The Good, the Bad, and the Ugly of the EHR Meaningful Use and Certification Final Rules:

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The Good, the Bad, and the Ugly of the EHR
Meaningful Use and Certification Final Rules
What Hospital Leaders Should Know about the
Medicare EHR Incentive Program
September 9 and 10, 2010
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Background and Overview
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HITECH Act
HITECH Act created the Medicare and Medicaid EHR
Incentive Programs

• HITECH Act was a section of the 2009 Federal
  Stimulus Bill the American Reinvestment and
  Recovery Act (ARRA).

• HITECH Act directs the Centers for Medicare and
  Medicaid (CMS) and the Office of the National
  Coordinator for Health Information Technology
  (ONC) to promulgate regulations implementing the
  EHR Incentive Programs.

Meaningful use and EHR certification rules

• Health care providers must be meaningful users
  of certified electronic health records in order
  to receive Medicare HIT incentive payments/not
  receive penalties.

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Rulemaking
Proposed Meaningful Use and EHR Certification
rules

• Released in December 2009.
• WHA and a number of Wisconsin hospitals submitted
  comments.

Final Meaningful use and EHR certification rules

• Published in July 2010.
• No comment period.

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Major Changes to Final Rule

• Final Rule - July 2010

• Proposed Rule - December 2009

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The Good
Modified all or nothing

• Proposed Rule 23 requirements

• Final Rule 14 requirements PLUS choose 5 of 10
  additional functionality requirements (1 public
  health related). Measures generally easier to
  meet.

CAHs now eligible for Medicaid EHR incentives
Exclusion for hospital-based physician narrowed

• Congress passed legislation correcting language
  that excluded many physicians who work in
  hospital-owned clinics from receiving EHR
  incentives

Reduction in reporting burden

• Certification rule now requires certified EHRs to
  automatically calculate the meaningful use
  measures.

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The Bad
Multi-campus hospital definition remains unchanged

• Hospitals are defined by their provider number.

Introduction of non-EHR related policy

• Measure - 10 of admitted patients are provided
  patient-specific education resources.

No long term plan

• CMS declined to follow recommendations to set
  requirements through 2017.

• Stage 2 begins as early as October 1, 2012.
  Stage 2 criteria expected by end of 2011.

• Unclear if new criteria for FY2015 (penalty year)
  and beyond.

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The Ugly.
Regulatory uncertainty will hinder hospitals
ability to meet timelines

• No certified EHRs currently exist certifying
  bodies just announced.

• Ambiguity in regulations CMS to provide
  additional guidance and explanation.

• Unknown future stages.

Widespread adoption of EHRs?

• CMS estimate As few as 32.1 of hospitals will
  get the maximum incentive.
• CMS estimate As many as 33.7 of hospitals will
  receive penalties.

CMS agrees that rural hospitals will have a more
difficult time achieving MU

• CMS believes additional 12K to CAHs (contingent
  on achieving MU) will lessen disparities.

Hidden functionality requirements in quality
measure requirements

• Significant changes to existing EHRs needed to
  calculate quality measures.

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WHAs Early Advocacy Strategy
House Ways and Means Subcommittee

• Letters to Reps. Kind and Ryan

• Contacts with their offices

D.C. visits
Multi-campus issue
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Key Provisions
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Medicare Incentive Timelines
First Qualifying Year Stage criteria EHs and EPs must meet in each payment year Stage criteria EHs and EPs must meet in each payment year Stage criteria EHs and EPs must meet in each payment year Stage criteria EHs and EPs must meet in each payment year Stage criteria EHs and EPs must meet in each payment year
FFY 2011 FFY 2012 FFY 2013 FFY 2014 FFY 2015 and Beyond
FFY 2011 Stage 1 Stage 1 Stage 2 Stage 2 TBD
FFY 2012 Stage 1 Stage 1 Stage 2 TBD
FFY 2013 Stage 1 Stage 1 TBD
FFY 2014 Stage 1 TBD
FFY 2015 TBD

• Only 90 days of compliance must be shown in first
  payment year.
• FFY begins October 1.

