ARRA

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ARRA HIT in Rural America
Louis Wenzlow RWHC Director of HIT HRSA Grantee
MeetingAugust. 31st, 2009
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American Recovery Reinvestment Actand Health
Information Technologyin Rural
AmericaPresentation Overview

• I - Medicare HIT Incentives in ARRA
• II - Certified Expense and Meaningful Use
• III - Rural HIT Challenges and Strategies
• IV - Preparing for ARRA Now

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Overview of RWHC

• Founded 1979
• Non-profit coop owned by 35 rural hospitals (net
  rev 3/4B 2K hospital LTC beds)
• 7M RWHC budget (70 member fees, 20 fees
  from others, 5 dues, 5 grants)
• 6 PPS 29 CAH 24 freestanding 11 system owned
  or affiliated

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I - HIT Incentives in ARRA

• Give 70 of Americans an electronic health record
  (EHR) within 5-10 years.
• Use Medicare to incentivize the adoption of EHRs
  to improve quality, provide data portability, and
  allow for performance evaluation.
• Eventually penalize non-adopters by reducing
  reimbursement.
• Some rural providers will also be eligible for
  Medicaid incentives.
• Last year was not if but when. This year not
  when but now. ARRA presents tremendous
  challenges for small and rural providers.

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Physician Medicare Incentives

• Those that are meaningful users will receive 75
  of estimated allowed charges limited to the
  following maximums Year 1- 15,000 Year 2 -
  12,000 Year 3 - 8,000 Year 4 4,000 and
  Year 5 -2,000.
• If first adopting in 2011 and 2012, maximum Year
  1 incentive increased to 18,000.
• Up to 44,000 in payments per physician.
• Penalties for non-users starting in 2015 (start
  at 1 fee schedule reduction and go to 3
  reduction).

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PPS Hospital Medicare Incentives

• Those that are meaningful users by 2013 are
  eligible for full 4 years of incentive payments
  (e.g., about 4 million average for
  Wisconsin hospitals).
• (2 million base volume adjustment) x (Medicare
  Share with charity adjustment). Payment reduced
  by 25 each of Years 2, 3, and 4.
• Penalties for non-users starting in 2015.
• Early adopters rewarded, since are paid
  regardless of their costs or timing prior to 2013.

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CAH Medicare Incentives

• CAHs that are meaningful users by 2011 are
  eligible for 4 years of enhanced Medicare
  payments (20 over Medicare Share with charity
  adjustment) with immediate full depreciation of
  certified EHR costs, including undepreciated
  costs from previous years.
• Penalties for non-users start in 2015 (0.33
  reduction in Medicare increases to 1 in 2017).
• Depreciated investments by early adopters are
  not eligible for any incentive payments

Definition for ARRA Medicare Share adds about
30 to definition in cost report 20 in ARRA
formula.
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What This Means to CAHs (1 of 2)

• CAHs must become meaningful EHR users between
  2011 and 2015 to qualify for bonus structure and
  avoid penalties.
• For CAHs that qualify, new and undepreciated
  certified EHR costs will get a roughly 50
  bump in Medicare Reimbursement (with 100
  Maximum).
• Bonus incentives initiate only after most of the
  investments need to be made the issue of
  capital/financing is left unaddressed.

Definition for ARRA Medicare Share adds about
30 to definition in cost report 20 in ARRA
formula.
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What This Means to CAHs ( 2 of 2)

• Maximizing incentive bonus will involve strategy
  to leave as much Certified EHR Expense as
  possible undepreciated at the time of reaching
  Meaningful User designation.
• Definition of Certified EHR will ultimately
  determine (and could significantly reduce) the
  value of the incentive.
• Definition of Meaningful Use will ultimately
  determine whether the incentive is reasonably
  attainable by rural providers.

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• II - Certified EHR Expense
• and Meaningful EHR Use

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What is a Certified EHR Expense?

• CAHs, unlike PPS Hospitals, will only receive an
  ARRA incentive for Certified EHR Expenses.
• Current certification programs cover only a
  fraction of the systems that make up an EHR.
• PACS, hardware, network infrastructure, and many
  other aspects of EHR do not have certification
  programs.
• Not currently clear what costs associated with
  EHR implementation can be applied to the CAH
  bonus.
• A timetable for answering the above not known.

