12TH ANNUAL SUMMER INSTITUTETUESDAY, JULY 19, 2011 12:30 P.M.
HILTON SEDONA RESORT - SEDONA, AZ
Patricia MacTaggart
CHANGING YOUR WORLDHEALTH INFORMATION
TECHNOLOGY
What ?
•Transformation of Health,
Care & You
Why?
•Better Health, Better
Care, Lower Costs thru
• Care & Connection
(Health IT),
• Communication
(Standardization)
• Quality (Effective
& Efficient Use)
CHANGING YOUR WORLD
HEALTH IT
WHY NOW – WHY CARE???
• Health Care Issues /
Medical Errors
• Health IT Options
WHERE TO START?State/Federal Government Role Baseline
• Medicaid as of 1/11: 15 States initiated Medicaid EHR Incentive Programs & paid $83 M incentive payments
• Medicare as of 5/19/11: first round of $75 M to providers who signed up in first two weeks
AL
AK
AZAR
CA
CO
CT
MD
FL
GA
HA
ID
IL IN
IA
KS KY
LA
ME
0
NH
MI
MN
MS
MO
MT
NE
NV
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VR
VA
WA
WV
WI
WY
DE
MA
SOURCE: CMS EHR Incentive Program : Commonwealth
What’s the Consumer Baseline?
What’s the Provider Baseline? US 2001-09 and Preliminary 2010: Commonwealth
Notes: An EMR/EHR is a medical or health record system that is either all or partially electronic, excluding systems solely for billing. The 2010 data are preliminary estimates, based only on the National Ambulatory Medical Care Survey. Estimates through 2009 include additional physicians sampled from community health centers. Estimates of basic and fully functional systems prior to 2006 were not collected in the survey. Fully functional systems are a subset of basic systems; a change in survey instruments and definitions of fully functional systems between 2009 and 2010 may have contributed to some of the increase in fully functional systems during that year. Includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists.SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey, and Hsiao et al., 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf
HOW IS HEALTH CARE DELIVERY TRANSFORMING?Focus on Where “Going” – Not Where “From”
• Accountable Care Plans:– Start 1/1/12 for 3 Yrs. & Voluntary for Patient/Providers– Coordinate Treatment across Continuum of
Care(Physicians, Hospitals, SNFs, LTC Hospitals, Other Providers & Supplier)
• Integration:– Physical and Behavioral Health– Integration Public-Private: Premium Based Subsidies– Integration Medicare-Medicaid: Standardized Assessment,
Extensive Data Analysis & Sharing, Financial Incentives for Quality
Triple Aim: Better Care, Better Health, Lower Costs 7
WHAT ARE NEW REIMBURSEMENT TRANSFORMATION OPPORTUNITIES?
• Bundling Payment Episode of Care Pilot
Medicare & Medicaid Program
• Medicaid Safety Net Global Payment Demo
• 1% FMAP increase for states that eliminate cost-sharing for preventive services (Sec. 4106, starts 2013)
WHAT ARE STATES DOING TO SUPPORT MEDICAID/MEDICARE PROVIDER TRANSFORMATION
THRU MU?
• entralized Provider Registry/Directory:
– Access: through a secure web-interface
– Authentication: individual and entity identity management
– Specific Levels of Security: authentication and access controls and necessary firewalls
ecure Messaging:
– Technical Functionality of a Secure Web Service using direct messaging or email attachments using national standards
– Role Based: access and management, message and data validation, privacy and security (encryption and signed data user agreement-DURSA), monitoring and auditing
HOW IS HEALTH CARE ADMINISTRATION TRANSFORMATING?
• Patient Centric: Consumer Engagement & Education
• Administrative Simplification:– No More Paper– e-Signature
• Standardization: – Public/Private– Across State Agencies
– State to National
10
11
EHR (Electronic Health Record) &EMR (Electronic Medical Record)
HIE (Health Information Exchange) & HIE (Health Insurance Exchange)
Health IT (EHRs, HIEs, Registries, Tele-health)
m-Health (Mobile-IPAD, IPhone,)
TRANSFORMATION OF YOU?
-everything
-EVERYTHING ≠ INTEROPERABILITY
HIT:
• Non-electronic Level of Interoperability: Paper
• Machine-transportable data : Fax/e-mail
• Machine-organizable data: Structured messages & unstructured content (pdf)
• Machine-interpretable data: Structured messages & standardized content
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Health IT
WHAT IS THE INFRASTRUCTURE REQUIRED TO GET US TO WHERE WE NEED TO GO?
14
IF HEALTH IT USED IN A MEANINGFUL USEGets Us Where We Need to Go
Better Health, Better Care, Lower CostsTO SUPPORT BETTER HEALTH, BETTER CARE,
LOWER COSTS?