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Medicare Incentive Timelines
Incentive Payment Transition Factor for PPS Hospitals Incentive Payment Transition Factor for PPS Hospitals Incentive Payment Transition Factor for PPS Hospitals Incentive Payment Transition Factor for PPS Hospitals Incentive Payment Transition Factor for PPS Hospitals Incentive Payment Transition Factor for PPS Hospitals Incentive Payment Transition Factor for PPS Hospitals
Year hospital first qualifies Year hospital first qualifies Year hospital first qualifies Year hospital first qualifies Year hospital first qualifies
FFY 2011 FFY 2012 FFY 2013 FFY 2014 FFY 2015
Year hospital meets MU and receives incentive payment FFY 2011 100
Year hospital meets MU and receives incentive payment FFY 2012 75 100
Year hospital meets MU and receives incentive payment FFY 2013 50 75 100
Year hospital meets MU and receives incentive payment FFY 2014 25 50 75 75
Year hospital meets MU and receives incentive payment FFY 2015 25 50 50 50
Year hospital meets MU and receives incentive payment FFY 2016 25 25 25

• Only 90 days of compliance must be shown in first
  payment year.
• FFY begins October 1.

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Medicare Incentive Timelines
Penalties if not adopting by FY 2015 Penalties if not adopting by FY 2015 Penalties if not adopting by FY 2015 Penalties if not adopting by FY 2015
FFY 2015 FFY 2016 FFY 2017
PPS Hospitals - Three-quarters of the applicable market basket update is reduced by 33.33 66.66 100
CAHs Allowable Medicare cost reimbursement percentage reduced to 100.66 100.33 100.00

• FFY begins October 1.

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PPS Hospital Medicare Incentive Payment Formula
Step 1 Calculate base dollar amount (2 million (your discharges from 1150 through and including 23,000)200)) Example assuming 3,149 discharges (2,000 within eligible range) 2 million 400,000 2,400,000
Step 2 Calculate Medicare Share Medicare inpatient days / (total inpatient days((gross revenue charity) / gross revenue))
Step 3 Multiply base by Medicare share Using an example Medicare Share of .50 2,400,000 X .50 1,200,000
Step 4 Determine payment for each year (Assuming 4 years of payments) Payment Year 1 1,200,000 (100) Payment Year 2 900,000 (75) Payment Year 3 600,000 (50) Payment Year 4 300,000 (25)
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CAH Medicare Incentive Payment Formula

• Basis for CAH Medicare EHR incentive payments is
  the reasonable cost reimbursement structure.

• Design of Medicare EHR incentives allows CAHs to
  accelerate and increase the inpatient payment for
  depreciation of reasonable costs for purchase of
  depreciable assets such as computers and
  associated hardware and software, to support
  meaningful use of certified EHR technology

• Reasonable costs can be depreciated in a single
  year, rather than over the life of the assets.

• The costs of assets incurred in previous years
  that have not been fully depreciated may also be
  included.

• Medicares share of CAH EHR incentives is
  calculated the same as the PPS hospital EHR
  incentives plus 20 percentage points (not to
  exceed 100).

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CAH Medicare Incentive Payment Formula
Step 1 Calculate Cost of HIT Hypothetical FY 2011 5 million FY 2012 5 million FY 2013 5 million FY 2014 5 million
Step 2 Calculate Medicare Share (Medicare inpatient days / (total inpatient days((gross revenue charity) / gross revenue))) 20
Step 3 Multiply Cost by Medicare Share Using an example Medicare Share of 50, plus 20 bonus 70 20,000,000 X .70 14,000,000
Step 4 Calculate 101 of Medicare Share of Costs Total Payment 101 14,000,000 14,140,000
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Medicaid EHR Incentive Program
Significant differences between the Medicare and
Medicaid EHR Incentive Programs

• Only eligible for Medicaid Incentive Program if
• The hospital is a childrens hospital or
• 10 or more of the hospitals volume is
  attributable to Title XIX Medicaid.

• Hospitals can receive both Medicaid and Medicare
  EHR incentive payments eligible professionals
  must choose either Medicaid or Medicare EHR
  incentive payments.