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Physician Meaningful EHR Use?

• ARRA requirements
• Implement certified physician practice EMR
• Participation in Information Exchange
• Quality reporting participation
• E-prescribing
• Meet function and reporting requirements as
  determined by ONC and ultimately CMS

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Hospital Meaningful EHR Use?

• ARRA Requirements
• Use of certified vendors
• Participation in Information Exchange
• Quality reporting participation
• Meet function and reporting requirements as
  determined by ONC and ultimately CMS

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HIT Policy Committee Recommendations

• CMS expected to make final rules by end of 2009.
• Adoption year 2011 is 1/1/11 to 12/31/12.
• Adoption year 2013 is 1/1/13 to 12/31/14 with
  more rigorous outcomes to be eligible. The
  Committees concession to rural concerns for
  providers at early stage of adoption is to allow
  the first adoption year metrics to slide into
  2013 specifics unknown.
• But Adoption year 2015 is in fact 2015 at this
  time penalties are expected to kick in for
  non-adopters.
• The Certification Commission of Health
  Information Technology initially to be the
  certifying body.

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Hospital Meaningful EHR Use? (1 of 5)

• HIT Policy Committee Recommendations to CMS on
  Quality Efficiency by 2011-12 two year cycle
• 10 of all orders entered by authorized providers
  through CPOE
• Drug contraindication checks
• Up-to-date problem lists of current/active
  diagnoses
• Active medication and allergy lists
• Demographic information advance directives
• Record vital signs smoking status

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Hospital Meaningful EHR Use? (2 of 5)

• HIT Policy Committee Recommendations to CMS on
  Quality Efficiency by 2011-12 two year cycle
• Lab results available in EHR
• Ability to generate patient lists by condition
• Report quality measures to CMS
• Implement one decision support rule for priority
  condition
• Electronic insurance eligibility checks
• Electronic claims submission

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Hospital Meaningful EHR Use? (3 of 5)

• HIT Policy Committee Recommendations to CMS on
  Patient Engagement by 2011-12 two year cycle
• Provide patients with electronic copy of lab
  results, problem lists, meds and allergies upon
  request (could be on CD or USB drive)
• Provide patients with electronic copy of
  discharge instructions upon request
• Provide patient specific educational resources

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Hospital Meaningful EHR Use? (4 of 5)

• HIT Policy Committee Recommendations to CMS on
  Care Coordination by 2011-12 two year cycle
• Capability to exchange key clinical information
  among providers of care
• Medication reconciliation at relevant encounters
  and care transitions
• Population and Public Health
• Submit data to immunization registries
• Submit lab results and syndromic surveillance
  data to public health

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Hospital Meaningful EHR Use? (5 of 5)

• HIT Policy Committee Recommendations to CMS on
  Security Privacy by 2011-12 two year cycle
• Compliance with HIPAA
• Compliance with fair data sharing practices
• Note There is more to come after the first two
  year cycle eg real-time patient portals, closed
  loop medicine management, etc
• Note Reporting of measures will be required to
  confirm all meaningful use outcomes/priorities.

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Eligible Physician Issues

• HIT Policy Committee Recommendations to CMS for
  physicians by 2011-12 two year cycle are similar
  to those noted for hospitals as well as
• CPOE for all orders
• Generate permissible prescriptions electronically
  
• Send reminders to patients for follow-up/preventiv
  e care
• Document a progress note for each encounter
• Provide clinical summaries for patients per
  encounter

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Impact on Rural Providers

• Rural providers have lower than average levels of
  adoption.
• They are starting from farther behind with fewer
  resources to devote to EHRs.
• AHA, RUHIT, NRHA and other provider and quality
  groups are concerned that the Committee
  recommendations are too aggressive to be
  reasonably achievable for the average small and
  rural provider.

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HIMSS EHR Adoption Model
HIMSS (Healthcare Information and Management
Systems Society)
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4th Quarter 2008 Adoption Rates (Data Provided
by HIMSS)
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Impact on Rural Providers

• Committee recommendations for 2011 roughly
  correspond to reaching 4.0 on HIMSS scale.
• While the Committee recommendations may be
  achievable by providers at 3.0 on the HIMSS
  scale, it is unclear, if not unlikely, they are
  achievable by those at 1.0 or lower on the scale.
• With providers being forced to rush, we may see a
  high rate of failed implementations, as well as
  setbacks in quality and efficiency.
• From provider perspective, important to move
  quickly but not at the expense of implementation
  success.

