01-10a - introduction to healthcare and public health in the us - unit 10 - meaningful use of health...

Introduction to Healthcare and Public Health in the USMeaningful Use of Health Information Technology Lecture aThis material (Comp1_Unit10a) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a

Meaningful Use (MU) Of Health Information Technology Learning ObjectivesDefine meaningful use of health information technology in the context of the Health Information Technology for Economic and Clinical Health (HITECH) Act (Lecture a)Describe the major goals of meaningful use (Lecture a)Define the criteria for Stages 1 and 2 of meaningful use for eligible professionals and eligible hospitals (Lecture b)Describe the standards specified for Stages 1 and 2 of meaningful use, including those devoted to privacy and security (Lecture c)Define the clinical quality measures (CQMs) for the meaningful use program (Lecture c)*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


HITECH, ARRA and Achieving Meaningful UseHealth Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA) (Blumenthal, 2010; Blumenthal & Tavenner, 2010)Incentives for meaningful use (MU) of the electronic health record (EHR) by physicians and hospitals (up to $27B)Direct grants administered by federal agencies ($2B)Enhancements to HIPAA Privacy and Security Rules

*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Meaningful Use (MU) Driven By Underlying Goals For Healthcare SystemConceptually originated in legislation by Congressman Rodney Pete Stark in 2010All MU criteria must map to one or more of five goals for the healthcare systemImproving quality, safety, and efficiencyEngaging patients in their careIncreasing coordination of careImproving the health status of the populationEnsuring privacy and securityExamplesImplement drug-drug interaction checks Improving quality, safety, and efficiencyProvide summary of care to patients Engaging patients in their care



Overall Requirements For Meaningful UseUse certified EHR technology in a meaningful mannerUse certified EHR technology connected in a manner that provides for health information exchange to improve the quality of careUsing certified EHR technology, the provider submits information on clinical quality measures



Three Stages of Meaningful Use Implementation(McGuire, 2011)*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Certified Electronic Health RecordsA qualified EHR certified by an approved certifying entityA qualified EHR is an electronic record of health-related information on an individual thatIncludes patient demographic and clinical health information, such as medical history and problem listsHas the capacity toProvide clinical decision supportSupport physician/provider order entryCapture and query information relevant to healthcare qualityExchange electronic health information with, and integrate such information from, other sources



ImplementationImplemented through increased Medicare or Medicaid reimbursement toEligible professionals (EPs)Medicare: MD, DO, DDS/DMD, DPM, OD, DCMedicaid: MD, DO, DDS/DMD, Certified Nurse Midwives, Nurse Practitioners, Physicians Assistants operating at an FQHC/RHCHospital-based EPs not eligible (>90% service in hospital, e.g., pathologist, emergency physician)Eligible hospitals (EHs)Medicare: Acute Care Hospitals, Critical Access Hospitals (CAHs)Medicaid: Acute Care Hospitals , CAHs, Childrens HospitalsWithin the 50 states and DCVarious differences in Medicare vs. Medicaid for amount reimbursed, rules, and other aspects



Payment for Medicare Eligible ProfessionalsLimited to 75% of Medicare charges

10.1 Chart: CMS.gov; Medicare and Medicaid EHR Incentive Program Basics (2012). *Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Additional Payment for Medicare Eligible Professionals In Health Professional Shortage AreasThese EPs can receive up to $48,400

10.2 Chart: CMS.gov; Medicare and Medicaid EHR Incentive Program Basics (2012)



Payment for Medicaid Eligible Professionals

10.3 Chart: CMS.gov; Medicare and Medicaid EHR Incentive Program Basics (2012). *Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Payment for Eligible HospitalsMore complex depending on Medicare vs. Medicaid, hospital type, and share of patientsMulti-campus hospitals count as one EHGeneral formula is that payment is multiplication of:Initial amount $2M + $200 per discharge for 1,150th to 23,000th discharge (maximum for 21,850 discharges is $2M + $4.37M = $6.37M)Medicare or Medicaid shareTransition factor 1.0, 0.75, 0.5, and 0.25 over four years depending on when become eligible