Focus of WHAs September 21 webinar

• Additional information on the Medicaid EHR
  Incentive Program can be found at
• http//www.wha.org/education/default.aspx

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Meaningful Use Measure Highlights
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Meaningful Use Measure Highlights
CPOE retained, but substantially revised

• Objective 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.

• Measure More than 30 of unique patients with
  at least one medication in their medication list
  admitted to the eligible hospitals or CAHs
  inpatient or emergency department (POS 21 or 23)
  have at least one medication order entered using
  CPOE.

• CPOE only required for medication orders in Stage
  1.

• Others may enter the order.

• Measure limited to patients whose records are
  maintained using certified EHR

• Emergency department included in measure.

• Stage 2 increases percentage to 60.

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Meaningful Use Measure Highlights
Quality measures and submission revised

• Hospitals must report 15 measures (3 sets)
• Endorsed by National Quality Forum
• Not in current quality reporting program
  (RHQDAPU)
• e-specified but not field tested

• Calculation through the EHR, but submission is
  through attestation in 2011
• Numerators
• Denominators
• Patient exclusions

Anticipate electronic submission in 2012
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Meaningful Use Measure Highlights
Quality measures and submission revised
Condition Measure Name
Emergency Department Throughput Median time from ED arrival to ED departure for admitted patients
Emergency Department Throughput Admission decision time to ED departure time for admitted patients
Stroke Discharge on anti-thrombotics
Stroke Anticoagulation for A-fib/flutter
Stroke Thrombolytic therapy for patients arriving within 2 hours of symptom onset
Stroke Anti-thrombotic therapy by day 2
Stroke Discharge on statins
Stroke Stroke education
Stroke Rehabilitation assessment
Venous Thrombo-embolism (VTE) VTE prophylaxis within 24 hours of arrival
Venous Thrombo-embolism (VTE) Intensive care unit VTE prophylaxis
Venous Thrombo-embolism (VTE) Anticoagulation overlap therapy
Venous Thrombo-embolism (VTE) Platelet monitoring on unfractionated heparin
Venous Thrombo-embolism (VTE) VTE discharge instructions
Venous Thrombo-embolism (VTE) Incidence of potentially preventable VTE
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Meaningful Use Measure Highlights
but the new quality measures contain hidden
functionality requirements

• The 15 quality measures require data capture
  functionality beyond the initial EHR functional
  requirements explicitly required in certification
  and MU rule.
• Examples
• Data sources for the quality measures include
  physician documentation, medication
  administration, computerized provider order entry
  and discharge instructions.
• Data elements for quality reporting must be in
  structured formats that are not widely used.

• Computer Sciences Corporation study
• Hospitals meeting the explicit data capture
  requirements under meaningful use will have only
  35 of the data needed for the hospital quality
  measures.
• The remaining 65 are hidden requirements of
  meaningful use.

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Certification Rule Highlights
Hospitals must attest that they have certified
EHR technology

• Complete EHR, or
• Combination of EHR modules.

Certification requirements linked to each
meaningful use criteria
No grandfathering of CCHIT certification

• All providers with existing CCHIT certified EHRs
  will need to re-certify

No EHRs will be certified until ONC establishes
certification entities

• ONC will approve ONC testing and certification
  bodies (ONC-ACTBs)
• First ONC-ACTBs announced last week CCHIT and
  the Drummond Group.
• ONC anticipates first certifications by the end
  of the year.

Certification will be for 2011-2012

• NEW certification will be required in 2013.

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Resources
WHA Toolkit

• http//www.wha.org/toolKit/default.aspx

WHA Education

• http//www.wha.org/education/default.aspx
• Sept 21 - Medicaid and Meaningful Use - The
  "Other" EHR Incentive Program What Hospital
  Leaders Should Know About the Medicaid EHR
  Incentive Program (Webinar)
• Third Party Webinars

EHR Consulting Database (coming soon)

• ONC Resources
• http//healthit.hhs.gov/portal/server.pt?open512
  mode2objID3006PageID20401

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Questions?