Making Sense of EHRs and the EHR Incentive Program (HITECH)

1. Making Sense of EHRs and the EHR Incentive Program (HITECH) Northern California ACP Chapter San Jose, CA October 29, 2011 Michael S. Barr, MD, MBA, FACP Senior Vice President Division of Medical Practice, Professionalism & Quality 202-261-4531 mbarr@acponline.org

2. Disclosures • Grants for program development (ACP) from: • Pfizer • UnitedHealth Care • NovoNordisk • Endo Pharmaceuticals • Merck • Sanofi • Wyeth

3. Goals • Focus on patient-centered care • Highlight key provisions of the HITECH Act • Examine Meaningful Use & its relation to PCMH • Explore a road map for building technology-enabled practices • Introduce resources available HITECH = Health Information Technology for Economic and Clinical Health Act 2009

4. Patient-Centered Medical Home Health Care Home Person-Centered Health Care Home Meaningful Use Certified EHR Technology Complete EHRs EHR Modules Accountable Care Organizations Affordable Care Act (PPACA, ACA) Maintenance of Certification Physician Quality Reporting Initiative - PQRI HITECH E-prescribing Incentive Program

7. What is Patient-Centered Care? • One of IOM’s six domains of quality • “Nothing about me without me” • The right care, the right way, at the right time • Providing the care that the patient needs in the manner the patient desires at the time the patient desires Shaller, D. Patient-Centered Care: What Does It Take? http://www.pickerinstitute.org/documents/PI%20Shaller%20Final%20Report.pdf

8. The Joint Principles of the PCMH Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others… • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinated and/or integrated • Quality and safety • Enhanced access to care • Payment to support the PCMH

9. Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat. Sun Tzu – Chinese Military General

10. Strategy Berwick, Nolan & Whittington; Health Affairs 2008

11. Tactics Berwick, Nolan & Whittington; Health Affairs 2008

12. Tactics Berwick, Nolan & Whittington; Health Affairs 2008

13. Information Organization Critical to Improving Care

14. Labs Radiology Suppliers Referral Requests Vendors & Suppliers Clinicians Home Health Hospitals Families/Pts Rx Payers/ Prior Auths Front Desk = Link to the “World”

15. Organized Charts Critical to Care

16. The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency. Bill Gates 640K ought to be enough for anybody. Bill Gates http://www.brainyquote.com/

17. Quality Pyramid

18. Quality Pyramid

19. Right number, skill sets, competencies • Clinical & administrative • Cross-trained • Assessment of readiness for change • Recognize potential “threats” to staff • Assess satisfaction with job activities • Remove barriers to working at level of training Personnel/Training/Competency

20. Identify any cultural issues that impede team-work and collaboration • Review hierarchy and org chart • Introduce team-huddles • Improve communication • Review facility layout and lines of sight Organization/Infrastructure

21. Evaluate work flow of common processes as well as uncommon yet critical pathways • Eliminate extraneous steps, layered “solutions” and misapplied technology • Consider the functionality of well-implemented technology to assist clinicians, staff, patients & families Workflow/Logistics

22. Technology • Right product(s) • Right prep & training • Right implementation • Right support • Right optimization • Right maintenance

23. Service • Organized, pro-active, responsive, accountable and accessible • Culturally competent • Addresses health literacy/numeracy • Focused on quality & safety • Addresses needs of individuals and the population • Incorporates patient preferences, stated needs/desires in formulating care strategies and follow-up • Uses health information technology to facilitate care

24. Bending the Curve Towards Transformed HealthAchieving Meaningful Use of Health Data • Improved outcomes • Advanced clinical processes • Data capture and sharing

25. HITECH Act(Medicare Provisions) • Provides monetary incentives for adoption of health IT ($44,000 per physician over 5 years) • Introduced concept of “Meaningful Use” • Decreasing incentives if start after 2012 • Must begin by 2014 to receive any payment • Reimbursement Penalty begins 2015 HITECH = Health Information Technology for Economic and Clinical Health Act 2009 http://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_081010.pdf

26. HITECH Act(Medicaid Provisions) • Medicaid – EPs who adopt, implement, upgrade, or meaningfully use certified EHR technology in their first year of participation in the program and successfully demonstrate meaningful use in subsequent years may be eligible for an incentive payment amount, subject to an annual limit. • Maximum = $63,750 HITECH = Health Information Technology for Economic and Clinical Health Act 2009 http://www.cms.gov/MLNProducts/downloads/EHRIncentivePayments-ICN903691.pdf

31. EHR Incentive Program • Core Set has 15 measures – need to meet all • Menu Set has 10 measures of which 5 have to be met • At least 1 of the measures needs to be: • Test of reporting to an immunization registry • Test of reporting to a public health agency for syndromic surveillance Blumenthal, D: NEJM, online July 13, 2010; in print, August 4, 2010 Also: http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

32. Meaningful Use in Practice Use the EHR (and staff) for the following 6 things: • Create problem lists • Enter allergies • Keep track of vaccinations and preventive care • Collect basic demographic data (date of birth, gender, race, ethnicity, and preferred language) • Check height, weight and blood pressure • E-prescribing AmericanEHR Blog Entry: http://blog.americanehr.com/americanehr-partners/meaningful-use/

33. And You Can… Satisfy 8 Core Set and 3 Menu Set Measures: • Core Set: 1) Computerized Physician Order Entry; 2) Drug-drug/Drug-allergy interactions; 3) Maintain up-to-date problem list; 4) E-prescribing; 5) Active medication list; 6) Active allergy list; 7) Recording of demographics; 8) Record/chart vital signs. • Menu Set: 1) Drug-formulary check (at least 1); 3) Generate list of patient with a specific condition; 4) Send reminders for preventive/follow-up care. AmericanEHR Blog Entry: http://blog.americanehr.com/americanehr-partners/meaningful-use/

34. Quality Measure Reporting • Six (6) total Clinical Quality Measures • 3 Core or Alternate Core, and… • 3 out of 38 from menu set • Align with PQRS quality measurement set

35. Quality Measure Reporting

36. Core Set/Alternate Core

41. Paper | EHR | EHR+MU

42. www.healthit.hhs.gov www.americanehr.com http://www.medscape.org/viewarticle/734299 Registration for EHR Incentive Program http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp#TopOfPage

43. http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401

49. Case Study • 10 physician multi-specialty practice • IM, ID, Rheum, Neuro Issues • Considering CMS EHR Incentive Program • Uncertainty about EHR meeting the needs of all specialists • Rural area; concerned about health IT support • Recently invested in new practice management system