Mirro_EMR

Health Reform and HIT Federal Support for Adoption Michael Mirro MD, FACC : Chair ACC Informatics Committee CCHIT Advanced Quality WG

Agenda • ACC HIT Efforts • Federal Financial Incentives a) PQRI b) e-Prescribing c) American Recovery Reinvestment Act • HIT : IC3 Workflow Solutions • Summary

ACC Informatics Committee Efforts • Health IT website (www.acc.org/healthIT) • Updated with ARRA information and relevance to members • EHR Toolkit – includes helpful hints, advice on contract negotiations, selection tools, educational resources, and Federal EHR incentive program information.

• E-Prescribing Initiative – includes overall benefits, minimum functional criteria, and CMS e-Prescribing Incentive Program information

• Unique Patient Identifiers Principles Document • Stance: A mandatory UPI is vital to increasing quality of care for patients and outweighs privacy concerns • Used to help advocacy and ACC members when approaching the Hill • Currently reaching out to peer organizations for notice and possible collaboration.

ACC Informatics Committee Efforts • ACC Data Definitions for Cardiovascular EHR • List of data elements that are essential for care in the cardiology domain.

• Consolidates data definitions from multiple data dictionaries • Receiving comments from other ACC committees

• CardioPath™ Pilot Project • Translates ACC/AHA clinical guidelines into clinical decision support • Guideline Adherence Tool web application is available • Working with EHR vendors to test proof of concept

The Cost of a Long Life U.S.

UC Project for Global Inequality

6

Accelerating EHR Adoption: Government Role • • • •

Financial Incentives PQRI ARRA e-Prescribing

HIT : Federal Incentives • PQRI $3,000-5,000/year – 2007: 1.5% – 2008: 2.0% – 2009: 2.0%

• E-Prescribing $3,000-5,000/year • ARRA EHR Funding : $44,000 – 5 years (plus 10% Bonus $48,400 :Medicaid)

PQRI Requirements • Report on PCPI/NQF Endorsed Performance Measures • Claims-Based Quality Data : Quality Data Codes (QDC) • Maximum Financial Incentive achieved if 3 measures reported on > 80% of eligible encounters • Use of CCHIT EHR : Performance Measure (2009)

America Recovery & Reinvestment Act (ARRA): 02/17/09 • Total: $790 Billion • Healthcare (total): $59 Billion • HITECH: $34 Billion – Key Components 1.Leadership 2.Funding and incentives 3.Standards 4.Certification 5.Research and development 6.Education and outreach 7.Privacy and security

ARRA Health IT Funding ($34B) • $20.8 billion – Medicare & Medicaid incentives to providers for EHR adoption • $4.7 billion – NTIA Broadband Technology • $2.5 billion – USDA distance learning, telemedicine, broadband technology • $2 billion – ONCHIT • $1.5 billion – HRSA for health centers • $1.1 billion – comparative effectiveness research (AHRQ, NIH, HHS) • $500 million – Social Security Administration • $85 million – Indian Health Service health IT • $50 million – VA information technology

Medicare EHR Incentives and Penalties

Definition of Certified EHR Technology • Meeting standards pursuant to ARRA • Includes demographic, clinical health information (history, problem lists)

• Provides clinical decision support • Supports order entry

• Capture, query, reporting on quality (process) • E-exchange, integration of health information

Role of Certification in the National Health IT Strategy American Health Information Community and AHIC Workgroups Office of the National Coordinator

Standards Harmonization HITSP NHIN Prototype & Implementation Projects Privacy & Security Policies, Laws, Regulations

Strategic Direction + Breakthrough Use Cases

Harmonized Standards Network Architecture Privacy Policies

CCHIT: Certifying Standards Compliance of Health IT

Certification of EHRs and HIEs

Accelerated adoption of robust, interoperable, privacy-enhancing health IT

Governance and Consensus Process Engaging Public and Private Sector Stakeholders

Certification is a voluntary, market-based mechanism to| accelerate the adoption of standards and interoperability Š 2008 | Slide 14 Nov 10, 2008

HITECH : $19 Billion • Physician Incentives : $17 Billion • HHS Discretionary Funds : $2 Billion a) Standards Requirements b) HIE Infrastructure (NHIN) c) Regional Health IT Resource Centers d) State Grants (2010) e) Promote EHR : Quality and DM

