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Pillsbury Winthrop Shaw Pittman LLP
Implementation of Health InformationTechnology
Gerry HinkleyCo-Chair, Health Care Industry TeamPillsbury Winthrop Shaw Pittman LLP
National Forum on Clinical IntegrationWashington, DC, November 15 - 17, 2010
2 | Implementation of Health Information Technology
Overview
Role of IT in Accountable Care
Implications for choosing and contracting with HIT vendors
Utilizing federal HIT incentive programs to buildan electronic system
3 | Implementation of Health Information Technology
Role of IT in Accountable Care
IT is essential to achieving clinical integrationCare coordination
at least 5,000 Medicare beneficiariesschedulingpatient monitoringreferrals
Data reportingQuality measuresPatient satisfaction
Implications for antitrust compliance
Significant challenge to limited resources for IT forPractice/hospital specific technologyHealth Information exchange
4 | Implementation of Health Information Technology
Implications for Choosing andContracting with HIT Providers
The once in a lifetime experienceFunctionalitySupport and maintenance
Approach to vendor selectionThe RFPMultiple finalists
The importance of the license and services agreement
Developing a working relationship
5 | Implementation of Health Information Technology
Vendor Selection – Basic EHR Functionality
Identify and maintain a patient record Manage patient demographics Manage problem lists Manage medication lists Manage patient history Manage clinical documents and notes Capture external clinical documents Present care plans, guidelines, and protocols Manage guidelines, protocols and patient-specific care plans Generate and record patient-specific instructions
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Vendor Selection – Additional Functionality
Specialized templatesInteroperability
CPOEePrescribingHealth information exchange
Patient connectivityData reporting
Disease registriesPublic healthQuality data
Evidence based clinical practice guidelinesFormulariesReferral tracking
7 | Implementation of Health Information Technology
Vendor Selection – the Basics beyond Functionality
Project managementStaffing
Choice of who is on the vendor implementation teamClause for not soliciting the hiring of practice staff
TimingImplementation and payment milestones
Technical environmentPractice requirements for readinessHardware specifications
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Vendor Selection – the Basics beyond Functionality
Training supportInitial training and on-goingIncluded in the maintenance agreement
Maintenance support24/7 help deskOn-site within 24 hours, if issue cannot be resolved remotelyFinancial remediation
9 | Implementation of Health Information Technology
Vendor Selection – the Basics beyond Functionality
UpdatesFixes to minor issuesCommitment to provide regular updatesIncluded in the maintenance fees
New releases
Errors and Lost FunctionalityCritical errorsRepair/replaceSubstitute software/equipment
10 | Implementation of Health Information Technology
Vendor Selection – the Basics beyond Functionality
Terminating maintenanceRequirements to return or destroy softwareTimeframes for notification
Application no longer supported
TaxesPhysical media versus electronic transmissionStrategies to mitigate
11 | Implementation of Health Information Technology
Vendor Selection – License and Services Agreement
Functional specificationsDocumentationAcceptance testingChange ordersProprietary rightsIs the vendor your HIPAA business associate?WarrantiesIndemnificationDamages, disclaimers and limitations on liabilityReciprocal obligationsSoftware escrow
12 | Implementation of Health Information Technology
Utilizing Federal HIT Incentive Programs to Build an Electronic System
Regional Extension Centers
Medicare/Medicaid Incentive Payments for EHR Adoption and “Meaningful Use”
13 | Implementation of Health Information Technology
Regional Extension Centers
The HITECH Act authorizes a Health Information Technology Extension Program
The extension program consists of Health Information Technology Regional Extension Centers (RECs) pursuant to 60 cooperative agreement awards and a national Health Information Technology Research Center (HITRC)
The HITRC will build a virtual community of shared learning to advance best practices that support providers’ adoption and meaningful use of EHRs
RECs will be fully operational by December 2010
$643 million ARRA funds for 2010 – 2012, $42 million thereafter
By December 2012, the RECs will be largely self-sustaining and their need for continued federal support in the remaining two years of the program will be minimal
14 | Implementation of Health Information Technology14 |
REC Charters
RECs willProvide training and support services to assist doctors and other providers in adopting EHRs Offer information and guidance to help with EHR implementation Give direct, individualized and on-site technical assistance in
Selecting a certified EHR product that offers best value for theproviders' needsAchieving effective implementation of a certified EHR productEnhancing clinical and administrative workflows to optimally leverage an EHR system's potential to improve quality and value of care, including patient experience as well as outcome of careObserving and complying with applicable legal, regulatory, professional and ethical requirements to protect the integrity, privacy and security of patients' health information
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What’s a REC to do? – EHR Implementer and Provider Education