Meaningful Use RulesStage 1 final rules published on July 28, 2010CMS Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final RuleONC Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record TechnologyFor those without time to read hundreds of pages, there are excellent summaries and other materials from HHS, HIMSS, CSC, and Geek Doctor blogCMS Web site for programhttp://www.cms.gov/ehrincentiveprograms/EHR certification process guided by Temporary Certification Rule released on June 24, 2010, to be superseded by Permanent Certification Rule released in January, 2011 to start in 2012http://healthit.hhs.gov/certification/*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Connecting CMS and ONC RulesHITECH ties the standards, implementation specifications, and certification criteria adopted in ONC rules to the incentives under the CMS Medicare and Medicaid EHR Incentive Programs by requiring the meaningful use of certified EHR technologyONC rules require specific standards in four areasVocabularyContent exchangeTransporting of informationPrivacy and securityhttp://www.cms.gov/ehrincentiveprograms/http://healthit.hhs.gov/*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Electronic Health Record CertificationDescription of ONC HIT Certification Program: http://www.healthit.gov/policy-researchers-implementers/certification-programs-policyList of certified EHR products: http://www.healthit.gov/policy-researchers-implementers/certified-health-it-product-list-chpl-0

(Health IT.gov; Certification Programs and Policy, 2012)



Electronic Health Record Certification ProcessTest procedures for EHR certification - http://www.healthit.gov/policy-researchers-implementers/2014-edition-draft-test-methods

(Health IT.gov; Certification Programs and Policy, 2012)



How Eligible Professionals and Hospitals Receive Incentive MoneyMeet and report on the MU criteriaMedicaid exceptionsIn first year, EP/EH can demonstrate they adopted, implemented, or upgraded (A/I/U) a certified EHRCan skip years but must begin by 2016

*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a(CMS.gov; EHR Incentive Programs, 2012)


Cost Of Economic StimulusCMS estimates of EPs and EHs at onset of program477,500 eligible as Medicare EP95,500 of these eligible as Medicaid EP44,100 eligible as Medicaid-only EP5,011 EHs3,620 acute care1,302 CAH78 childrens11 cancerEstimated achievement of MU in ten yearsLow 95.6% of EHs and 36% of EPsHigh 100% of EHs and 70% of EPsTotal cost: $9.7B (low) to $27.4B (high)



Meaningful Use Of Health Information Technology Summary Lecture a

The HITECH Act of ARRA legislated incentives for the meaningful use (MU) of health ITMU means that criteria for use of IT are tied back to goals of the health care systemThese criteria are met by eligible professionals and eligible hospitals to receive incentive payments for use of EHRs in three stages*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture a


Meaningful Use Of Health Information Technology References Lecture aReferences Blumenthal, D. (2010). Launching HITECH. New England Journal of Medicine, 362, 382-385. Blumenthal, D., & Tavenner, M. (2010). The meaningful use regulation for electronic health records. New England Journal of Medicine, 363, 501-504. Metzger, J. and Rhoads, J. (2012). Summary of Key Provisions in Final Rule for Stage 2 HITECH Meaningful Use. Falls Church, VA, Computer Sciences Corp. http://assets1.csc.com/health_services/downloads/CSC_Key_Provisions_of_Final_Rule_for_Stage_2.pdf.

Charts, Tables, Figures10.1 Chart: CMS.gov; Medicare and Medicaid EHR Incentive Program Basics. (2012). Retrieved December 2012, from Centers for Medicare & Medicaid Services website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html10.2 Chart: CMS.gov; Medicare and Medicaid EHR Incentive Program Basics. (2012). Retrieved December 2012, from Centers for Medicare & Medicaid Services website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html10.3 Chart: CMS.gov; Medicare and Medicaid EHR Incentive Program Basics. (2012). Retrieved December 2012, from Centers for Medicare & Medicaid Services website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html



Meaningful Use Of Health Information Technology References Lecture a (continued)*Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US Meaningful Use of Health Information Technology Lecture aImagesSlide 6: McGuire, E. (2011). Focus on Healthcare Blog. Retrieved December 2012, from http://healthcarehis.files.wordpress.com/2011/02/meaningful-use.jpgSlide 15: Health IT.gov; Certification Programs and Policy. (2012). Retrieved December 2012, from U.S. Department of Health & Human Services website: http://www.healthit.gov/policy-researchers-implementers/onc-hit-certification-programSlide 16: Health IT.gov; Certification Programs and Policy. (2012). Retrieved December 2012, from U.S. Department of Health & Human Services website: http://www.healthit.gov/policy-researchers-implementers/about-certification#benefits_of_certificationSlide 17: CMS.gov; EHR Incentive Programs. (2012). Retrieved December 2012, from Centers for Medicare & Medicaid Services website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms


