Navigating “Meaningful Use Rapids” – Physician Onboarding

April 14, 2015 Karen Wilding / Director of Operations / University Of Maryland Medical System

Anantachai (Tony) Panjamapirom / Senior Consultant / The Advisory Board Company

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

“EHR4ALL," The Legacy of Robin Raiford

Health IT Enthusiast and Advocate Robin "sang the gospel" of the meaningful use program. She was a tireless advocate of its aims. One of her crowning achievements was the White Board Story, which "told the story" of all the meaningful use-related regulations in one huge "poster."

To say Robin commanded a room when she spoke about health IT, is an understatement. Her dedication for this industry and its hope for transformative change exuded from her every cell. We carry on Robin's vision for that future where everyone uses the systems she believed would change the way we provide healthcare, and for the better.

Robin Stillings Raiford February 4, 1952 - June 26, 2014

Conflict of Interest Karen Marie Wilding Salary: University Of Maryland Medical System, Community College of Baltimore County Other: Board of Directors, Maryland HIMSS, Chair of Program Planning Anantachai (Tony) Panjamapirom Salary: The Advisory Board Company

© HIMSS 2015

Learning Objectives 1. Identify at least three components to assess when onboarding a provider into

an existing organization's meaningful use program.

2. Recognize two elements of risk in the meaningful use program that can arise in the EHR incentive program that are beyond the scope of the regulation in the circumstance of a provider changing practices, or in the situation of an acquired practice.

3. State the year and stage of meaningful use that a provider would be in if he/she was acquired by an practice that was currently in Stage 2, Year 1 of meaningful use - but previously in the same reporting period that provider was demonstrating Stage 1, Year 1 objectives and measures.

An Introduction to the Benefits Realized for the Value of Health IT

S Savings

P Prevention and Patient Education

E Electronic

Information/Data

T Treatment/

Clinical

S Satisfaction

• Increase provider satisfaction by reducing administrative burdens

• Assist operational teams with actionable guidance

• Develop tools and checklists to ensure operational consistency

• Generate a high level of data integrity, useful for performance evaluation

• Ensure all providers, especially in an acquisition or new hire situation, achieve meaningful use, which provides better quality of care

• Maintain program status by meeting and exceeding the critical patient objectives of VDT, patient education, clinical reminders etc.

• Reduces risk of payment adjustments

• Provides consistency in processes, reducing operational inefficiencies

• Identifies Total Cost of Ownership, more accurately

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Roadmap

Tracking EP meaningful use statistics and trending provider mobility and practice changes Identifying potential unintended consequences/risks of provider mobility

Operationalizing successful practices in physician onboarding preparation for meaningful use success

86%

14%

EP Registration, Attestation, and Payment Break Down as of February 2015

Registration Attestation Incentive Payments

32%

46%

22%

64% 32%

4%

Medicaid Medicare

Source: February 2015: EHR Incentive Program” Centers for Medicare and Medicaid, available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/February2015_SummaryReport.pdf (accessed April 8, 2015); Data Analytics Update: Health IT Policy Committee Meeting, The Office of National Coordinator for Health Information Technology, available at http://www.healthit.gov/FACAS/sites/faca/files/HITPC_Data_Analytics_Update_2015-04-07_FINAL.pdf, The Advisory Board research and analysis.

Estimated Actual

369,000 393,000

145,000 176,000

AIU

MU Registered

only

Medicaid

Medicare

MU

Registered only

Medicare

Medicaid

Medicare Advantage

Total: $11,117,356,994

Growing Larger, Hospital-Owned Practices

Declining Reimbursements

Increasing Operating Costs

Sequestration cuts

Potential Shortage of Physicians

Regulations such as the ACA

Business Complexity

Market Consolidation

69%

39% 26%

58%

2005 2006 2007 2008 2009 2010

Physician Owned Hospital Owned

Medical Group Ownership

41%

33%

12% 10%

13% 18%

3% 4% 1996-1997 1998-1999 2000-2001 2004-2005

1-2 3-5 6-50 >50

Changes in Physician Practice Size

Source: MGMA, “2012 MGMA Physician Compensation and Production Survey Report,” available at: mgma.com; Center for Studying Health System Change, http://facts.kff.org/chart.aspx?ch=185 and http://www.hschange.com/CONTENT/941/?topic=topic22; The Advisory Board research and analysis.

UMMS Experiencing High Influx B

usin

ess

Driv

ers

Reg

ulat

ory

Driv

ers

Acquisition New Service Line

Affordable Care Act Maryland

HSCRC

Population Health Management

9 12

Change in Number of Hospitals

Change in Number of Employed Physicians

125

450+

2010 2014

2010 2014

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Roadmap

Tracking EP meaningful use statistics and trending provider mobility and practice changes

Identifying potential unintended consequences/risks of provider mobility

Operationalizing successful practices in physician onboarding preparation for meaningful use success

Key Areas to Watch with Moving EPs

2 Financial

Issues

1 3 Legal Issues

Operational Issues

Source: The Advisory Board research and analysis.

