Meaningful Use in HIT: The Consumer and Purchaser Perspective

Background and Overview of the Proposed Rule

Peter V. LeeCo-chair, Consumer-Purchaser Disclosure Project

National Policy Director, Pacific Business Group on Health

David LanskyPresident and CEO

Pacific Business Group on Health

Eva PowellDirector, Consumer Partnership for e-HealthNational Partnership for Women & Families

WebinarMarch 9. 2010

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Agenda

Welcome and Background on Meaningful Use Notice of Proposed Rule Making (NPRM)– Peter Lee, Disclosure Project and PBGH

Elements Most Relevant to Consumers and Purchasers/Crosswalk with Disclosure’s Comments to CMS – David Lansky, PBGH– Eva Powell, NPWF

Discussion and Q&A– Peter Lee

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Health Reform Elements

Major Policy Area Critical Value Policies

Coverage expansion and Financing

1. Align public and private policies2. Connector or Exchange promoting value

Benefits 3. Assure core benefits promote affordable “right care”

System Reforms 4. Full measures and public reporting (including release Medicare data)

5. Promote wellness 6. Consumer and provider incentives for shared

decisions7. Payment reform – Change payments AND the decision

process 

Infrastructure 8. Patient-centered comparative effectiveness 9. HIT that promotes better care10. Foster innovation

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HIT that Promotes Better Care – Making Sure Information Technology is “Bridge to Somewhere

NOT about boxes in doctors offices – it is about fostering true “meaningful use”

• Supporting decisions by clinician at the point of care and reduce errors

• Involving patient in their own information• Collecting real-time performance information for

measurement purposes• Gives feedback to patients and clinicians• Promotes innovation

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Meaningful Use Background• HITECH provisions of ARRA created voluntary Medicare &

Medicaid incentives for meaningful users of EHRs– Carrot and stick approach: incentives in 2011, 2013, and 2015;

penalties after 2015

• Core Criteria in HITECH:1. Use certified EHR in a meaningful manner, including eRx2. Engage in electronic exchange of health information to improve

quality3. Report on clinical quality measures

• In July 2009, HIT Policy Committee recommended framework definition of Meaningful Use. – CMS used this as the basis for the proposed rule released in

December 2009, comments due March 15, 2010.

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The Proposed CMS Rule Moves Health Care To Being More Patient-Centered:

– Increased focus on improving health care and outcomes– Inclusion of patients and families as primary participants in health

information sharing. – Criteria stages build upon each other to provide a glidepath for

phased implementation that avoids dead-ends. – Balances achievability by a broad array of health care professionals

with the urgency to stimulate significant progress toward improved health and health care.

– Aligns Federal policy levers and ARRA programs to support meaningful use (Funding for RECs, Beacon, etc)

– Prioritizes use of resources to provide support to areas and providers that have the greatest need.

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Consumer and Purchaser Opportunities

• Participate in the national dialogue to be sure “Meaningful Use” is defined to meet patient and purchaser needs – as well as providers

• Make sure your voice is heard:– Sign-on to the Disclosure Project letter, and send individual

letters from your organization supporting CMS’ proposed definition in the face of provider challenges

– Send your own letter– Engage nationally and locally in discussions on Meaningful

Use

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Advocacy Messages for Consumers and Purchasers• CMS’ proposed meaningful use definition supports the

elements necessary to create a patient-centered health care system – The purpose of incentive payments for meaningful use is not to reward

the status quo, or to digitize paper health records. It is to accelerate transformation of the system and ensure that transformation leads to significant differences for patients and their families.

• We urge consumer, labor, and employer organizations to voice strong support for CMS in its efforts– CMS is facing strong opposition from the provider community, which

argues that the requirements for incentives are too burdensome.• The proposed definition is directionally appropriate and we

encourage CMS to maintain its robust meaningful use criteria. – Public dollars are being devoted to assuring that HIT is used in a

meaningful way; thus public goals MUST be met despite provider opposition

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How to Voice Your Support

• Add your organization’s name to the Disclosure Project’s comment letter

• Submit a letter from your organization:– Go to www.regulations.gov– Cite CMS-0033-P– If you submit your own letter, please send

a copy to talteras@nationalpartnership.org!

