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

ACHIEVING MEANINGFUL USE FOR YOUR PRACTICE

Huong Le, DDS,MA

Yankee Dental Congress 2014

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OBJECTIVES2

1. Overview and Updates of Meaningful Use Incentive program: stage II

2. Oral health measures 3. How to report the data through EHR 

Overview3

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

Meaningful Use Program4

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

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

Goals of Using Certified EHR to Achieve Meaningful Use

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A Conceptual Approach to Meaningful Use

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Data Capture and Sharing

Advanced clinical Processes

Improved Outcomes

Goals of Meaningful use7

Adoption

MeaningfulUse

Exchange

Improved Individual and Population Health Outcomes

Increased Transparency and efficiency

Improved ability to study and improve care delivery

• Regional Extension Centers• Medicaid EHR Program 1st year

incentive• Workforce Training

• 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

Health IT Practice Research

Eligibility: Practices Predominantly & Needy Individuals

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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

The Medicaid EHR Incentive ProgramSummary

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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

Medicare vs. Medicaid10

Medicare EHR Incentive Program Medicaid EHR Incentive Program

Run by CMS Run by Your State Medicaid Agency

Maximum incentive amount is $44,000 Maximum incentive amount is $63,750

Payments over 5 consecutive years Payments over 6 years, does not have to be consecutive

Payment adjustments will begin in 2015 for providers who are eligible but decide not to participate

No Medicaid payment adjustments

Providers must demonstrate meaningful use every year to receive incentive payments.

In the first year providers can receive an incentive payment for adopting, implementing, or upgrading EHR technology. Providers must demonstrate meaningful use in the remaining years to receive incentive payments

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REQUIREMENTS FOR MU

Recommendations for Health Center Dental programs

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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?

Requirements for MU Reporting13

15 Core Objectives14 Objective Measure Exclusion Dentist

RoutineRecord patient demographics (sex, race, ethnicity, date of birth, preferred language)

More than 50% of patients’ demographic data recorded as structured data

None Yes

Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children)

More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data

An EP who either sees no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice

Yes: Blood pressure

 No: Other

vitals

Maintain up-to-date problem list of current and active diagnoses

More than 80% of patients have at least one entry recorded as structured data

None Yes

Maintain active medication list More than 80% of patients have at least one entry recorded as structured data

None Yes

Maintain active medication allergy list More than 80% of patients have at least one entry recorded as structured data

None Yes

Record smoking status for patients 13 years of age or older

More than 50% of patients 13 years of age or older have smoking status recorded as structured data

An EP who sees no patients 13 years or older

Potential

Provide patients with clinical summaries for each office visit

Clinical summaries provided to patients for more than 50% of all office visits within 3 business days

An EP who has no office visits during the EHR reporting period

Potential

On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies)

More than 50% of requesting patients receive electronic copy within 3 business days

An EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period

Potential

15 Core Objectives… continued15 Objective Measure Exclusion Dentist Routine

Generate and transmit permissible prescriptions electronically

More than 40% are transmitted electronically using certified EHR technology

An EP who writes fewer than 100 prescriptions during the EHR reporting period

Potential

Computer provider order entry (CPOE) for medication orders

More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE

An EP who writes fewer than 100 prescriptions during the EHR reporting period

Potential

Implement drug-drug and drug-allergy interaction checks

Functionality is enabled for these checks for the entire reporting period

None Yes

Implement capability to electronically exchange key clinical information among providers and patient-authorized entities

Perform at least one test of EHR’s capacity to electronically exchange information

None Yes

Implement one clinical decision support rule and ability to track compliance with this rule

One clinical decision support rule implemented

None Yes

Implement systems to protect privacy and security of patient data in the EHR

Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies

None Yes

Report clinical quality measures (CQMs) to CMS or states

For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures. Note: NNOHA has proposed additional CQMs for consideration that are relevant to oral health.

None 

Potential

Select 5 out of 10 menu objective

16Objective Measure Exclusion Dentist Routine

Implement drug formulary checks Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period

None Yes

Incorporate clinical laboratory test results into EHRs as structured data

More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data

An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period

Potential

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach

Generate at least one listing of patients with a specific condition

None Yes

Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate

More than 10% of patients are provided patient-specific education resources

None Yes

Perform medication reconciliation between care settings

Medication reconciliation is performed for more than 50% of transitions of care

An EP who was not the recipient of any transitions of care during the EHR reporting period

Potential

Provide summary of care record for patients referred or transitioned to another provider or setting

Summary of care record is provided for more than 50% of patient transitions or referrals

An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period

Potential

Select 5 out of 10 menu objectives continued

17Objective Measure Exclusion Dentist Routine

Send reminders to patients (per patient preference) for preventive and follow-up care

More than 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders

An EP who has no patients 65 years old or older or 5 years old or younger with records maintained using certified EHR technology

Potential

Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies)

More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

An EP that neither orders nor creates any of the information listed at 45 CFR 170.304(g) during the EHR reporting period

Potential

*PH* Submit electronic immunization data to immunization registries or immunization information systems

Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions)

An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically

No 

*PH* Submit electronic syndromic surveillance data to public health agencies

Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically

Potential 

CORE #2: COMPUTER PROVIDER ORDER ENTRY (CPOE)

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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.

REPORTABLE CORE MEASURES

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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.

REPORTABLE CORE MEASURES

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Maintain an up-to-date problem list of current and active diagnoses.

Provide patients with an electronic copy of their health information including:

1. Diagnostics test results2. Problem list3. Medication lists4. Medication allergies

REPORTABLE CORE MEASURES

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Provide clinical summaries for patients for each office visit.