Welcome to Introduction to Health Care and Public Health in the US: Meaningful Use of Health Information Technology. This is Lecture (a).The component, Introduction to Health Care and Public Health in the US, is a survey of how health care and public health are organized and services are delivered in the US.*The objectives for Meaningful Use of Health Information Technology are:Define meaningful use of health information technology in the context of the Health Information Technology for Economic and Clinical Health (HITECH) Act; Describe the major goals of meaningful use; Define the criteria for Stages 1 and 2 of meaningful use for eligible professionals and eligible hospitals; Describe the standards specified for Stages 1 and 2 of meaningful use, including those devoted to privacy and security; Define the clinical quality measures (CQMs) for the meaningful use program. *This lecture will discuss the implementation of meaningful use of health information technology in the context of the Health Information Technology for Economic and Clinical Health (HITECH) [high-tech] Act. With the American Recovery and Reinvestment Act (ARRA, air-uh), also known as the economic stimulus bill, the United States entered a new era for health information technology. The portions of ARRA addressing health information technology are known as the Health Information Technology for Economic and Clinical Health, or HITECH, Act. HITECH provides incentives for adoption of the electronic health record (EHR) by physicians and hospitals, for which it will fund up to $27 billion. HITECH also provides direct grants administered by federal agencies, such as the Regional Extension Centers and workforce development programs, to develop the infrastructure to support the program.HITECH also includes enhancements to the Health Insurance Portability and Accountability Act of 1996 (HIPPA, hip-uh) privacy and security rules.*The HITECH program is predicated on financial incentives for the meaningful use (MU, emm-you) of health information technology. It is administered by the Office of the National Coordinator for Health Information Technology, often called ONC [oh-enn-see].The idea behind meaningful use is that it does not just put computers in physician offices and hospitals but instead requires that health information technology be used in clinically meaningful ways. The notion of this was first proposed in legislation by Congressman Rodney Pete Stark, who is known for other contributions to health care legislation. The required criteria for technology under meaningful use must map back to one or more of five goals for the health care system. These five goals are:Improving quality, safety, and efficiency of care,Engaging patients in their care,Increasing coordination of care,Improving the health status of the population, and,Ensuring privacy and security.Meaningful-use criteria will be detailed later in this lecture, but for now, two examples will illustrate how criteria map back to the meaningful use goals. One of the criteria is implementing checks for drug-drug interactions in the EHR; that is, seeing whether prescribed drugs have any serious clinical interactions that could harm patients. This pertains to the goal of improving quality, safety, and efficiency. Quality is improved because clinicians may prevent the administration of a drug that causes adverse effects or some sort of interaction.A second example is providing a summary of care to patients. This activity pertains to the goal of engaging patients in their care.

*This slide spells out the overall requirements for meaningful use from the HITECH legislation. There are essentially three requirements. The first is that those eligible for incentives must use certified EHR technology in a meaningful manner (that is, meaningful use). Furthermore, this certified EHR technology must be connected in a manner that allows the exchange of health information about the patient across different care settings. Finally, the health care provider or organization must use this certified EHR technology to submit information on clinical quality indices that allow measurement and ultimately improvement in the quality of care.

*The HITECH program will implement meaningful use in three stages. Each stage aims for higher functionality and improvement of care as part of an effort originally called health information technology-enabled health reform. The program began in 2009 when the HITECH policies were developed. The Stage 1 rules were finalized in 2011 and focused on capturing and sharing data. Stage 2 rules were announced in 2012 and are slated to begin in 2014 - these will support advance care processes with decision support. And finally, Stage 3, proposed for 2015, will focus on improved health outcomes.