Meaningful Use in HIT: The Consumer and Purchaser Perspective

David LanskyPresident and CEO

Pacific Business Group on Health

Eva PowellDirector, Consumer Partnership for e-HealthNational Partnership for Women & Families

WebinarMarch 9. 2010

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The Proposed Rule: What It Is & Why It Matters

David LanskyPresident and CEOPacific Business Group on Health

Eva PowellDirector, Consumer Partnership for e-HealthNational Partnership for Women & Families

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Bottom Line on the Proposed Rule:

• CMS is on the right track with the proposed rule.

• The final rule must maintain its strong and ambitious direction to ensure that the public truly benefits from this incredible investment of taxpayer dollars.

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The Definition of Meaningful Use Supports Critical Goals:• Increasing care coordination and fostering better

doctor-patient communications• Reducing medical errors and improving patient safety• Supporting delivery of evidence-based care• Reducing disparities by recording demographic

information• Improving quality while fostering more cost-effective

delivery• Advancing payment reform • Providing patients with their own, portable health

information

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Definition is Directionally Appropriate

• Strongly supports a patient-centered view of health care

• Offers providers flexibility, yet retains patient privacy and security

• Appropriately uses clinical quality measurement

• Makes appropriate allowances for the current state of technology infrastructure

• Will result in vast improvements in data collection and understanding of how care is delivered

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A Definition that Takes Consumer and Purchaser Concerns Into Account

• For consumers: Focuses on improving care and outcomes and not just automating processes and digitizing data

• For purchasers : Focuses on evidence-based strategies that can ultimately reduce the rate of cost increases, improve care and outcomes, and reduce spending

• Two important components: – Quality measurement using clinical data– Race, ethnicity, language and gender (“RELG”)

data collection

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Need for Consumer and Purchaser Voice in Face of Provider “Slow Down”

• Providers and other health care industry stakeholders voicing strong opposition to this proposed definition

• Consumers and Purchasers must take advantage of the advocacy opportunities available in this arena

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Meaningful Use Addresses Provider Concerns: Concerns & Responses

• Very few providers would be able to fulfill all of the criteria today. We should scale it back so more providers can receive payments– Rather than weakening the definition to increase participation rates, we

should take this opportunity by harnessing the efforts of various national- and state-level technical assistance programs to support provider participation and make great strides toward a patient-centered health care system.

• It takes years to fully adopt and implement EHR technology. The MU definition is asking too much, too soon for 2012– In the first year providers will only have to demonstrate MU for 90 days,

giving them 9 months to improve their systems.• The criteria are focused too much on primary care. Specialists will

not be motivated to meet the requirements to receive incentives– The definition’s orientation toward primary care is appropriate and

necessary, given the role primary care providers play in our system, the shortage of providers, and the existing inequity in reimbursement for PC services.

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Arguments and Responses, con’t

• Small primary care practices won’t have the resources to implement such high-level technology– HITECH includes funding for Regional Extension Centeres to provide small

practices with technical assistance. Medicaid providers will also receive funding in the first year to adopt, implement, or upgrade certified EHR technology.

• Collecting RELG data is not as simple as adding a data field– Having better information about patient demographics is critical to

eliminating health disparities and improving care for vulnerable populations. Providers can and should communicate this to patients, while assuring them that personal identifiable information will be protected.

• There are too many quality measures required for receiving incentives, making it redundant with other pay-for-reporting programs– The HITECH program is not a reporting program. We advocate for required

MU measures to be clearly linked to improved outcomes, thereby meeting the intent behind MU of HIT.

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Make HIT Truly Meaningful to Consumers and Purchasers

• Current definition of meaningful use focuses – appropriately – on specific goals, objectives, and measures to determine whether those objectives are met

• Ultimately need to get away from this silo’d view of the system to understand whether the health care system is truly meeting consumers’ and purchasers’ needs.

