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The Compliance Officer’s Role in

“Meaningful Use”

Nancy Vogt, RHIT, CHC, CHP

Director/Deputy Chief Compliance Officer

Aurora Health Care – Milwaukee, Wisconsin

The journey from denial to acceptance–“who, what, me?”

• EHR Incentive Program is new and

complex, with many moving parts

• Can be significant dollars

• Incentives now, penalties in 2015

• Security risk assessment/mitigation

• 2012 OIG Work Plan

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Leadership certification

I certify that the foregoing information is true,

accurate, and complete. I understand that the

Medicare EHR Incentive Program payment

requested will be paid from Federal funds, and

that the use of any false claims, statements, or

documents, or the concealment of material fact

used to obtain Medicare EHR Incentive Program

payment, may be prosecuted under applicable

Federal or State criminal laws and may be

subject to civil penalties.

Where to begin?

1. www.cms.gov/EHRIncentivePrograms/

2. CMS Specification Sheets

3. Federal Register commentary

4. CMS FAQ’s

5. ONC FAQ’s (healthit.hhs.gov)

6. Federal advisory committee meeting minutes

7. EHR Information Center (888-734-6433)

8. EHR Incentive Programs Listserv

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Meaningful use in a nutshell

• ARRA/HITECH incentive program

– Use certified EHR technology

– Be a “meaningful EHR user”

– Attest for incentive payments

• The use of certified EHR technology:– In a meaningful manner (3 stages)

– For electronic exchange of health information to improve quality of health care

– To report/submit clinical quality and other measures

Why?

1. Improve quality, safety, efficiency, and

reduce health disparities

2. Engage patients and families

3. Improve care coordination

4. Improve population and public health

5. Ensure adequate privacy and security protections for personal health information

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Medicare vs Medicaid Programs

• Medicare EHR Incentive Program:– Eligible participants must successfully demonstrate MU of

certified EHR technology for 90-day period in first year, then a full year thereafter

• Medicaid EHR Incentive Program– Eligible participants may qualify for incentive payments if

they adopt, implement, upgrade or demonstrate MU in their first year

• Adopted = acquired and installed

• Implemented = have begun using certified EHR technology

• Upgraded = expanded existing technology to meet certification requirements

– Must successfully demonstrate MU for subsequent years

Eligibility (and this is the easy part)

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And now for the nutty part…

• Hospital Requirements

– 19 measures (14 core, 5 from menu of 10-1 of

which must be public health)

– 15 core clinical quality measures

• Eligible Professional Requirements

– 20 measures (15 core, 5 from menu of 10)

– 6 clinical quality measures (3 core, 3 alternate

core, 3 of 38 additional measures)

Of course we own a certified EHR (or two)…

• EHR vendor certification methods:

modular or complete (or both?)

• Using certified functionality (no good

innovation goes unpunished)

• Possessing functionality for deferred

measures (ONC FAQ 12-10-021-1)

• Clinical quality measure reports (ONC

FAQ 3-11-024-1)

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Certification

The measures are clear and simple, aren’t they?

• Hospital

– Testing exchange

– Clinical quality measures

– E-copies

– Protect electronic health information

– Smoking status

– Demographics

– Clinical lab test results

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The measures are clear and simple, aren’t they?

• EP

– Clinical Summaries

– Clinical quality measures

– CPOE

– ePrescriptions

– Vital signs

Checking on the clear and simple

• CPOE: only licensed health care

professionals

• Content of clinical summaries (“after-visit

summaries”)

• Offering electronic discharge instructions

• Drug formulary and interaction checks “on”

• Patient list generated

• Security risks addressed

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Accurate clinical quality measures?

• Abstracting

• Accurate and complete– FAQ 10589: “CMS considers information to be

accurate and complete for CQM’s insofar as it is

identical to the output that was generated from

certified EHR technology”

– AHA: results can vary from those derived through

existing manual abstraction

The road to attestation

• Standing meetings

• External counsel

• Routine tracking

• EHR policy team

• Reference tools

• Advocate for clear

regulations

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Attesting with confidence

• Register early

• Determine the role of Compliance– Attesting individual will have access to payment

information

– Constitutes submitting a claim

• Mock audit

• Documentation for accurate attestation

• Documentation and report retention

10,365

Denominator: Number of unique patients with at least one

medication in their medication list seen by the eligible hospital or CAH during the EHR reporting period

9,852Numerator: Number of patients in the denominator that have at least one

medication order entered using CPOE

95.1%Goal: >30% Score:

Objective: Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed health care 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 admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) have at least one medication order entered using CPOE

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Measure ValuesMeasure Information#

Sample attestation document

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Reports – a snapshot in time

Audit-readiness

Per CMS website:

• Save the supporting electronic or paper

documentation that support your

attestation.

• Save the documentation to support your

Clinical Quality Measures (CQMs).

• Hospitals should maintain documentation

to support their payment calculations.

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Non-numerical measure examples

• Screen shots to provide evidence of:– Testing exchange

– Drug formulary and interaction checks

– Smoking nomenclature

– One decision support rule (hospital)

– Sources of CQM data

– Examples of structured clinical lab

– Public health exchange (we included interface transactions)

• E-copy process flow

• Security risk assessment and mitigation

• Sample patient list (hospital)

Other Documentation

• EHR vendor contract

• Report specifications

• Certification documents, if any

• Attestation confirmation

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What if (oh no!) a mistake was made?

• Could be vendor or provider

• Repayments may be required if reports

over-reported compliance with a measure

Lessons learned

• Significant time requirement; varied with

implementation

• The value of diversity in the compliance

team – knowledge of I.T.

• The value of clear ownership

• Documentation (in case you really do get

hit by a bus)

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On the horizon

Questions