Health IT in ARRA Leadership • •

Established Office of National Coordinator $2B in appropriations Established 2 Federal Advisory Committees •

•

HIT Policy Committee – recommendations to ONC regarding e-exchange, use of health information HIT Standards Committee - recommendations to ONC regarding standards, implementation specifications, and certification criteria

HIT : e-Prescribing Requirements • Electronic Transmission of Prescriptive Data (Bi-directional) • SureScripts/RxHub Certified • Drug-Drug Interaction Reconciliation • Drug Allergy Reconciliation • CCHIT, AHIC, HITSP Compliance • HIPPA Compliance • Surrogate Prescriptive Function(e-confirm) • Patient Prescriptive Eligibility/Formulary Reconciliation

EHR : Physician Perspective • Analog Medical Record : Static Documents • Documentation : Guilty until Innocent • Physician Time : Cognitive not Clerical • Analog Medical Record : Lack of Redundancy • EHR : Critical to Guideline Compliance • EHR : Cardiac Care Team Communication • EHR : Improved Efficiency – Chart Pulls

EHR : Patient Perspective • • • • • • •

One Chart : Secure and Web Based No Need to Repeat History Entry Medications/Allergies : Accessible Imaging &Testing Accessible one Site Alerts for Appropriate Testing Quality Assurance Web Access : Appointments/Refills

EHR : Payer Perspective • • • • •

Improved Documentation Enhanced Clinical Transparency Improved Billing/Coding/Claims Data/Document Transfer Pay-for-Performance Potential

EHR : Burning Platform • EHR Adoption: Not if but when • EHR: Critical for Quality, Efficiency • Pay-for-Performance: Gaining Momentum • Demand for Best Practices • Demand for Transparency

Health Information Technology • Automation • Connectivity • Clinical Decsion Support • Data-Mining Capabilities

Accelerating EHR Adoption: Government Role • EHR Standards • EHR Vendor Certification • Financial Incentives • Data Storage and Exchange

Percentage of Office-Based Physicians in the United States Using Electronic Medical Records, 2001-2006

Steinbrook R. N Engl J Med 2008;358:1653-1656

Percentage of Physicians Using Electronic Medical Records (EMRs) According to Practice Size, in 2005

Blumenthal D and Glaser J. N Engl J Med 2007;356:2527-2534

EHR Selection Acceleration of Quality Improvement

Minimally Invasive Investment • Web-based EMR – Minimal up-front investment – Accessible from any PC with a Web browser, anywhere, anytime

• Incremental, scalable EMR – Pay for what you need, when you need it – Don’t pay for what you don’t need

• Interoperable EMR – No/low cost integration – Require IHE Certification and proof of interoperability.

HIT and Aviation • • • •

Complex Tool Sets Training Essential to Success Implementation Plan Key Good Technology cannot Succeed without Infrastructure Support • Technology Upgrades require Retraining • Good and Poor Technology Design Exist

Health IT: A means to an end Health IT works in real-world clinical settings but some unanswered questions • How does Health IT drive safety and quality improvement?

• How can we ensure that doing the right thing is the easy thing to do?

• How can we use the power of Health IT to provide better quality measures faster?

Explosion of “EvidenceBased Medicine/Practice” 1000

No. of EBM Medline References

900 800 700 600 500 400 300 200 100 0

1990

1992

1994

1996 Year

1998

2000

Culture Issues : Quality • • • • •

Patients Physicians Hospitals Health Plans Purchasers

Critical Elements : CV EHR • Web Based Solution • ASP Model for Guideline Software updates • Allows differing modes of data input • DICOM Functionality • Inter-operability (IHE) • C-CHIT Certification

TurboCharging the EHR • Clinical Decision Support – Evidence-based medicine at the point-of-care • Congestive Heart Failure • Atrial Fibrillation • Coronary Artery Disease

Congestive Heart Failure: Quality Indicators • • • • •

ACE-Inhibitors Beta-Blockers Spironolactone (Class III/IV) Assessment LVEF (Echo/Nuclear) TLC : diet/exercise/wt-bp monitoring

Clinical Decision Support − Active prompts/reminders to encourage changes in patient management, regardless of reason for visit − Reminders drawn established care guidelines − Pharmacy decision support draws from patient specific database, which includes age, weight, allergies and lab results − Drug utilization review − Rules-based triggers