Recall reminders: eMessage or letter

EXAMPLE OF CLINICAL SUMMARIES22

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

Information in visit summary

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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.

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LET’S TALK ABOUT MONEY!

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Stages of payments26

Payments: EP Adoption Timeline27

2011 2012 2013 2014 2015 2016

2011 $21,250

2012 $8,500 $21,250

2013 $8,500 $8,500 $21,250

2014 $8,500 $8,500 $8,500 $21,250

2015 $8,500 $8,500 $8,500 $8,500 $21,250

2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250

2017 $8,500 $8,500 $8,500 $8,500 $8,500

2018 $8,500 $8,500 $8,500 $8,500

2019 $8,500 $8,500 $8,500

2020 $8,500 $8,500

2021 $8,500

TOTAL

$63,750 $63,750 $63,750 $63,750 $63,750 $63,750

Payment schedule28

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).

PAYMENT SCHEDULE29

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

Payment Methodology30

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.

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CALCULATIONS

COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE)

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Measure Information and Measure 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

Stage I reporting changes33

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.

From Stage I to Stage II34

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.

From Stage I to Stage II35

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.

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 1. Patient and Family

Engagement 2. Patient Safety 3. Care Coordination 4. Population and Public Health 5. Efficient Use of Healthcare

Resources 6. Clinical

Processes/Effectiveness

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Stage II MU Core set

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1. Use computerized physician order entry (>60% medication, 30% lab and 30% radiology orders)

2. Prescribe permissible drugs electronically (>50%)

3. Record patient demographics (>80%)

4. Record and chart changes in vital signs (>80%)

5. Record smoking status (>80%)

6. Use clinical decision support (at least five interventions)

7. Incorporate clinical lab results into EHR (more than 55%)

8. Generate lists of patients by specific conditions (at least one list)

Stage II MU Core set (cont.)38

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

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WHAT DO DENTISTS NEED TO DO?

From the CMS Final Rule

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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.

41Proposed Top Three Alternate Core Set Measures for Dentists (substitute when any of thecurrent CQMs do not apply)

Dentist Routine

Annual Oral Health Visit Yes

Topical Fluoride or Fluoride Varnish Treatment Yes

Periodontal Disease Assessment Yes

Proposed Other Alternate Core Set Measures for Dentists Dentist Routine

Dental Sealant Yes

Oral Cancer Risk Assessment & Counseling Yes

Completed Comprehensive Treatments Plan Yes

NNOHA’S PROPOSED CQMS

Stage 2 CQM: NQF ORAL HEALTH MEASURES

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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.

Accepted Oral Health Measures

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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.

DENTAL QUALITY ALLIANCE (DQA) PROPOSED MEASURES

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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

DENTAL QUALITY ALLIANCE PROPOSED MEASURES

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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.  

Stage III46

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

HOW TO ATTEST47

Varies state by state. Please check your Medicaid website

Registration & Attestation process NPI Registry CMS Identify and Access CMS Registration and Attestation

HOW TO ATTEST (CONT)48

STEP 1:  Select and adopt a certified EHRSTEP 2:  Register at the CMS Registration Portal  STEP 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

STEP #149

Select a certified product listed in the Certified EHR list

STEP #250

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).  

STEP #351

Visit the Certified Health IT Product List (CHPL) to obtain your unique CMS EHR Certification ID.

STEP #452

 Attest through the Medicaid portal. In addition to reporting your EHR Certification ID, this website will require

you to attest to the required 30% Medicaid patient volume. The patient volume will be calculated based on any continuous 90 days in the year previous to applying for the incentive.

You will have the ability to choose one of the following two options to calculate patient volume:

Patient Encounters – The total number of Medicaid encounter divided by the total patient encounters.  Patient Panel – The total number of Medicaid Panel Assignments and Encounters divided by total panel assignments and total panel encounters.   

The following events are considered Medicaid Encounters Services rendered on any one day to an individual where Medicaid paid

for any portion, or all of the service provided. Services rendered on any one day to an individual where Medicaid paid

all or part of their premium, co-payment, or cost-sharing.  

STEP #553

 Incentive Payment The federal Medicaid EHR incentive is

$21,250 in the first year of program participation and $8,500 over program years 2-6. The total incentive is $63,750 over six years

STEP #654

Complete 90 days of "meaningful use" in the second year of program participation.

$8,500,: complete 90 days of meaningful use. EPs must complete a set of 15 core criteria and choose 5 from 10 criteria on a menu set for Stage 1 meaningful use criteria. 

E-prescribe.  If you are eligible, you can receive both the Medicaid EHR incentive and the e-prescribing incentive in the same year. Meaningful use requires you to generate and transmit permissible prescriptions for more than 40 percent of all permissible prescriptions.  If you only accept Medicaid, there are no punitive penalties scheduled for failure to comply with meaningful use or e-prescribing.

Once you've successfully completed a 90 day period of meaningful use, log back on to the CMS Registration and Attestation website to enter attestation data. If you have not successfully met each required measure, you will be required to resubmit.

Additional resources55

Get information, tip sheets and more at CMS’ official website for the EHR incentive programs:

http://www.cms.gov/EHRIncentivePrograms Follow the latest information about the EHR

Incentive Programs on Twitter at http://www.Twitter.com/CMSGov

Learn about certification and certified EHRs, as well as other ONC programs designed to support providers as they make the transition

http://healthit.hhs.gov www.nnoha.org

THANK YOU!56

QUESTIONS?