ACHIEVING MEANINGFUL USE FOR YOUR PRACTICE

1. ACHIEVING MEANINGFUL USE FOR YOUR PRACTICE Huong Le, DDS,MA Yankee Dental Congress 2014

2. OBJECTIVES • Overview and Updates of Meaningful Use Incentive program: stage II 2. Oral health measures 3. How to report the data through EHR

3. Overview • President Bush began the EHR Initiative April 2004 , emphasizing “innovations in electronic health records and the secure exchange of medical information will help transform healthcare in America.” • Bush appointed the head of National Health Information Infrastructure within DHHS (Dr Tommy Thompson) that will speed up the adoption of technology • HL7 EHR was adopted • 10-year plan, $50M in 2004 in grants to local and regional organizations to create system to share healthcare information; $100 M for demonstration projects to test effectiveness of HIT and best practices and also create incentives and opportunities for providers to use the EMR technology

4. Meaningful Use Program • The American Recovery and Reinvestment Act of 2009 authorizes CMS to provide incentive payments to eligible professionals (EPs) and hospitals who adopt, implement, upgrade or demonstrate meaningful use of certified electronic health record (EHR) technology. • Providers have to meet specific requirements in order to receive incentive payments

5. Goals of Using Certified EHR to Achieve Meaningful Use • Improve quality, safety, efficiency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health • All the while maintaining privacy and security • CMS definition

6. A Conceptual Approach to Meaningful Use

7. Goals of Meaningful use • Regional Extension Centers • Medicaid EHR Program 1st year incentive • Workforce Training Adoption Improved Individual and Population Health Outcomes Increased Transparency and efficiency Improved ability to study and improve care delivery Meaningful Use • Medicare and Medicaid EHR Incentive Programs • State Grants for Health Information Exchange • Medicaid Administrative Funding for HIE • Standards and Certification Framework • Privacy and Security Framework Exchange Health IT Practice Research

8. Eligibility: Practices Predominantly & Needy Individuals • EP is also eligible when practicing predominantly in FQHC/RHC providing care to needy individuals • Practicing predominantly is when FQHC/RHC is the clinical location for over 50% of total encounters over a period of 6 months in the most recent calendar year • Needy individuals (specified in statute) include: • Medicaid or CHIP enrollees; • Patients furnished uncompensated care by the provider; or • Furnished services at either no cost or on a sliding scale

9. The Medicaid EHR Incentive ProgramSummary • The Medicaid EHR Incentive Program provides incentive payments to eligible professionals, eligible hospitals, and CAHs as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years. • Eligible professionals can receive up to $63,750 over the six years that they choose to participate in the program • The Medicaid EHR Incentive Program is voluntarily offered by 43 individual states and territories, and more states will begin offering the program in 2012. Check with your State Medicaid Agency for more information. • The EHR Incentive Program provides incentive payments for eligible healthcare providers to use EHR technology in ways that can positively impact patient care

10. Medicare vs. Medicaid

11. REQUIREMENTS FOR MU

12. Recommendations for Health Center Dental programs Before embarking on Meaningful Use, Health Centers should consider the following strategic roadmap questions: • What are the implications of participating in Meaningful Use? • Are the dentists eligible for Meaningful Use incentives? • What external organizations can assist in the early planning, implementation and achievement of Meaningful Use of EDR/EHR systems? • What features and capabilities should be included beyond suggested requirements? • What is the Center’s capital and operating budget for an EDR/EHR solution? • What EDR/EHR selection process and deployment model should be used?

13. Requirements for MU Reporting

14. 15 Core Objectives

15. 15 Core Objectives… continued

16. Select 5 out of 10 menu objective

17. Select 5 out of 10 menu objectives continued

18. CORE #2: COMPUTER PROVIDER ORDER ENTRY (CPOE) Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. Generate and transmit permissible prescriptions electronically (eRx). • Implement drug-drug and drug-allergy interaction checks • Maintain an up-to-date problem list of current and active diagnoses.

19. REPORTABLE CORE MEASURES • SMOKING STATUS: 13 y.o. and older • VITALS: A) Height. (B) Weight. (C) Blood pressure. (D) Calculate and display body mass index (BMI). (E) Plot and display growth charts for children 2–20 years, including BMI.

20. REPORTABLE CORE MEASURES • Maintain an up-to-date problem list of current and active diagnoses. • Provide patients with an electronic copy of their health information including: • Diagnostics test results • Problem list • Medication lists • Medication allergies

21. REPORTABLE CORE MEASURES • Provide clinical summaries for patients for each office visit. • Recall reminders: eMessage or letter

22. EXAMPLE OF CLINICAL SUMMARIES • Objectives: Provide clinical summaries for patients for each office visit. • Measure: Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days. • DENOMINATOR: Number of office visits by the EP during the EHR reporting period. • NUMERATOR: Number of office visits in the denominator for which the patient is provided a clinical summary within three business days. • The resulting percentage (Numerator ÷ Denominator) must be more than 50 percent in order for an EP to meet this measure. • Exclusion: Any EP who has no office visits during the EHR reporting period. EPs must enter ‘0’ in the Exclusion box to attest to exclusion from this requirement

23. Information in visit summary • the patient name, • provider’s office contact information, • date and location of visit, • an updated medication list, • updated vitals, • reason(s) for visit, • procedures and other instructions based on clinical discussions that took place during the office visit, • any updates to a problem list, • immunizations or medications administered during visit, • summary of topics covered/considered during visit, • time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, • list of other appointments and tests that the patient needs to schedule with contact information, • recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.

