications

Number of CCHIT Certified EHR Applications Number of CCHIT Certified EHR Applications (Comprehensive Certification)(Comprehensive Certification)

20072007CriteriaCriteria

20082008CriteriaCriteria

AmbulatoryAmbulatory 5555 2020

InpatientInpatient 1313 33

ED (new in 08)ED (new in 08) 88

Additional certifications for Cardiovascular Medicine and Children’s HealthAdditional certifications for Cardiovascular Medicine and Children’s Health Approximately 50 certification applications are currently pending.Approximately 50 certification applications are currently pending. Additional certification criteria evolving continuouslyAdditional certification criteria evolving continuously

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Meaningful UseMeaningful Use

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ARRA “Meaningful” Use?ARRA “Meaningful” Use? shall include the use of electronic prescribing

electronic exchange of health information

clinical quality measures and such other measures

Secretary shall provide preference to clinical quality measures that have been endorsed the Secretary

Prior to any measure being selected the Secretary shall publish in the Federal Register such measure and provide for a period of public comment on such measure

Measures will evolve, with initial measures for 2011, and expanded measures in each of 2013 and 2015

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ONC Meaningful UseONC Meaningful UseObjectives and MeasuresObjectives and Measures

Can be found at healthit.hhs.gov

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““Meaningful Use” Meaningful Use” Ascension PathAscension Path

““Meaningful Use” criteria are the minimum standardsMeaningful Use” criteria are the minimum standards Without reporting of meaningful use measures, Without reporting of meaningful use measures,

providers can not qualify for incentive payments.providers can not qualify for incentive payments.

Meaningful Use Ascension Path

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Health IT ExchangeHealth IT ExchangeNational Coordinator shall establish a

program to facilitate and expand electronic movement and use of health information among organization according to nationally recognized standards

EHR information available regionally/nationally Electronic Ordering and Results Radiology images Patient Transfers ePrescribing Public and Population Health Reporting

HL7 based transaction set likely

Page 17: The Circuit EHR Presentation

IncentivesIncentives

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Subtitle A – Medicare IncentivesSubtitle A – Medicare Incentives

Incentives for Ambulatory Care Incentives for Ambulatory Care FacilitiesFacilities

Incentives for implementation and “meaningful” use of EHR 1st year: $18,000

If the first payment year is 2013 or later, payment will be $15,000

Must be implemented and in use before 2015 2nd year: $12,000 3rd year: $8,000 4th year: $4,000 5th year: $2,000

Those engaged in Physician Quality Reporting Initiative (PQRI) and electronic prescribing can earn an additional $6,000 - $8,000 per year beginning immediately

Maximum payout limited to 75% of an eligible professionals Medicare billings

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Subtitle A – Medicare IncentivesSubtitle A – Medicare IncentivesAmbulatory FacilityAmbulatory Facility

EHR Implementation IncentivesEHR Implementation IncentivesPayment per "Eligible Professional"Payment per "Eligible Professional"

Final Payment methods and timelines not yet final• Hospitals cannot receive first payment prior to November 2010• Eligible Professionals cannot receive first payment prior to January 2011

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Subtitle A – Medicare IncentivesSubtitle A – Medicare Incentives

Penalties for Non-Penalties for Non-ComplianceCompliance

Beginning in 2015, any eligible professional who is not a meaningful user of EHR, the Medicare reimbursement for covered services will be reduced:

YearYear Reimbursement Reimbursement

20152015 99%99%

20162016 98%98%

20172017 97% 97%

2018 2018 (75% rule)(75% rule) 96%96%

20192019 (75% rule) (75% rule) 95%95%

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Subtitle A – Medicare IncentivesSubtitle A – Medicare Incentives

Incentives for Acute Care Facilities Annual Payment =

Initial Amount * Medicare Share * Transition Factor

Initial Amount $2,000,000 plus $200 per discharge for each

discharge over 1,149 and up to 23,000. Initial Amount range of $2,000,000 to $6,370,200

Medicare Share(Medicare Part A Bed Days + Medicare Advantage Bed Days)

(Total Bed Days * % Non-Charity Care Charges)

Transition FactorYear : 1 Factor :

12 ¾3 ½4 ¼5 and beyond 0

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Subtitle A – Medicare IncentivesSubtitle A – Medicare IncentivesAcute Care FacilityAcute Care Facility

EHR Implementation IncentivesEHR Implementation Incentives

•A 300 bed hospital with 40% Medicare population and 4% Charity Care.

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Subtitle A – Medicare IncentivesSubtitle A – Medicare Incentives

Other Applicable ConditionsOther Applicable Conditions Eligible professional who predominantly furnish

services in a health professional shortage area, the amount shall be increased by 10%.

If the first payment year for an eligible professional is after 2014 then the applicable amount specified for such year and any subsequent year shall be $0.

No incentive payment may be made in the case of a hospital-based eligible professional.

the Secretary shall establish rules to coordinate the incentive payments for eligible professionals furnishing covered services in more than one practice.

Special conditions apply to Critical Access Hospitals and Medicare Advantage (MA) hospitals.

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Subtitle B – Medicaid Subtitle B – Medicaid IncentivesIncentives

The term ‘Medicaid provider’ means Eligible professional who has at least 30% Medicaid

patient volume Pediatrician who has at least 20% Medicaid patient

volume Eligible professional who practices predominantly in

a Federally qualified health center or rural health clinic and has at least 30% “needy individuals” patient volume

Acute-care hospital that has at least 10% Medicaid patient volume

An eligible professional cannot qualify for both Medicare and Medicaid incentives.

