Meaningful Use Stage Two: The Future of Care Coordination
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Transcript of Meaningful Use Stage Two: The Future of Care Coordination
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Meaningful Use Stage 2 – The Future of Care CoordinationAdele AllisonNational Director of Government Affairs, SuccessEHS
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New Focus – Care Coordination
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• Big Tactic Step in next wave of health care reformoAccountable Care Organizations
(ACOs)oPatient-Centered Medical Homes
(PCMHs)• PPACA → CMS Medicare FFS:
Establish ACOs by 1.1.2012
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• ACO Final Rule (Issued 10.20.2011, 696 pages)oNew Care Model for FFS Medicare
– anticipating 270 to contractoFocus on Care Coordination as a
CommunityoMust be Patient-Centered
(definition follows)
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• Patient-Centered is defined to include: Patient Survey, Communication
and Involvement in governance Population Management Targeting high-risk patients Technologies to Coordinate Care Performance Measuring and
Ongoing Process Improvements
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• PPACA → §3007 - CMS apply a MD value-based modifier by 2015 • CMS Payment Final Rule (Issued
11.2.2011, 1,235 pages)o2012 EHR-Based PQRS Reporting –
includes all 44 Stage 1 MU CQMsoParticipation in the PQRS EHR-based
Incentive Pilot satisfies MU CQM reporting and provides incentives above MU
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• SuccessEHS is 2011 CMS Qualified for EHR-based PQRS reporting• SuccessEHS is testing for
2012
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Key Stage 2 Recommendations
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• > 60% structured lab results with at least 1 order in CPOE• 1 Radiology Test Ordered using CPOE• > 10% of patients – record care plan
fields (goals and instructions)• > 10% of patients - record care team
members (including PCP, if applicable)
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• > 25 unique patients with advance directives• 25 patients sent secure online
messages• 20% of patients recorded for
preferences in communication• Summary of Care Record sent
electronically for 25 Transactions
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Clinical Quality Measures & National Quality Strategy
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•No “alternative core” measures → just Core• Selection from 69 NQF Measures – eReporting Ready• 23 new clinical measures proposed – ↑ provider diversity
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• Menu measures divided into 6 domains to align with the 6 National Quality Strategieso Population and Public Health
Managemento Care Coordinationo Clinical Processo Patient and Family Engagemento Efficiency o Patient Safety
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Practice Redesign Considerations
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Clinic Culture Assessment• Think about Users and Roles• Create a Vision Statement• Identify Leadership (Formal /
Informal)• Communicate Plans
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Workflow Self-Assessment• Identify sources of:–Assessment Worksheet–Inefficiency / Delay / Duplication–Risk / Liability / Non-Compliance
(e.g. HIPAA)–Quality concerns–High costs
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Leadership in Administration• Remember – this is a Provider
Program• Remember – the Providers are
part of a Clinic / Group Practice• Plan for Administration Ease–Consistency in measures–Evaluate Technology and Workflows
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Provider Assessment• Identify potential barriers before
reengineering⁻ Low comfort level with technology (Provider /
Support Staff)⁻ Gaps in Hardware ⁻ Impact on productivity⁻ What additional problems can be solved?
• Workflows MUST BE CONSISTENT for data capture and reporting
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Practice Redesign• Compliant and Certified for
MU EHR Software• Senior Leadership and Staff –
Awareness and Understanding• Identified Champions – Formal
and Informal
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Practice Redesign• Key Partner Collaboration– Lab Interfaces : (ORM/ORU)
Results to Patient Chart– Immunization Interface : (VXU)
Single entry / upload to Registry– HIE Interface : (CDA, C32, XDS)
Human Readable Format
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Practice Redesign• HIPAA Security Analysis• Implementing New Technologies−Patient Portal, CDS, Formulary
Management, HIE, Structured Knowledge Base, etc.−IT Needs such as iPads, Smartphones,
Business Continuity Plans
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Practice Redesign• Data Collection Considerations• Must be consistent• Like CDS - Identifying the “5 Rights” in
Workflow• Right Information• Right Person Collecting• Right Format• Right Channel (e.g. EHR, Portal, PM)• Right Time in Workflow
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Practice Redesign• Consider Data Needs – E.g., Vitals,
Smoking Status, Rx Reconciliation, Refills, Health Disparities
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Technology Partner – Critical Importance
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SuccessEHS & HIE• SuccessEHS can produce a C32
message (CDA/CCD)• SuccessEHS has developed an
Interoperability engine to automate support of interoperability
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SuccessEHS & HIE• This transport engine can be
leveraged to provide data to:o State Registrieso Lab results to public health agenciesoQuality Reporting to CMS and other
collaboratives
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SuccessEHS & HIE• SuccessEHS will leverage this
transport/support engine for a variety of CCDs used in transitions of care
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SuccessEHS & ACOs• SuccessEHS is strongly positioned
to integrate PCP into the ACO model
• EHR-based PQRS
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SuccessEHS & ACOs• Health IT Tools SuccessEHS can deliver:
• Prospective / Retrospective Payment System• Utilization Trending and Reporting• Evidence-based Clinical Decision Support
Tools• Patient Survey Tools• Tele-health Tools
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SuccessEHS & ACOs• Health IT Tools SuccessEHS can deliver:
• Population Management Technology• Digital Dashboard• Health Information Exchange• Lab, Radiology and Device Interfacing• Enterprise Business Intelligence
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SuccessEHS & PCMH• SuccessEHS is working with the ONC CCBC
to recertify 13 of its CHCs for PCMH• SuccessEHS has created a PCMH
Development Branch that includes:• Secured Messaging to the Patient through
Patient Portal• Patient Questionnaires available through
Portal or Kiosk• Robust Order Tracking
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SuccessEHS & PCMH• SuccessEHS has created a PCMH
Development Branch that includes:• Pre-defined, evidence-based clinical decision
support rules• Leveraging MEDCIN for use in Care Plan
workflows• Ability for patients to request test results /
consults through Portal• PCMH-specific reporting
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SuccessEHS & PCMH• SuccessEHS has created a PCMH
Development Branch that includes:• PCMH data capture and reporting for referral
management and transitions of care
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