24. LET’S TALK ABOUT MONEY!

26. Stages of payments

27. Payments: EP Adoption Timeline

28. Payment schedule • Medicaid:  Payments began in 2011, as determined by each state and continue to pay on a diminishing scale over six years, through 2021. • Stage I Year 1: Under the Medicaid EHR Incentive Program, incentives can also be paid for the adoption, implementation, or upgrade of certified EHR technology which can qualify your practice for the first year.  • Stage I Year 2: meaningful use must be maintained for 90 days and for year 3, the eligible providers must be meaningfully using their certified EHR technology for the entire 12 month period (calendar year for EPs, federal fiscal year for hospitals) (stage II).

29. PAYMENT SCHEDULE • Payment Information • Adopt, implement, or upgrade in 2012/2013. • Year 1 Payment: $21,250.00 • Demonstrate 90 days of Stage 1 of meaningful use in year 2 -2014. • Year 2 Payment: $8,500.00 • Demonstrate a full year of Stage 1 of meaningful use in year 3-2015. • Year 3 Payment: $8,500.00 • Demonstrate a full year of Stage 2 of meaningful use in year 4. • Year 4 Payment: $8,500.00 • Demonstrate a full year of Stage 2 of meaningful use in year 5. • Year 5 Payment: $8,500.00 • Demonstrate a full year Stage 3 of meaningful use in year 6. • Year 6 Payment: $8,500.00

30. Payment Methodology How will the EHR incentive payments actually be distributed to the eligible professionals? • They are distributed and taxed as income to the Tax ID number that the eligible providers uses when they register at the CMS registration system for both Medicare and Medicaid’s EHR Incentive Programs, which went live on January 3, 2011. • Taxable income unless signing over to health centers.

31. CALCULATIONS

32. COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) • Measure Information andMeasure Values • 1. Objective: Use computerized provider order entry (CPOE) for medication orders directly entered by a licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines • Measure: More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE Exclusion: Any EP who writes fewer than 100 prescriptions during the EHR reporting period would be excluded from this requirement • Does this exclusion apply to you? • Numerator: The number of patients in the denominator that have at least one medication order entered using CPOE • Denominator: Number of unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period • 2. Objective: Implement drug-drug and drug-allergy interaction checks • Measure: The EP has enabled this functionality for the entire EHR reporting period • Note: This measure only requires a yes/no answer • Numerator: N/A • Denominator: N/A

33. Stage I reporting changes • 2014- Reporting periods for meaningful use will be three months long regardless of what stage an eligible professional is following( Rob Anthony, a health specialist with the CMS Office of E-Health Standards and Services) • Also beginning in 2014, a physician group can submit a meaningful use attestation for all of its eligible professionals in one file, saving the practice from entering each individual’s information separately.

34. From Stage I to Stage II • Stage I: 70% of physicians who achieved stage 1 requested an exclusion to the requirement that practices needed to provide, to 50% of patients who requested them, an electronic copy of their records within three days, according to CMS data. They qualified for exemptions because no patients asked for the records • Stage II: require at least 5% of patients to download their records.

35. From Stage I to Stage II • Stages 1 and 2 each require meeting 20 total objectives, but stage 2 makes mandatory some EHR measures that are optional for stage 1, such as whether the electronic systems can incorporate clinical laboratory test results. • Other measures stay the same but have higher thresholds, such as a requirement that EHRs send more than 50% of applicable prescriptions electronically, up from more than 40%. • The number of required core set measures goes up to 17 in stage 2 from 15 in stage 1. • Physicians also must choose and comply with three out of six additional “menu” set measures, as well as report at least nine clinical quality measures.

36. Stage I vs. stage II STAGE I • 15 core objectives • 5 objectives out of 10 from menu set • 6 total Clinical Quality Measures (3 core or alternate core, and 3 out of 38 from additional set) • Complete set for Stage II can be found on www.cms.gov STAGE II 2014 and beyond • 17 core objectives • 3 of 6 menu objectives • 9 out of 64 CQMs • 3 of the 6 key health care policy domains • Patient and Family Engagement • Patient Safety • Care Coordination • Population and Public Health • Efficient Use of Healthcare Resources • Clinical Processes/Effectiveness

37. Stage II MU Core set Use computerized physician order entry (>60% medication, 30% lab and 30% radiology orders) Prescribe permissible drugs electronically (>50%) Record patient demographics (>80%) Record and chart changes in vital signs (>80%) Record smoking status (>80%) Use clinical decision support (at least five interventions) Incorporate clinical lab results into EHR (more than 55%) Generate lists of patients by specific conditions (at least one list)

