HITECH EHR

8/14/2019 HITECH EHR

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Implementing the American

Reinvestment & Recovery Act of 2009

Office of E-Health Standards and ServicesCenters for Medicare & Medicaid Services


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HITECH Legislation: Purpose

Improve outcomes, facilitate access, simplify care and

reduce costs by providing:

Majorfinancial supportto providers and States

Learning opportunities created and leveraged through TA

from CMS and others

Far-reachingframeworks are being established that will

orchestrate federal, State and local, public and privatehealth care resources for generations to come

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American Reinvestment & Recovery Act(Recovery Act) February 2009

Electronic Health Record (EHR) IncentiveNotice of Proposed Rulemaking (NPRM) onDisplay 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 IncentiveProgram

Medicare Advantage (MA) EHR Incentive Program

Medicaid EHR Incentive Program

Collection of Information Analysis (PaperworkReduction 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, andCertification Criteria for EHR Technology

EHR certification requirements ONC NPRM - Establishment of Certification

Programs for Health Information Technology Procedures to become a certifying body

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Harmonizes MU criteria across CMS programsas much as possible

Closely links with the ONC certification andstandards IFR

Builds on the recommendations of the HITPolicy Committee and external stakeholders

Coordinates with the existing CMS quality

initiatives Provides a platform that allows for a staged

implementation over time

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Medicare FFS Eligible professionals (EPs)

Eligible hospitals and critical access hospitals(CAHs)

Medicare Advantage (MA) MA EPs

MA-affiliated eligible hospital

Medicaid EPs

Eligible hospitals

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Eligible Providers in MedicareEligible Professionals (EPs)Doctor of Medicine or Osteopathy

Doctor of Dental Surgery or Dental Medicine

Doctor of Podiatric MedicineDoctor of Optometry

Chiropractor

Eligible Hospitals*Acute Care HospitalsCritical Access Hospitals (CAHs)

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*Subsection (d) hospitals that are paid under the PPS and are located in the 50 Statesor DC (including Maryland hospitals)


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Eligible Providers in Medicare Advantage (MA)MA Eligible Professionals (EPs)

Must furnish, on average, at least 20 hours/week of patient-careservices and be employed by the qualifying MA organization

-or-

Must be employed by, or be a partner of, an entity that throughcontract with the qualifying MA organization furnishes at least 80percent of the entitys Medicare patient care services to enrolleesof the qualifying MA organization

Qualifying MA-Affiliated Eligible HospitalsWill be paid under the Medicare Fee-for-service EHR incentiveprogram

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Eligible Providers in MedicaidEligible Professionals (EPs)

Physicians (Pediatricians have special eligibility &payment rules)

Nurse Practitioners (NPs)

Certified Nurse-Midwives (CNMs)

Dentists

Physician Assistants (PAs) who lead a FederallyQualified Health Center (FQHC) or rural health clinic(RHC) that is directed by a PA

Eligible HospitalsAcute Care Hospitals

Childrens Hospitals


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Hospital-based EPs do not qualify forMedicare EHR incentive payments

Most hospital-based EPs will not qualify forMedicaid EHR incentive payments

Defined as an EP who furnishes 90% or moreof their services in a hospital setting(inpatient, outpatient, or emergency room)

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Entity Minimum Medicaidpatient volumethresholdOr the Medicaid EP

practicespredominantly in anFQHC or RHC30%

needy individualpatient volumethreshold

Physicians 30%

- Pediatricians 20%

Dentists 30%

CNMs 30%

PAs when practicingat an FQHC/RHC thatis so led by a PA

30%

NPs 30%

Acute care hospitals 10% Not an option forhospitalsChildrens hospitals No requirement

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The Recovery Act specifies the following 3components of Meaningful Use:1. Use of certified EHR in a meaningful manner (ex:

e-prescribing)

2. Use of certified EHR technology for electronicexchange of health information to improve qualityof health care

3. Use of certified EHR technology to submit clinical

quality and other measures

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Definitiono To be determined by Secretary

o Must include quality reporting, electronicprescribing, information exchange

Process of definingo NCVHS hearings

o HIT Policy Committee (HITPC) recommendations

o Listening Sessions with providers/organizations

o Public comments on HITPC recommendationso Comments received from the Department and the

Office of Management and Budget (OMB)

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Datacapture and

sharing

Advanced

clinical

processes

Improved

outcomes

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Meaningful Use will be defined in 3 stagesthrough 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, andreducing health disparities

Engage patients and families in their healthcare

Improve care coordination

Improve population and public health

Ensure adequate privacy and security

protections for personal health information

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*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Effortsto Transform Americas Healthcare. Washington, DC: National Quality Forum; 2008.


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EPs 25 Objectives and Measures

8 Measures require Yes or No as structured data

17 Measures require numerator and denominator

Eligible Hospitals and CAHs 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; oneyear subsequently

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1. Use CPOE2. Implement drug-drug, drug-allergy, drug-

formulary checks3.