CHF: CV Physician Chart Audit 100 90 80 70 60 50 40 30 20 10 0

SPLC III/IV ACE-I BBLOC

MD-A

MD-B

MD-C

MD-D

CHF: CV Physician Chart Audit 100 90 80 70 60 50 40 30 20 10 0

SPLC III/IV ACE-I BBLOC

MD-E

MD-F

MD-G

MD-H

CHF: CV Physician Chart Audit 100 90 80 70 60 50 40 30 20 10 0

SPLC III/IV ACE-I BBLOC

MD-I

MD-J

MD-K

MD-L

Condition/Problem list reviewed and updated.

Observations are collected and entered.

Quality Care Guidelines are reviewed and alerts are presented.

Orders are entered to satisfy alerts.

Prescriptions are printed.

Patient education is printed.

Compliance Data: Year One 100 90 80 70 60 50 40 30 20 10 0

Beta Blocker ACE-I SPLCT

1st Qtr

2nd Qtr

3rd Qtr

4th Qtr

Next Steps • • • • • •

www.acc.org/healthIT www.cchit.org Organizational Change Assessment Develop Implementation Team Develop Training/Implementation Plan Vendor Selection (CCHIT & IHE)

HIT : NCDR IC3 Adoption • First Office-Based Registry Designed to Assess Physician Adherence to ACC/AHA Performance Measures • Provides Powerful Tool to Assess Clinical Care for CAD and CHF patients • A Potential Vehicle to Transform Performance Measurement to Quality Improvement at Point of Care

You could do this on paper • Requiring valuable FTE time and introducing the opportunity for error • And sending it to the ACC where it will be entered into a database (again introducing the opportunity for error)

Or you could do this electronically…

• The timing is ideal – Select EHR vendors now certified for IC3 – IC3 satisfies PQRI requirements – EHR vendors also incorporate e-prescribing – Current CMS bonus payments help offset EHR investment costs – EHR adoption incentives start in 2011 and total $44,000 per physician • FOR IMPLEMENTED AND MEANINGFUL EHR USE • START NOW!

EHR with integrated

3 IC

• Simplified data collection and reporting – Existing data in EHR can populate collection forms – As you document encounters in EHR, that data can also populate collection form – At conclusion of encounter, completed collection form is submitted and transmitted to ACC for entry into IC3 database

Sep-09

Aug-09

179

176

175

168

160

149

149

530

530

626

624

623

600

578

531

504

700

Jul-09

Jun-09

May-09

Apr-09

Mar-09

144

136

274

264

600

Feb-09

86

82

224

211

184

174

152

Practices

Jan-09

Dec-08

Nov-08

66

60

50

44

38

150

145

300

Oct-08

Sep-08

Aug-08

Jul-08

Jun-08

36

34

100

May-08

0 0

200

Apr-08

Mar-08

3 IC

Program at ACC

IC3 Program Enrollment

500 Office Sites

400

0

3 IC

Program at ACC

IC3 Pilot Encounter Records Entered 213,799

200,000

158,000

150,000

109,479

100,000

Sep-08

Oct-08

Sep-09

Aug-08

Aug-09

Jul-08

Jul-09

Jun-08

Jun-09

May-08

10,899 11,500 5,722 8,152 1,910 2,466 3,246 4,267 May-09

940

Apr-09

0

Mar-09

0

Feb-09

0

Jan-09

0

Dec-08

0

Nov-08

0 Apr-08

0

0 Mar-08

50,000

Fort Wayne Cardiology…

• Is currently the only practice using its EHR for electronic data collection, reporting and population of the IC3 registry • Medical Informatics Engineering – Is the only EHR vendor currently offering a fully integrated IC3 data collection and reporting module – Recently signed a strategic agreement with the ACC to foster the adoption of EHR products with integrated IC3 functionality

Significant opportunity • To encourage cardiology practice adoption of EHR systems with integrated quality registry module(s) • Timing is ideal – ARRA incentives for physician adoption include meaningful use criteria focused on quality reporting • The ACC and its vendor partners are ready to provide enthusiastic support

3 IC is

now…

How will you spend your $44,000?

Consider a workhorse

Questions ??