38. Stage II MU Core set (cont.) 9. Identify patients who need reminders for preventive or follow-up care (>10%) 10. Provide at least half of patients with access to health information (>5% use access) 11. Provide clinical summaries for patients within one business day (>50%) 12. Identify patient-specific education resources (>10%) 13. Communicate with patients on relevant health information (>5%) 14. Perform medication reconciliation during care transitions (>50%) 15. Send summaries of care during referrals (more than 50%) 16. Submit electronic data to immunization registries (ongoing submissions during reporting period) 17. Protect EHR information

39. WHAT DO DENTISTS NEED TO DO?

40. From the CMS Final Rule • Dentists must report on 6 clinical measures; 3 core measures and 3 additional measures . ***Please refer to NNOHA Guide to the Future or CMS website • If any of the core measures have a 0 as the denominator because it is not within the dentists’ scope of practice to capture that information then (s)he must choose from the alternates list. If the alternates don’t apply he/she must verify that the alternates are not applicable to his/her scope of practice. **It is possible that the EP because of his/her specialty will not report on 3 of the core/alternate measures. • If a dentist cannot find three measures within the menu set of 38 quality measures on which to report because it falls outside of his/her scope of practice, dentist has the option of sending a statement attesting to that fact. **It is possible that the dentist will not report on 3 menu clinical measures.

41. NNOHA’s Proposed CQMs

42. Stage 2 CQM: NQF ORAL HEALTH MEASURES Measure 1: Children who have dental decay or cavities Description: Percentage of children ages 0-20, who have had tooth decay or cavities during the measurement period. Measure 2: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Description: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.

43. Accepted Oral Health Measures I. Oral Evaluation • Measure Concept: Children who received a comprehensive or periodic oral evaluation • Aligned Administrative Measure: Percentage of enrolled children who accessed [dental/ oral health] care (received at least one service) who received a comprehensive or periodic oral evaluation within the reporting year. II. Prevention: Fluoride or sealants • Measure Concept: Children who received topical fluoride or sealants • Aligned Administrative Measure: Percentage of enrolled children at elevated risk who accessed [dental/ oral health] care (received at least one service) who received topical fluoride or sealants within the reporting year.

44. DENTAL QUALITY ALLIANCE (DQA) PROPOSED MEASURES III. Prevention: Sealants for 6 – 9 years-To be tested • Measure Concept: Children aged 6-9 years who receive sealants in the first molar • Aligned Administrative Measure: Percentage of enrolled children aged 6-9 years at elevated risk who accessed [dental/ oral health] care (received at least one service) who received a sealant in the first molar within the reporting year. IV. Prevention: Sealants for 10 – 14 years • Measure Concept: Children aged 10-14 years who receive sealants in the second molar • Aligned Administrative Measure: Percentage of enrolled children at elevated risk aged 10-14 years who accessed [dental/ oral] health care (received at least one service) who received a sealant in the second molar within the reporting year

45. DENTAL QUALITY ALLIANCE PROPOSED MEASURES V. Prevention: Topical Fluoride –Already tested • Measure Concept: Children who receive topical fluoride • Aligned Administrative Measure: Percentage of enrolled children at elevated risk who accessed [dental/ oral] health care (received at least one service) who received topical fluoride within the reporting year. VI.Care Continuity-Ready to be tested • Measure Concept: Children who received a comprehensive or periodic oral evaluation in two consecutive years • Aligned Administrative Measure: Percentage of enrolled children who accessed [dental/ oral health] services (received at least one service) who received a comprehensive or periodic oral evaluation in the year prior to the measurement, who also received a comprehensive or periodic oral evaluation within the reporting year. VII. Dental caries-Already Tested • Measure Concept: Children who have new caries or untreated caries • Aligned administrative measure: NA.

46. Stage III • Public comment period opened in January 2013 • Mystery as only a handful of proposed measures • AMA is asking to delay • No date has been set • Likely to follow the same format with a divide core (mandatory) and menu (optional) requirements, with continuation of stage I and II and some new ones

47. HOW TO ATTEST • Varies state by state. Please check your Medicaid website • Registration & Attestation process • NPI Registry • CMS Identify and Access • CMS Registration and Attestation

48. HOW TO ATTEST (CONT) STEP 1:  Select and adopt a certified EHRSTEP 2:  Register at the CMS Registration PortalSTEP 3:  Obtain EHR certification code (instructions)STEP 4:  Attest through the Medicaid portal. STEP 5:  Receive incentive paymentSTEP 6:  Year two: "meaningfully use" for 90 days and attest.              You can skip years. The last year is 2021

49. STEP #1 • Select a certified product listed in the Certified EHR list

50. STEP #2 • Log in to the site using your National Plan and Provider Enumeration System (NPPES) web user account.  If you do not already have an NPPES account, visit the NPPES website to register.  (Note: If you have an NPI number, you automatically have an NPPES account.)  • CMS has a Medicaid EHR Incentive Program registration user’s guide (PDF) for the registration and attestation system. • Before you can proceed with the attestation process, you will be prompted for a certification ID. This number is a unique identifier assigned to each certified EHR (see step 3).