*For eligible professionals and eligible hospitals to meet the meaningful use criteria, they must use an EHR that is qualified, or certified, by an entity approved by the ONC. A qualified EHR, then, is an electronic record of health-related information on an individual that includes patient demographic and clinical health information, such as medical history and a problem list. It must also have the capacity to provide clinical decision support, support physician and provider order entry, capture and query information relevant to health care quality, exchange electronic health information with other sources, and integrate such information. EHR certification will be discussed in greater detail later in this lecture.*How is the meaningful use program implemented? How are the incentives paid to healthcare providers? Basically, healthcare providers who achieve meaningful use will receive the incentive funding through increased reimbursement from Medicare or Medicaid, the government-funded health care payment systems in the US. There are two categories of providers who are eligible - eligible professionals, or EPs (ee-peez) and eligible hospitals, or EHs (ee-ayches). Eligible professionals are individual healthcare providers who provide health care under Medicare or Medicaid and practice in the states and territories of the US. Physicians, osteopaths, and dentists will qualify under both. Podiatrists, optometrists, and chiropractors will be eligible under Medicare. Those eligible under Medicaid include certified nurse-midwives, nurse practitioners, and physician assistants who work at certain types of health centers (federally qualified health centers). Of note, physicians who spend more than 90% of their time in hospitals, such as pathologists and emergency physicians, are not eligible under the EP program they are considered a part of the hospital where they work. Eligible hospitals under Medicare and Medicaid include acute-care hospitals and critical-access (poor or rural area) hospitals. Children's hospitals are eligible under Medicaid. Eligible hospitals need to be located in the 50 states of the US or the District of Columbia. The coming slides will show that there are differences in procedure depending on whether one is an eligible professional or eligible hospital and whether one obtains incentive funding under Medicare or Medicaid.

*This slide shows the payment schedule for Medicare eligible professionals. There are two axes, one is the first year that an incentive payment is received while the second is the calendar year in which payment starts. As you can see the later an eligible professional starts to implement meaningful use, the lower the amount of money he or she receives. Eligible professionals who achieve meaningful use under the Medicare rules will receive $44,000. The amount of money depends on which year meaningful use has been achieved. To receive the maximum amount of money, the eligible professional must start either in 2011 or 2012. If meaningful use is not achieved until later, such as 2013 or 2014, the reimbursement amount decreases, and if it is not achieved until 2015 or later, no funds are received.*Medicare-eligible professionals who work in health-professional shortage areas can receive an additional 10% payment ($4,400) if they achieve meaningful use. Therefore, eligible professionals can receive up to a total of $48,400 over the life of the program.

*Eligible professionals receiving incentive payments under Medicaid are eligible for even more money. They can receive $21,250 in the first year they achieve meaningful use, and then further amounts for up to an additional five years if they maintain meaningful use. They can qualify for a total of $63,750. These professionals can receive the funding in the first year without achieving all the criteria of meaningful use, as long as they implement or upgrade to a qualified EHR.

*Payment for eligible hospitals is somewhat complex. The amount depends on whether meaningful use is achieved through Medicare or Medicaid. It also depends on the hospital type and on the share of patients who receive care through Medicare or Medicaid. There has also been a debate about hospitals that have multiple campuses. The Centers for Medicare & Medicaid Services (CMS) has determined that multi-campus hospitals count as one eligible hospital, although legislation may change this in the future.The general formula for payment is a multiplication of three factors. The initial amount is a base of $2 million and then $200 per discharge, starting at the 1,150th discharge up to the 23,000th discharge. This means that the hospital can receive $200 per discharge for a maximum of 21,850 patients, for a total of $6.37 million. There is also a factor that accounts for the share of Medicare and Medicaid patients, and a transition factor that pays the full amount the first year, three quarters the second year, half the third-year, and one quarter the fourth year. Depending on when a hospital becomes eligible, most hospitals end up in the range of $4 to $9 million under this program, but again it depends on a number of factors that are listed on this slide.*The final rules for Stage 1 of meaningful use were published in the Federal Register on July 28, 2010. There are two sets of rules. One comes from CMS, and describes the program that provides incentives for EHR adoption, to be paid for by increased Medicare and Medicaid reimbursement. The other comes from the ONC and provides the initial set of standards, implementation specifications, and certification criteria for EHR technology. The official CMS website for the incentive programs is listed on this slide it includes instructions and forms that enable an eligible professional or eligible hospital to sign up. More information on EHR certification is available on the ONC website.