• We need processes to evaluate whether greater use of HIT through EHRs and Personal Health Records (PHRs) is positively affecting consumers’ experience at the point of care, by measuring changes in how patients are actually experiencing care.

Until we understand how consumers are reacting to the implementation of HIT, we will not truly recognize the

investment being made by HITECH

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How to Voice Your Support

• Add your organization’s name to the Disclosure Project’s comment letter

• Submit a letter from your organization:– Go to www.regulations.gov– Cite CMS-0033-P– If you submit your own letter, please send

a copy to talteras@nationalpartnership.org!

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Appendix: Details of the Meaningful Use

Proposed Definition

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Timeline for Phase-In

• Stage 1: Centers on health information collection and using it to track key clinical conditions, communicate about care needs (including provider-provider and provider-patient communication), facilitate disease and medication management, and report key quality and public health information.

• Stage 2: Focuses on exchanging and using information to improve the care of individual patients.

• Stage 3: Concentrates on promoting systematic improvements through promoting improvements in quality, safety and efficiency, advancing decision support for national high priority conditions, providing patient access to self-management tools, facilitating access to comprehensive patient data, and improving population health.

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Structure of Incentive Payments

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Staged Implementation

• Linked to each stage is a set of criteria for meaningful use of EHRs that providers must satisfy to receive an incentive or avoid a payment reduction (in 2015)

• Staging will both reward early adopters as well as encourage broad adoption over time

• This NPRM focuses on the Stage 1, 2011-2012 criteria

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Overview of Functional Criteria

• Priority Areas:– Improving quality, safety, efficiency, and reducing

health disparities– Engage patients and families in their health care– Improve care coordination– Improve population and public health– Ensure adequate privacy and security protections for

personal health information

• The Priority Areas All Track to Those Identified by the National Priorities Partnership

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Stage 1 Functional Criteria• Focus is on:

– Electronically capturing health information in a coded format; – Using information to track key clinical conditions and

communicating that information for care coordination purposes;

– Implementing clinical decision support tools to facilitate disease and medication management; and

– Initiating the reporting of clinical quality measures and public health information.

• Examples: Record demographic data, maintain up-to-date problem list, test ability to exchange information.

• Proposed rule sets thresholds for each– E.g. Record demographic data for 80% of patients

• EPs would fulfill 25 functional criteria. • Eligible Hospitals would fulfill 23

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Quality Reporting Component

• Eligible providers (EPs) would report summary data on 2 sets of quality measures:– 4 Core measures– 3-5 Select specialty measures

• Hospitals would report on a subset of 43 proposed measures, based on public input

• Providers use attestation via survey to report summary data on clinical quality measures in 2011, while CMS works to build infrastructure for accepting data collected through EHRs– Expect electronic reporting in 2012

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Flexibility That Does Not Sacrifice Privacy

Ways the proposed rule provides flexibility:• Providers can choose the payment year in

which they start (doesn’t have to be 2011)• Providers choosing to start in later years can

still receive significant payments• In PY1, required to demonstrate MU for 90

days• Thresholds vary across functional

requirements

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Appendix: Detailed Analysis of Proposed Rule

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Strengths and Weaknesses of the Definition

• Within Specific Goal Areas:– Care Coordination– Reducing Medical Errors and Improving

Patient Safety– Patient and Family Engagement– Reducing Health Disparities

• In Cross-Cutting Areas:– Quality Measurement

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Increased care coordination and fostering of better doctor-patient communication

Where MU Succeeds:• Connecting information across internal silos, improving

providers’ ability to coordinate care.• Medication reconciliation• Summary care records• Test ability to exchange key clinical data, based on capabilities

of certified records today

Where Improvements Are Still Needed:– Reinstate patient education criteria– Add more care coordination measures (i.e. NQF measures

recently endorsed) in later stages

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Reduced medical errors and improving patient safety

Where MU Definition Succeeds:– CPOE Requirements – Providers must maintain up-to-date problem lists of patients’

current and active diagnoses– Drug-drug, drug-allergy, drug-formulary safety checks– Implement 5 clinical decision support rules– E-prescribing and transfer of Rx information

– Medication reconciliation

Where Improvements Still Needed: – Definition is strong for the first year of incentives, and should

evolve to be even stronger in succeeding years.