A hospital can qualify for both Medicare and Medicaid incentives.

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Subtitle B – Medicaid IncentivesSubtitle B – Medicaid Incentives

Incentives for Eligible Incentives for Eligible ProfessionalsProfessionals

For each Medicaid provider, incentives not in excess of 85% of net average allowable costs for certified EHR technology and support services including maintenance and training

Net average allowable costs per eligible Medicaid provider not to exceed $25,000 for first year’s implementation services $10,000 per subsequent year, up to 5, for

maintenance and support Total incentive per eligible Medicaid

professional is not to exceed $63,750 $50,000 for pediatricians with 20% Medicaid volume

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Subtitle B – Medicaid IncentivesSubtitle B – Medicaid Incentives

Incentives for Acute-Care Incentives for Acute-Care HospitalsHospitals

Payments to a Medicaid hospital shall not exceed: the product of the overall amount

expended for the EHR and the Medicaid share for that provider

in any year, incentive payment shall not exceed 50% of the EHR product

In any 2 year period, payments shall not exceed 90% of the costs of the EHR

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OpportunityOpportunity

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EHR Market PenetrationEHR Market PenetrationEligible ProfessionalsEligible Professionals

DesRoches CM et al., N Engl J Med 2008;359:50-60.

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Market Penetration of EHRMarket Penetration of EHRHospitalsHospitals

Approximately 50% have Approximately 50% have implemented, but fewer than 10% implemented, but fewer than 10% have qualified EHR and can have qualified EHR and can demonstrate meaningful use.demonstrate meaningful use.

1.5% have comprehensive system across all 1.5% have comprehensive system across all departmentsdepartments

10.9% have basic system10.9% have basic system

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Barriers to SuccessBarriers to Success Barriers to implementation Barriers to implementation

costcost physician resistance physician resistance lack of confidence in HITECH provisionslack of confidence in HITECH provisions system selectionsystem selection availability of qualified implementation staffavailability of qualified implementation staff the complexities of the ARRA law the complexities of the ARRA law

Barriers to demonstration of meaningful useBarriers to demonstration of meaningful use interoperability requirementsinteroperability requirements availability of qualified implementation staffavailability of qualified implementation staff acceptance and use by all staffacceptance and use by all staff annual reporting requirementannual reporting requirement

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Conclusion Conclusion

ConsultantsConsultants establish expertiseestablish expertise maintain product maintain product

independenceindependence provide selection, provide selection,

implementation, and implementation, and training support, but training support, but focus on meaningful usefocus on meaningful use

EHR VendorsEHR Vendors get certifiedget certified clearly identify your clearly identify your

strengths and stick to strengths and stick to themthem

commit to maintaining commit to maintaining compliance with compliance with meaningful use criteriameaningful use criteria

partner with others to fill partner with others to fill gapsgaps

support interoperabilitysupport interoperability

HospitalsHospitals proceed soon, but proceed soon, but

cautiouslycautiously evaluate solutions evaluate solutions

and plan and plan implementationsimplementations

dedicate resources dedicate resources or hirer consultantsor hirer consultants

Eligible ProfessionalsEligible Professionals don’t go it alone or don’t go it alone or

rely exclusively on a rely exclusively on a vendor for directionvendor for direction

consider vendor consider vendor commitment to their commitment to their product and ease of product and ease of integrationintegration

Commit the time and Commit the time and effort to do it righteffort to do it right

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Physician AttitudesPhysician Attitudes

Massachusetts study of physicians Massachusetts study of physicians attitudes after EHR implementationattitudes after EHR implementation

GoodGood NeutralNeutral BadBad Ability to Ability to prevent errorsprevent errors

Control of Control of practicepractice

Increased Increased earnings earnings potentialpotential

Improved Improved productivityproductivity

Cost of Cost of implementatiimplementationon

Page 33: The Circuit EHR Presentation

HIT Extension CentersHIT Extension Centers The HITECH Act authorizes resources to facilitate the adoption and The HITECH Act authorizes resources to facilitate the adoption and

use of EHRs by providing technical assistance and the capacity to use of EHRs by providing technical assistance and the capacity to exchange health information.exchange health information.

Regional Centers offer providers within their geographic service Regional Centers offer providers within their geographic service areas technical assistance in the selection, acquisition, areas technical assistance in the selection, acquisition, implementation, and meaningful use of EHRs—including health implementation, and meaningful use of EHRs—including health information exchange (HIE).information exchange (HIE).

Implementation and Project Management: Support end-to-end Implementation and Project Management: Support end-to-end project management over the entire EHR implementation process, project management over the entire EHR implementation process, including individualized and on-site coaching, consultation, including individualized and on-site coaching, consultation, troubleshooting.troubleshooting.

Progress Towards Meaningful Use: Participate in program training Progress Towards Meaningful Use: Participate in program training and be able to provide effective assistance in attaining meaningful and be able to provide effective assistance in attaining meaningful use.use.

Funding of Extension Centers begins 11 Dec 2009.Funding of Extension Centers begins 11 Dec 2009.

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Q & AQ & A

Dan [email protected](513) 227-2740

Jeff [email protected](513) 702-6846