Potential Industry Payment Adjustments in 2015

Average Incentives Received as of February 2015

Financial Issues

Incentive Payments Payment Adjustments

$1,110 Internal Medicine (Income2: $185K)

$1,668 $2,430 Oncology

(Income2: $278K) Orthopedics

(Income2: $405K)

Per Medicaid Eligible Professional

Per Medicare Eligible Professional

Per Medicare Advantage Eligible Professional

$25,833

$25,348 $29,831

Assume 60% Medicare Reimbursements

Source: February 2015:: EHR Incentive Program” Centers for Medicare and Medicaid, available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/February2015_SummaryReport.pdf (accessed April 8, 2015); The Advisory Board research and analysis.

Questions to Consider for both Incoming and Departing Providers

1. Who should receive an incentive payment? EP, the previous

employer, or the current employer?

Majority of time rule? 2. Who is responsible for

payment adjustment of the EP’s past performance? EP, the previous

employer, or the current employer?

Shared responsibility?

Legal Issues

Legal and Compliance Must Be Engaged to Ensure Onboarding and Departing Agreements

Contract Development

• Screening questionnaires embedded into hiring process

• Consider incorporating provisions to address financial and operational risks incurred by an EP’s inability to meet MU

Partnership with Finance Collaboration with the Meaningful Use Team

• Identify potential financial risks of a non meaningful user status

• Understand the risks in the total acquisition cost and consider negotiation

• Keep an ongoing pulse check of an individual provider status

• Provide advisory support for an unprecedented issue

Source: The Advisory Board research and analysis.

Operational Issues

Incoming Eligible Provider

Departing Eligible Provider

Successful coordination with the previous and next employer is key!

Identify Provider Meaningful Use

Status

Retrieve Performance Data

and Reporting

Request Audit Documentation

Source: The Advisory Board research and analysis.

Roadmap

Tracking EP meaningful use statistics and trending provider mobility and practice changes

Operationalizing successful practices in physician onboarding preparation for meaningful use success

Identifying potential unintended consequences/risks of provider mobility

Addressing 6 Critical Components

Governance and Skillsets

z z z

z z z

Onboarding Process

Eligibility and Registration

Performance Monitoring and Improvement

Attestation Process Departing Process

1 2 3

4 5 6

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Building a Robust Team

Case in Brief: University of Maryland Medical System’s Meaningful Use Governance

• Reported to Executive Steering

Committee • Led by an executive sponsor, CMIO • Enterprise program manager

oversees day-to-day MU operations • Assigned a dedicated, site-specific

MU lead for tracking and coordination • Separate, collaborating teams for:

1) financial and compliance matters; 2) documentation oversight; and 3) EP affiliate compliance

Setting Up a Meaningful Use Governance and Identifying Staff with Specific Skills

for EP Onboarding Success

Team Structure • Executive Steering Committee Core Meaningful Use Team

Committee o Operational/Program

team o Practice manager

1

Skillsets • Policy analysis • EHR workflow coordination • IT implementation • Communications and training

2

Component 1: Governance and Skillsets

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Strong Collaboration between MU Steering Committee and Local Leadership

Case in Brief: UMMS Governance Components • Divided by Communities/EHR

Vendors • Local Executive leadership

engaged in specific community steering committee

• EHR Director/Coordinator – connected with local medical group/practice leadership

• Centralized compliance, financial and program standards

Component 1: Governance and Skillsets

Source: University of Maryland Medical System; The Advisory Board research and analysis.

If You Fail to Plan, You Are Planning to Fail

Component 2: Onboarding Process

Accepting Risks with New EPs – means understanding and preparing your team and program infrastructure for:

Off-cycle eligibility and enrollment

EHR vendor competency misalignment with existing

reporting periods

Prior documentation (Book of Evidence)

Unsuccessful audits from prior employers (reminder – penalty is

attached to an EP – NPI)

Requests from an EP’s previous

employer

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Create an Onboarding Shield Component 2: Onboarding Process

Partner with multiple internal stakeholders on information gathering

Legal/Provider Contracting

Compliance Finance Information Technology

• Ownership of payments, documentation, and potential audits for shared reporting periods

1

2

Understand how providers enter your organization, create a process flow

• Identification of enrollment and status of all federal and state programs

• Identification of received payments and potential penalties

• Timeline to be “live” on EMR; map with reporting period requirements

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Determining Eligibility to Identify Specific Program Opportunity

Component 3: Eligibility and Registration

Eligibility Considerations

Medicare or Medicaid Program • Mine data for any 90-day

period within the 12-month preceding the EP’s attestation to determine Medicaid patient volume