*The two sets of rules -- from CMS and ONC -- are connected in a straightforward manner. HITECH ties the standards, implementation specifications, and certification criteria adopted in the ONC rules to the incentives that are then covered in the CMS rule. The ONC rule focuses more on informatics by specifying standards in four areas: vocabulary, content exchange, transporting of information, and privacy and security. These will be described in more detail in the next lecture.*Recall that in order to meet meaningful use, an eligible professional or eligible hospital must use a certified EHR. EHR certification is required of all inpatient and outpatient systems, whether they are vendor-supplied or self-developed systems. The certification process can certify complete EHR systems or EHR modules that meet at least one criterion for meaningful use.Prior to 2012, EHR certification was funded by the government but run by the private, nonprofit Certification Commission for Health Information Technology (CCHIT; see-see-aych-eye-tee). The original CCHIT process focused on functionality and usability, whereas the new certification process essentially focuses on the ability of systems to meet the meaningful use criteria.This slide outlines the current EHR certification process. Vendors create EHR products that are tested and certified by authorized testing and certification bodies, also known as ATCBs (ay-tee-see-bees) designated by the ONC. These bodies use tools and techniques developed by the National Institute for Standards and Technologies, or NIST (nisst). ONC maintains a list of certified EHR products called the Certified Health IT Product List, or CHPL (see-pee-aych-ell), now available at http://oncchpl.force.com/ehrcert, that eligible professionals and eligible hospitals can use to identify systems and system modules that are certified for use in meeting the meaningful use objectives and measures.Once the meaningful use criteria are met using a certified EHR, the eligible professional or hospital can then attest that they have met the requirements and receive incentive payments from CMS. More details on the certification process can be found at the website listed on this slide.

*This slide further details the testing process for certification. In essence, there are two steps. First, there is the testing process to determine whether the EHR systems are able to pass the tests that demonstrate meaningful use. Then there is accreditation, where there are certifying bodies that certify the product has gone through the testing process. There is a firewall between the testing entities and the certifying entities, even though they can be the same company. The website listed on this slide describes the testing procedures in great detail.

*How do eligible professionals and eligible hospitals receive this money? The process is simple: they need to meet the meaningful use criteria and then report that they have met them. In 2011, eligible professionals and hospitals were required to achieve meaningful use for a period of 90 consecutive days. After 2011, meaningful use has to be achieved throughout the year. Initially, reporting was attestation only, mainly because CMS did not yet have systems in place to receive the information. Going forward, eligible professionals and hospitals will have to report numbers on their measures of the various criteria for meaningful use, and in subsequent years, they will be required to provide all the data for these calculations to CMS.There are some important exceptions in the funding for Medicaid. One is that in the first year, Medicaid-eligible professionals and hospitals do not need to achieve complete meaningful use. They only need to demonstrate that they have adopted, implemented, or upgraded a certified EHR. Those receiving funding under Medicaid (but not Medicare) can also skip years; for example, if they do not meet the criteria in the second or third year, they can receive funding in the next year that they achieve meaningful use. The details of the payment programs are on the CMS website listed on this slide.

*One may well wonder how much all of this is going to cost. Remember that this program is part of the economic stimulus package, designed in part to aid the economic recovery and to support the notion of health information technology-driven health care reform. The amount of money that the program will cost will depend on how many eligible professionals and eligible hospitals can meet the meaningful use criteria. CMS prepared some estimates of costs based on low adoption versus high adoption. In the United States there are 477,500 eligible professionals who would qualify under Medicare if they meet meaningful use. About a fifth of these, or 95,500, would also be eligible under Medicaid if they chose to receive the incentive funding through that pathway. There are another 44,100 professionals who would be eligible under Medicaid only. In terms of hospitals, it is estimated that 5,011 are eligible in the US. Of these, 3,620 are acute-care hospitals and 1,302 are critical-access hospitals, which provide care in predominantly rural and other underserved areas. There are also 78 children's hospitals and 11 cancer hospitals. To calculate the amount of money involved, CMS has made two estimates of achievement of meaningful use over ten years, a low estimate and a high estimate. The low estimate assumes that 95.6 percent of eligible hospitals and 36 percent of eligible professionals will achieve meaningful use over ten years; the high estimate states that 100 percent of eligible hospitals and 70 percent of eligible professionals will do so. If the low figure is achieved, the cost of the program will be $9.7 billion, and if the high figure is achieved, it will be $27.4 billion. The latter is the relevant number when people say that up to $27 billion will be available through the HITECH program for meaningful use of the EHR.

*This concludes Lecture (a) of Meaningful Use of Health Information Technology. In summary, the HITECH Act of ARRA legislated incentives for the meaningful use of health information technology. Meaningful use means that criteria for the use of information technology are tied back to the goals of the health care system. These criteria are met by eligible professionals and eligible hospitals to receive incentive payments for the use of EHRs in three stages.*References slide. No audio.

*References slide. No audio.*

01-10a - introduction to healthcare and public health in the us - unit 10 - meaningful use of health...

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