Maintain an up-to-date problem list ofcurrent and active diagnoses based on ICD-9-CM or SNOMED CT

4. Maintain active medication list5. Maintain active medication allergy list6. Record demographics7. Record and chart changes in vital signs

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8. Record smoking status for patients 13 years and older

9. Incorporate clinical lab-test results into EHR as structureddata

10. Generate lists of patients by specific conditions to use forquality improvement, reduction of disparities, and outreach

11. Report ambulatory quality measures to CMS or the States12. Implement 5 clinical decision support rules relevant to

specialty or high clinical priority, including diagnostic testordering, along with the ability to track compliance withthose rules

13. Check insurance eligibility electronically from public andprivate payers

14. Submit claims electronically to public and private payers

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15. Provide patients with an electronic copy of their health informationupon request

16. Capability to electronically exchange key clinical information amongproviders of care and patient-authorized entities

17. Perform medication reconciliation at relevant encounters and each

transition of care18. Provide summary care record for each transition of care and referral

19. Capability to submit electronic data to immunization registries andactual submission where required and accepted

20. Capability to provide electronic syndromic surveillance data to publichealth agencies and actual transmission according to applicable law

and practice21. Protect electronic health information created or maintained by the

certified EHR technology through the implementation of appropriatetechnical capabilities

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1. Generate and transmit permissibleprescriptions electronically

2. Send reminders to patients per patientpreference for preventive/follow-up care

3. Provide patients with timely electronic accessto their health information within 96 hoursof information being available to the EP

4. Provide clinical summaries for patients foreach office visit

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1. Provide patients with an electronic copy oftheir discharge instructions and procedures

at time of discharge, upon request2. Capability to provide electronic submission

of reportable lab results, as required by stateor local law, to public health agencies and

actual submission where it can be received.

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2011 Providers required to submit summaryquality measure data to CMS or States byattestation

2012 Providers required to electronically

submit summary quality measure data to CMS orStates

EPs are required to submit clinical data on the 2measure groups: core measures and a subset ofclinical measures most appropriate to the EPs

specialty Eligible hospitals are required to report summary

quality measures for applicable cases

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Preventive care and screening: Inquiryregarding tobacco use

Blood pressure management

Drugs to be avoided by the elderly:o Patients who receive at least one drug to be avoided

o Patients who receive at least two different drugs tobe avoided

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EPs will need to select one of the following specialtiesCardiology Obstetrics and Gynecology

Pulmonology Neurology

Endocrinology Psychiatry

Oncology Ophthalmology

Proceduralist/Surgery Podiatry

Primary Care Radiology

Pediatrics Gastroenterology

Nephrology

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Hospitals are required to report summarydata to CMS or States on 35 clinical qualitymeasures

For the Medicaid program incentive, hospitals

have the option to select 8 alternativeMedicaid clinical quality measures to meetthe requirements for reporting if the 35measures do not apply to their patient

population Hospitals only eligible for Medicaid will report

directly to the States

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Adopt, implement, upgrade (AIU) First participation year only

Meaningful use (MU) 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 theNPRM NPRM is the MU base-level requirement

Prioritizing coordination between: CHIPRA and HITECH

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Adopt: Acquired and installed

- e.g., evidence of acquisition, installation etc.

Implement: Commenced utilization

- e.g., staff training, data entry of patientdemographic information into EHR, data useagreements

Upgrade: Version 2.0; expanded functionality

- e.g., ONC EHR certification (short-term) oradditional functionality such as clinical support orHIE capacity (longer-term)

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Eligible hospitals, unlike EPs, may receiveincentives from Medicare and Medicaid Subsection(d) hospitals, also acute care

Hospitals meeting Medicare MU requirementsmay be deemed for Medicaid , even if theState has an expanded (approved) definitionof meaningful use

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There is a deliberate overlap between theCHIPRA core measures and the Stage 1measures for MU. BMI 2-18 yrs old

Annual hemoglobin A1C testing (all children andadolescents diagnosed with diabetes)

Pharyngitis - appropriate testing 2-18 yrs old

Follow-up care for children prescribed attention-

deficit/hyperactivity disorder (ADHD) medication

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The Medicaid EHR Incentive Program starts in2011 and ends in 2021

The latest that a Medicaid provider caninitiate the program is 2016

A Medicaid provider can initiate the programunder the Adopt, Implement and Upgrade barbut in their 2nd and subsequent years, theymust meet MU at the stage that is in place,per rule-making (Stage 3 by 2015).


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EPs Medicare FFS

Medicare Advantage

Medicaid

Eligible Hospitals and CAHs Medicare FFS

Medicare Advantage (paid under Medicare FFS)

Medicaid

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Eligible professionals (EPs)o Calendar Yearo 2011-2016 (Medicare) Up to $44,000 over 5 years

if meaningful EHR usero 2011-2021 (Medicaid) Up to $63,750 over 6 years

Adopt/Implement/Upgrade or meaningful use inYear 1, MU Years 2-6

o 2015 and later If not meaningful EHR user up to3% payment adjustment in Medicare reimbursement

o

We propose that after the initial designation, EPs beallowed to change their program selection onlyonce during payment years 2012 through 2014

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First Calendar Year in which the EP receives an IncentivePaymentCalendar