15
ResearchInstitute
Beacon Community
IntegratedDelivery System
Community Practice
Health Information Exchange
Health CenterNetwork
FederalAgencies
State Public Health
Aggregation
Analysis
Dissemination
State Agencies
Adapted from ONC
Diagram
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CARE & CONNECTIONNationwide Exchange of Health IT
Policy & Legal
Governance
Technical
Technical & Business Operations
WHO IS ESTABLISHING THE STANDARDIZED “RULES OF THE ROAD”?
• ONC = lead for standards and certification of EHR
• CMS = lead for Medicaid/Medicare Incentive Program
• Incentives to Standardize: Meaningful Use: – EMR = $0
– Certified EHR = Maximum of $63,500 (Medicaid) & $43,000 (Medicare)
STRATEGIES TO GET STANDARDIZATION THRU AIU & MEANINGFUL USE
Follow the Money
• State Activities for 2011-2012: State Strategic/Operational Plans, State Medicaid HIT Plans & State HIT to Support MU
• Provider Activities for 2011-2012:
– Medicaid: Adopt, Implement, Upgrade of certified EHRs (AIU)
– Medicare: Meaningful Use for EPs & EHs (Medicaid Optional)
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MEANINGFUL USE STAGE ONE EP Core Measures (15)
Medications
• CPOE *
• Drug Interaction Checks *
• e-Prescribing
• Active Medication List *
• Medication Allergy List
Management of Care
•Maintain Problem List *•Record Vital Signs *•Record Smoking Status *•Record Demographics *•Clinical Decision Support *•E-Exchange of Clinical *
Quality Measures * Patient Centric Engagement
•Electronic Copy of Health Information *•Clinical Summaries *•Protect Electronic Health Information *
EH Core Measures (14)
MU STAGE 1 QUALITY MEASUREMENT
Core – Alternative
EP• 3 Core Clinical:
– Hypertension– Smoking
Assessment/Intervention– Adult Weight
Screening/Follow Up
• 3 Alternative Clinical:– Children Weight Assessment &
Counseling **– Child Immunization Status **– 50+ Influenza Immunization
• 3 Additional Clinical:– Select from 38 Options
** Overlap CHIPRA National
4 Total
EH - 15• VTE Prophylaxis within 24 hrs• Intensive Care Unit VTE prophylaxis• VTE discharge instructions• Incidence of potentially preventable VTE • Anticoagulation overlap therapy• Platelet therapy on unfractionated heparin • Thrombolytic therapy for patients arriving
within 2 hours of symptom onset• Ischemic stroke: Discharge on Anti‐thrombotics• Ischemic stroke: Anticoagulation for Arterial
Fibrillation/flutter• Ischemic or hemorrhagic stroke: Antithrombotic
Therapy by day 2• Ischemic stroke: Discharged on Statin
Medication• Ischemic or hemorrhagic stroke: Stroke
Education• Ischemic or hemorrhagic stroke: Rehabilitation
Assessment • Admission decision time to ED departure for
admitted patients• Median time from ED arrival to ED departure
for admitted patients
MEANINGFUL USE EP Menu Measures (5 of 10)
Medications•Drug Formulary Checks *•Medication Reconciliation *
Management of Care•Clinical Lab Test Results *•Patient Lists *•Transition of Care Summary *
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Patient Centric Engagement
•Patient Reminders•Patient Electronic Access•Patient-specific Education Resources *
Public Health
•Immunization Registries Data Submission *•Syndromic Surveillance Data Submission *
EH: 5 of 10, including Advanced Directives & Lab ResultsEHs/EPs: 1 must be from PH
STRATEGIES TO GET STANDARDIZATION OF MEDICAID ELIGIBILITY SYSTEMS
Single Doorway = Computer Screen
• Design, development, installation or enhancement (DDI) of a state eligibility determination and redetermination and/or enrollment system• 90% federal-10% state for DDI up to 2015 • 75% federal-25% state for ongoing operation
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STRATEGIES TO STANDARDIZE COVERAGEAccountable Care Act Health Insurance Exchanges
•Single Integrate Pathway •Easy for Individuals to Explore Health Coverage Options•Individuals can Quickly and Accurately Enroll into Coverage
•Common systems and High Levels of Integration: No “Gap” in Coverage
•100% FFP for IT Infrastructure
Medicaid138% FPL
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Basic Health Plan139% to 200%
Tax Subsidy138% to
400%
OPTIONS/REQUIREMENTS FOR IT COST ALLOCATION Exchanges- Medicaid- CHIP – State Programs
• Health Care Coverage Portal: direct input and interface from other systems for single, streamlined application.