Emphasis on Security – Brochures emphasizeUnderstand your areas of risk by doing a risk assessment, as required by HIPAATrain your staff on proper security techniquesDefine staff roles and responsibilitiesPhysically secure your portable computing and storage devicesSelect EHR vendors that provide certified EHR technologiesDevelop security policies that are simple, understandable and enforceable Know what you must do, under the law, to protect your patients’ information
16 | Implementation of Health Information Technology
Federal Incentives to Reward “meaningful use”
To receive the financial incentives, beginning in 2011, eligible professionals and hospitals must achieve “meaningful use” of a certified electronic health record (“EHR”)How do hospitals and eligible professionals qualify for incentive payments? How is “meaningful use” defined and what are its goals? July 13, 2010 – Final Rules:
CMS Final Rule on Meaningful UseONC Final Rule on Certification
17 | Implementation of Health Information Technology
Broad Goals for Meaningful Use
Vision: Enable significant and measurable improvements in population health through transformed health care delivery system
Goals: Improve quality, safety, efficiency, and reduce health disparitiesEngage patients and familiesImprove care coordinationEnsure adequate privacy and security protections for personal health informationImprove public health
18 | Implementation of Health Information Technology
Incentive Payments: Basic Details
Medicare and Medicaid incentives for hospitals and eligible professionals achieving “meaningful use” of EHR technology beginning as early as 2011
Three stages of implementation, tied to year of adoption.
Eligible professionals and hospitals must meet specific criteria
Report by attestation in 2010/2011For first year, must report for a 90 day consecutive period
Initial implementation timeline may have been to aggressive
19 | Implementation of Health Information Technology
Medicare Incentives for Eligible Professionals
Incentive payment for certain professionals for the “meaningful use” of a certified EHR“Eligible professionals” means all physicians participating in Medicare, except hospital-based physicians, and includes Medicare Advantage participating physicians as determined by HHS“Certified EHR Technology”Incentive payments equal to 75% of allowed charges for all Medicare covered services provided by a physician, not to exceed stated caps – payable to the physicianRural provider in a Health Professional Shortage Area (HPSA) will get an extra 10% of allowed charges
20 | Implementation of Health Information Technology
Medicare Incentives for Eligible Professionals
Source: HIMSS; IFR+NPRM; maximum incentive for Eligible Providers, Medicare (not Medicaid or underserved geographies)
21 | Implementation of Health Information Technology
Medicare Incentives for Hospitals
Incentives under the IPPS for hospitals participating in Medicare that demonstrate meaningful use of EHR
Formula for incentives: $2 million plus $200 multiplied by the number of discharges between 1,150 and 23,000 and multiplied by the hospital’s Medicare percentage, adjusted upward for charity care
Diminishing over a 4-year period
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Medicare Incentives for Hospitals
Incentive payments calculation: ($2,000,000 + Discharge Amount) (Medicare Share) (Transition Percentage)Source: HIMSS
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Incentives for Critical Access Hospitals
Incentive structure takes into account cost-based reimbursement for CAH
EHR incentive payments will be made to a CAH for a Medicare fiscal year equal to the product determined by multiplying:
Reasonable costs incurred for the purchase of Certified EHR Technology (including depreciation and interest expense), byThe lesser of the following: 100%; the Medicare share percentage plus 20 percentage points
CAH that is not a meaningful user by 2015 will have reimbursement cut for 2015, 2016, 2017
24 | Implementation of Health Information Technology
Medicaid Incentives
Eligible professionals: professionals not hospital-based with 30% Medicaid patients or 20% for pediatricians; or FQHC-based with 30% needy population; children’s hospitals; acute hospitals with 10% Medicaid load
Includes Physicians, Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), Dentists, and Physician Assistants (PAs) who provide services in a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is led by a PA
Professionals: 85% of allowable cost of certified EHR for up to 5 years (deducting amounts funded by other government sources) up to $25,000 for year 1 and $10,000 for years 2-5; starting no later than 2015 and ending by 2021; pediatricians get 66% of these amounts unless Medicaid share is 30% or moreHospitals: about half of EHR allowable amount times Medicaid share over 6 years; can receive both Medicare and Medicaid incentives
25 | Implementation of Health Information Technology
HITECH Definition of “Meaningful Use”
An eligible provider and an eligible hospital shall be considered a meaningful EHR user if they meet the following three requirements:
(1) demonstrates use of certified EHR technology in a meaningful manner;(2) EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care such as promoting care coordination; (3) using its certified EHR technology to submit to the Secretary, in a form and manner specified by the Secretary, information on clinical quality measures and other measures.