YearCY 2011 CY 2012 CY 2013 CY 2014 CY 2015

and later

2011 $18,000

2012 $12,000 $18,000

2013 $8,000 $12,000 $15,000

2014 $4,000 $8,000 $12,000 $12,000

2015 $2,000 $4,000 $8,000 $8,000 $0

2016 $2,000 $4,000 $4,000 $0TOTAL $44,000 $44,000 $39,000 $24,000 $0

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YearCY 2011 CY 2012 CY 2013 CY 2014 CY 2015

and later

2011 $1,800

2012 $1,200 $1,800

2013 $800 $1,200 $1,500

2014 $400 $800 $1,200 $1,200

2015 $200 $400 $800 $800 $0

2016 $200 $400 $400 $0TOTAL $4,400 $4,400 $3,900 $2,400 $0

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YearCY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016

2011 $21,250

2012 $8,500 $21,250

2013 $8,500 $8,500 $21,2502014 $8,500 $8,500 $8,500 $21,250

2015 $8,500 $8,500 $8,500 $8,500 $21,250

2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250

2017 $8,500 $8,500 $8,500 $8,500 $8,500

2018 $8,500 $8,500 $8,500 $8,500

2019 $8,500 $8,500 $8,500

2020 $8,500 $8,500

2021 $8,500

TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750


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Eligible hospitals 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 ifthey initiated the program before 2016 No penalties for Medicaid NPRM has narrative and sample calculation

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Medicare can pay incentives to EPs no soonerthan January 2011

Medicare can pay eligible hospitals and CAHsno sooner than October 2010

Medicaid EPs can potentially receive paymentsas early as 2010 for adopting, implementingor upgrading

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Prior approval for reasonable administrativeexpenses (P-APD, I-APD)

Establish a State Medicaid HIT Plan (SMHP)

State may receive 90% FFP and 100% FFP forthe payments themselves

NPRM defines numerous previously undefinedterms in CFR

Medicaid Management Information Systems (MMIS) Medicaid IT Architecture (MITA)

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Statutory Conditions of Use of the HITECH AdminFunds:

1. Administration of incentives, including tracking of

meaningful use by Medicaid EPs and eligiblehospitals;

2. Oversight, including routine tracking of meaningfuluse attestations and reporting mechanisms; and

3. Pursuing initiatives to encourage the adoption ofcertified EHR technology for the promotion ofhealth care quality and the exchange of health careinformation.

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3 Key Elements: What is the current HIT landscape?What is the States Vision for the next 5 years? Howwill they implement and oversee a successful EHRIncentive Program?

NPRM proposes States uses MITA principles indeveloping SMHP

SMHP will include States methodologies forverifying eligibility; disbursing payments;

coordinating with stakeholders; contracting; privacy& security; curtailing fraud & abuse; and otheractivities

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States and CMS must assure there is noduplication of payments to providers (betweenStates and between States and Medicare)

States are required to seek recoupment of

erroneous payments and have an appealsprocess CMS/Medicaid has oversight/auditing role

including how States implement the EHRIncentive Program (90% FFP) and how they

make correct payments to the right providersfor the right criteria (100% FFP).

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Other Medicare IncentiveProgram Eligible for HITECH?Medicare Physician QualityReporting Initiative (PQRI)

Yes, if the PQRI incentive is extended in its currentformat beyond 2010, EPs can participate in both if theyare eligible

Medicare Electronic Health

Records Demonstration(EHR Demo)

Yes, if the EP is eligible

Medicare CareManagement PerformanceDemonstration (MCMP)

Yes, if the practice is eligible. The MCMP demo will endbefore EHR incentive payments are available

Electronic PrescribingIncentive Program (eRx) If the EP chooses to participate in the Medicare EHRIncentive Program, they cannot participate in theMedicare eRx Incentive Program simultaneously. If theEP chooses to participate in the Medicaid EHR IncentiveProgram, they can participate in the Medicare eRxIncentive Program simultaneously

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Medicare MedicaidFeds will implement (will be an optionnationally)

Voluntary for States to implement (maynot be an option in every State)

Fee schedule reductions begin in 2015for providers that are not MeaningfulUsers

No Medicaid fee schedule reductions

Must be a meaningful user in Year 1 A/I/U option for 1st participation year

Maximum incentive is $44,000 for EPs Maximum incentive is $63,750 for EPs

MU definition will be common forMedicare

States can adopt a more rigorousdefinition (based on common definition)

Medicare Advantage EPs have specialeligibility accommodations

Medicaid managed care providers mustmeet regular eligibility requirements

Last year an EP may initiate program is2014; Last payment in program is 2016;Payment adjustments begin in 2015

Last year an EP may initiate program is2016; Last payment in program is 2021

Only physicians, subsection (d) hospitals

and CAHs

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)

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Visit http://www.regulations.govo Document type: Proposed Rule

o Keyword or ID: CMS-2009-0117-0002

Comments are due March 15, 2010 at 5 p.m.

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http://www.regulations.gov/http://www.regulations.gov/


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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 ClinicalHealth Act

HITPC Health Information TechnologyPolicy Committee

HIPAA Health Insurance Portability and

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

Documents

HITECH EHR