• Business Rules Management/Operations System: eligibility system functionality/processing logic for individuals covered by MAGI
• Interfaces: federal data services hub & other verification sources
• Account Creation and Case Notes: e-case file
• Notices & Customer Service Technology Support: assist applicants, including interfaces to community assisters or other outreach organizations.
Get the Data Once – Use it Multiple Times
ONC’S KEY STRATEGIES TO GET/KEEP CONSUMERS ENGAGED
Consumer Ecosystem
• Access:
– Freeing Data
– Infrastructure Building
– Data Sharing Incentives
• Action
– Tools to take Action
– Ensuring Vulnerable Groups are not left out)
• Attitude
– Individuals Engage
– Providers Partner with Patients
– Beacon Communities/states
WHAT ARE THE COMPETING IT DEMANDS WHILE BUILDING THE DIGITAL HIGHWAY?
• 4010 TO 5010: Updating the Book (1/1/12)
• ICD-9 to ICD-10:
Whole New Book
(10/1/13)
• Privacy & Security
Requirements: “Breaches”
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WHAT ARE THE COMPETING IMPLEMENTATION DEMANDS ON PROVIDERS & STATES?
New Requirements on States & Providers•Administrative Simplification & Program Integrity Provisions•Interfaces with HIEs (Information & Insurance)
Medicaid/Medicare Changes• Provider Rates-Incentives-Penalties• Payment Methodologies•Service Delivery Innovations
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Increased Volume • Transactions• Providers
New Aged & Disabled Consumer Benefits & State Opportunities
•Dependent Adults up to 26 on Parent’s Plans even Married (2011)•No Pre-existing Condition Exclusions for Children (2011)• Prohibitions against Lifetime Benefit Caps & Rescissions (2011)•Preventive Care Coverage & No Cost-Sharing Medicare (2011)
QUALITY HEALTH AND HEALTH CAREHow Do We Know We Aren’t Stalled?
Data on Performance:
• CHIPRA Quality Measures for Children
• MU Measures
• ACA Quality Measures for Adults
• HCBS Measures for Waivers
• PQRI Measures
• MCOs: External Reviews & Quality Improvement
• ACO Measurement
WHAT ARE THE NEXT STEPS FOR QUALITY? Critical for Community Integration
Transition of Care Summary Vocabulary of Transition of Care
• “Scope”
• Time Line
• Performance Standards
QUALITY & PATIENT SAFETY THRU PUBLIC- PRIVATE Partnerships for Patient
•Patient Safety: CMS Center for Innovations $500 million to organizations to safely transition patients between settings of care.
•Preventable Hospital-Acquired Conditions: By 2013 Decrease by 40% Compared to 2010.
•Preventable Complications during a Transition from 1 Care Setting to Another: By the end of 2013, all hospital readmissions would be reduced by 20-percent compared to 2010.
•Portion of Hospital Medicare Payments linked to delivering safer care, using information technology effectively and meeting patient needs by 2015. (Also Medicaid Payment Incentives/Supports )
Berwick: “Against Cutting – For Improving Care To Save Money” 29
Transform HC thru Rapid Learning & Technological
Advancement
Empower Individuals with HIT to Improve Care
and HC System
Inspire Confidence & Trust in HIT
Better Care, Better Health, Lower Costs through HIT
Achieve Adoption & Information
Exchange through
Meaningful Use of HIT
HHS STRATEGICPLAN 2010-2015
KNOCKING ON THE DOOR TO GET INHIT for Behavioral Health
• Behavioral Health Information Technology Act of 2011 (S 539) – Sen. Sheldon Whitehouse (D-R.I.) to expand Medicare &
Medicaid Meaningful Use Incentive Payment Eligibility to Behavioral Health, Mental Health and Substance Misuse Treatment Professionals and Facilities.
– Eligible Providers would include Licensed Psychologists and Clinical Social Workers & Eligible Hospitals would include Psychiatric Hospitals
• Medicare Proposed Community MH Center Reg– emphasizing the need for communication regarding client
needs at the time of discharge or transfer
– evaluating outcome and client satisfaction data
“Traction” Hard to get in Environment of “Cuts” 31
LAST BUT NOT LEASTInitial Question: Is it worth it? Real Question: Is the
destination worth the journey? Can we afford not to do it?
Benefits• Improved Information
Availability (value of information)
• Clinical Benefits
• Financial B e.g., greater efficiency, lower administrative costs, better coding
Costs
• Investment Costs
– Equipment
– Personnel/productivity
– Training
• Maintenance Costs
– IT support staff
– Future upgrades
– Continued training
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NEED MORE INFORMATION?
* AHIMA * HIMSS
* NAMD * NCIO
* NASHP
* NeHC
* CMS * ONC
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