26 | Implementation of Health Information Technology
CMS Final Rule
Final Rule – July 13, 2010For STAGE ONE, meaningful use includes both a “core set” and a “menu set” of objectives. For eligible professionals, there are 25 meaningful use objectivesA total of 20 must be completed to qualify for an incentive payment15 of these are core objectives are required, and the remaining 5 may be chosen from a list of 10 menu set objectives
27 | Implementation of Health Information Technology
Core Set of Meaningful Use Objectives
From the core set of objectives, the following must be achieved:
Use CPOEImplement drug to drug and drug allergy interaction checksE-Prescribing (EP only)Record demographicsMaintain an up-to-date problem listMaintain active medication listMaintain active medication allergy listRecord and chart changes in vital signs
28 | Implementation of Health Information Technology
Core Set of Meaningful Use Objectives (continued)
Record smoking statusImplement one clinical decision support ruleReport quality measures as specified by the SecretaryElectronically exchange key clinical informationProvide patients with an electronic copy of their health informationProvide patients with an electronic copy of their discharge instructions (Eligible Hospital/CAH Only)Provide clinical summaries for patients for each office visit (EP Only)Protect electronic health information created or maintained by certified EHR
Each of the core objectives must be met unless a provider qualifies for an exclusion
29 | Implementation of Health Information Technology
Menu Set of Meaningful Use Objectives
Of the menu-set objectives, choose five with which to comply:Implement drug formulary checksRecord advanced directivesIncorporate lab results as structured dataGenerate lists of patients by conditionSend reminders to patients (EP only)Provide patients with timely electronic access (EPs only)Provide educational resourcesPerform medication reconciliationSummary care record for transfersSubmit electronic data to immunization registriesSubmit reportable lab results to public health (hospitals only)Submit electronic surveillance data to public health
30 | Implementation of Health Information Technology
ONC Final Rule – Certification
Standards, implementation specifications, and certification criteria for EHR technology
Physicians and hospitals must adopt and use to satisfy “meaningful use” standard
General criteria, criteria specific to ambulatory settings, criteria specific to inpatient settings
“Qualified EHR”
“EHR Module”
“Certified EHR Technology”
31 | Implementation of Health Information Technology
ONC Final Rule – Certification (continued)
Content exchange and vocabulary implementation specifications
Transport standards
Privacy and security standards
HIPAA electronic transactions and code set standards
Certification criteria and accounting of disclosures standards
32 | Implementation of Health Information Technology
Reporting and Payment
For 2011, CMS will accept provider attestations to demonstrate all the meaningful use measures, including clinical quality measures
Starting in 2012, CMS will continue attestation for most of the meaningful use objectives, but plans to initiate the electronic submission of the clinical quality measures
CMS expects to begin Medicare incentive payments nine months after publication of the final rule (which would be April of 2011)
States will support attestation initially and then subsequent electronic submission of clinical quality measures for Medicaid providers' demonstration of meaningful use
States are determining their own deadlines for launching their Medicaid EHR incentive programs, but are required to make timely payments
CMS expects that the majority of states will have launched their programs by the summer of 2011
33 | Implementation of Health Information Technology
Challenges Ahead
Program “voluntary,” so compliance with standards may be uneven
Meaningful use criteria will change over time
Rate of adoption – difficult to predict
Ultimate impact on expenditures for medical treatments (e.g., reducing errors, expedited treatment, etc.) unknown
34 | Implementation of Health Information Technology
Other Considerations
For eligible professionals: is effort worth the recompense?
“Hospital-based eligible professionals” definition
Minimum recompense for Critical Access Hospitals
Widening digital divide between early adopters and those without significant resources (e.g., rural hospitals)
Administratively burdensome to both providers and CMS
35 | Implementation of Health Information Technology
The purpose of this presentation is to inform and comment upon recent developments in health law. It is not intended, nor should it be used, as a substitute for specific legal advice – legal counsel may only be given in response to inquiries regarding particular situations.
36 | Implementation of Health Information Technology
Contact information
Gerry HinkleyPillsbury Winthrop Shaw Pittman LLP
50 Fremont StreetSan Francisco, CA 94105
Direct: (415) [email protected]