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Increasing Patient and Family EngagementWhere MU Definition Succeeds:• Connects patients and families to the health care system, giving

them timely access to their personal health information• Electronic copy of medical information within 48 hours of request• Electronic after-visit clinical summaries • Electronic discharge instructions • Ongoing, timely electronic access to information

Improvement Still Needed:• Providing electronic copies of information is a success, but in the

proposed definition patients still have to request it. A better model would be for all patients to be asked if they want this information, since not all will know to ask for it.

• Reinstate advance directives in EHRs

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Reducing Health Disparities

Where MU Definition Succeeds:– Requirement that EHRs collect information on

patients’ race, ethnicity, language, and gender (RELG).

Where Improvements Still Needed:– Require that providers stratify quality data by

RELG– When generating lists of patients by specific

condition, require that providers stratify lists by RELG

– Bottom line: collection of RELG is not enough; data must be used to be effective

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Quality Measurement Strengths• Stage 1 only requires providers to demonstrate

whether they adequately use EHR capabilities; Defends against providers’ concerns that CMS is moving too fast

• Initial set of measures are reasonable and align well with the criteria set out by the HIT Policy Committee:– Capturing patient health information– Using EHR tools for provider decision-making,

patient reminders and insurance activities– Giving patients access to their health information– Exchanging information and facilitating care

coordination– Security and Privacy

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Quality Measurement Weaknesses

• Core Measure Set measures are not strong or representative of true core measures

• EP and Eligible Hospitals’ Quality measures mainly process-oriented

• Lack of discussion in the proposed rule of integration of registry data

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Room for Improvement in Quality Measurement

• Require all appropriate EPs to report on the three core measures in the NPRM for 2011-2012; redesign the core measure set for 2013 and beyond

• To streamline reporting requirements, drop measures that require manual tallying. Focus on exemplar measures that:– Require providers to utilize different functions of the EHR in providing

care for their patients– Can be collected easily as a byproduct of the care process– Involve using clinical (vs. administrative) data

• Add measures that are meaningful to consumers and purchasers in the areas of pediatrics, obstetrics/gynecology, long-term care, oral health, and substance abuse and mental health. Meaningful measures include ones that address outcomes and overuse of diagnostics and procedures

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About the HIT Policy Committee and CPeH

• HIT Policy Committee: Charged with making recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information.– Meaningful Use Workgroup included consumer and purchaser

representation– http://healthit.hhs.gov/portal/server.pt?open

=512&objID=1813&parentname=CommunityPage&parentid=4&mode=2&in_hi_userid=10741&cached=true

• The Consumer Partnership for e-Health: CPeH is a non-partisan coalition led by by the National Partnership for Women & Families. It includes over 50 consumer, labor, and patient organization members working at both the national and local levels, and advocates for HIT that plays a critical role in the creation of a patient-centered health care system– For more information go to www.nationalpartnership.org/hit

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The Consumer-Purchaser Disclosure Project is an initiative that is improving health care quality and affordability by advancing public reporting of provider performance information so it can be used for improvement, consumer choice, and as part of payment reform. The Project is a collaboration of leading national and local employer, consumer, and labor organizations whose shared vision is for Americans to be able to select hospitals, physicians, and treatments based on nationally standardized measures for clinical quality, consumer experience, equity, and efficiency. The Project is funded by the Robert Wood Johnson Foundation along with support from participating organizations.

Previous Discussion Forums are available at: http://healthcaredisclosure.org/activities/forums/

For More Information Contact:Tanya Alteras, MPPAssociate Director202-238-4820talteras@nationalpartnership.org

About the Disclosure Project