• Work with the state to review the data for eligibility

1

Medicaid Volume via Group Proxy • Identify an EP’s opportunity

to participate in the Medicaid program

2

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Ensure Accuracy of an EP’s Data across Multiple Systems

Component 3: Eligibility and Registration

• Create “One Proxy Access” fro an authorized official to attest on an EP behalf

• Ensure a provider approval of the request for proxy access in the I&A system

• Confirm each provider has an assigned NPI

• Confirm online enrollment in PECOS

• Reassign an incentive payment to a specific NPI or TIN in the Registration and Attestation System

• Confirm Medicaid eligibility before registering in eMIPP

Identity & Access Management System (I&A)

Flow of Data in Registration Systems

Medicare Provider Enrollment, Chain, and Ownership System (PECOS)

National Plan & Provider Enumeration System (NPPES)

EHR Incentive Program Registration and Attestation System

EHR Medicaid Incentive Payment Program (eMIPP)

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Performance Monitoring and Improvement

Learning Curve

• Learning how to use an EHR system can take time. There will likely be multiple issues during the initial period where the curve is steep, especially for new providers - experienced with the same EHR or not

Workflow Compliance

Data Integrity

• Providers may be familiar with the objectives, but every organization has workflow variations that must be taught and adhered to. Providers must understand how these workflows impact objectives and reporting

• “Certifying the data is true and accurate” means ensuring attestation data is accurate and truly reflect their performance, volumes and utilization of the EHR

Component 4: Performance Monitoring and Improvement

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Ensure Data Integrity and Compliance

1

2 Set acceptance tolerance to field provider adherence

Identify outliers based on individual performance

3

4

Build new mindset as a foundation and gradually raise the bar

5 Form a SWAT team to target a specific group of underperforming EPs

6 Ensure data accuracy and performance compliance

Validate accuracy of performance reports/ Perform positive-negative test

Improve Performance through Close Monitoring and Ongoing Support

Component 4: Performance Monitoring and Improvement

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Attestation Checklist and Buddy System

Component 5: Attestation Process

Authorized Official

• Understand, identify and support authorized officials (they may need a new job description)

Provider Acknowledgement

Attestation Sign Off “Buddy System”

• Implement a provider acknowledgement process and documentation to payment turnover to employer

• Ensure provider sign off on the certified performance reports prior to attestation

• Utilize “Buddy System” when entering & submitting data to CMS and state

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Prevent Departure Gone Wrong! Component 6: Departing Process

Support the next employer and supply documentation

Copy of certified performance report

Summary of payments received by the organization and the provider’s meaningful use timeline

Contact information in the event of an audit

Case in Brief: A health system in Southern California Issue: CMS sent an incentive payment after the provider has changed the PECOS and registration information Solution: • Collaborate with the Finance to track

incentive payments • Engage the Legal and Compliance office • Create an incentive payment request

letter and send to the provider and the new employer

• Provide any support documentation to the provider should there be any tax implication

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Takeaways

Three Key Actions for Organizations to Support Transitioning Providers on Achieving Meaningful Use

Evaluate Your Infrastructure and

Resources

• Document, document, document!

• Develop Book of Evidence and form centralized structure

• Enhance your documentation to denote specific issues

Keep Up the Pulse Check

Form Your Defense

• Secure leadership buy-in and involvement

• Engage stakeholders from various departments

• Get a pulse check on their commitment to meaningful use success

• Instill skillsets among practice managers

• Leverage existing policy and procedures for further adjustments

• Align efforts to optimize the governance structure

Source: University of Maryland Medical System; The Advisory Board research and analysis.

An Review of Benefits Realized for the Value of Health IT

S Savings

P Prevention and Patient Education

E Electronic

Information/Data

T Treatment/

Clinical

S Satisfaction

• Increase provider satisfaction by reducing administrative burdens

• Assist operational teams with actionable guidance

• Develop tools and checklists to ensure operational consistency

• Generate a high level of data integrity, useful for performance evaluation

• Ensure all providers, especially in an acquisition or new hire situation, achieve meaningful use, which provides better quality of care

• Maintain program status by meeting and exceeding the critical patient objectives of VDT, patient education, clinical reminders etc.

• Reduces risk of payment adjustments

• Provides consistency in processes, reducing operational inefficiencies

• Identifies Total Cost of Ownership, more accurately

Source: University of Maryland Medical System; The Advisory Board research and analysis.

Questions Thank You!

Karen Marie Wilding Director of Operations, Information Services & Technology University of Maryland Medical System (UMMS) kwilding@umm.edu Office: 410.328.8253

Anantachai (Tony) Panjamapirom Senior Consultant, Research and Insights The Advisory Board Company panjamat@advisory.com Office: 202.266.6072