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• III - Rural HIT Implementation Challenges and
  Strategies

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Hospital EHR Modules Functions

• Facility Management Medical Records
  Inpatient Clinicals
• 1. Data Repository 1. HIM Core
  Module 1. Inpatient Charting
• 2. Master Patient Index 2. Chart Film
  Tracking 2. Multidisciplinary
• 3. Database Reporting 3. Chart deficiency
  tracking 3. e-MAR
• 4. Registration/ADT 4. Release
  of Info. Tracking 4. Barcoding
• 5. Billing 5.
  Coding abstracting 5. Patient Education
• 6. General Ledger 6. Reg.
  Scanning 6. Physician Portal
• 7. Accounts Payable 7. HIM Scanning 7.
  CPOE
• 8. Fixed Assets 8. Electronic
  Signature 8. Decision Support
• 9. Materials Management
• 10. Payroll/HR Departmental Systems Other
  Modules
• 11. Time Attendance 1. Pharmacy
  1. Long Term Care
• 12. Executive Information 2. Lab
  2. QI
• 13. Budgeting 3. Radiology 3. Physician EMR
• 14. Enterprise Scheduling 4. Other Ancillaries
  4. Practice Management
• 15. Order Entry 5. ER 5.
  Contract Management
• 6. OR 6.
  PACS

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Challenge Underestimating Scope

• Strategies
• This is transformative culture change, not simply
  putting in new systems.
• Recognize every department will be impacted.
• Focus on improving workflow and quality.
• Understand that many small and rural facilities
  have experienced the same challenges and have
  come out of the process better off.

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Challenge Limited HIT Expertise

• Strategies
• Invest in someone capable of leading the charge.
• HIT leadership requires healthcare, project and
  change management expertise.
• The new federally funded Regional Extension
  Centers may help.
• Use consultants strategically without creating a
  dependency relationship.

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Challenge Normal Resistance to Change

• Strategies
• Solicit user feedback from early stages.
• Provide lots of opportunities to learn.
• Advertise anticipated system benefits.
• Administration/Directors lead by example.
• Stress that soon EMR will be the status quo.

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Challenge Physician Acceptance

• Strategies
• Bend over backwards to involve physicians in
  selecting the systems that will impact them.
• ARRA will require significant physician HIT use,
  which may help motivate engagement.
• Again, provide educational opportunities to help
  physicians overcome what will be a steep learning
  curve.

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Challenge Interdepartmental Tension

• Strategies
• Recognize that implementation process is
  stressful.
• View this as an opportunity make it a goal to
  fix dysfunctional workflow between departments.
• Provide non-threatening forum for stakeholders to
  discuss resolution strategies.
• Interdepartmental cooperation and communication
  are critical in an EMR environment.

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Challenge Staff Burnout

• Strategies
• Provide staff with the time and resources they
  need to successfully navigate the change events.
• Accept that implementation and Go Live activities
  will necessitate higher staff/patient ratios.
• Find opportunities to celebrate implementation
  milestones.

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Challenges Ongoing Costs

• Strategies
• Pursue cost effective strategies, but make sure
  they will lead to the goals of meaningful use.
• Find return on investment where possible, though
  this is a challenge for small facilities.
• Consider collaborative opportunities.

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• IV - Preparing for ARRA Now

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First Three Key Questions

• Are you currently using a certified vendor?
• http//www.cchit.org/choose/inpatient/2007/
• http//www.cchit.org/choose/ambulatory/08/
• If yes, will that vendor likely provide you with
  a migration path to meaningful use?
• If yes, are you strategically committed to
  staying with your current vendor?

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Recommendations If Yes to All Three

• Continue an HIT Planning Workgroup.
• Educate key stakeholders on ARRA meaningful
  use.
• Determine what vendor modules will likely need to
  be implemented by 2011 to achieve meaningful use.
• Determine what 3rd party products may be required
  to fill primary vendor gaps and begin selection
  process.
• Work with vendors to identify likely scheduling
  issues and challenges.
• Continue assessing workflow and change goals at
  the department level.

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Recommendations If No to Any of Three

• Convene an HIT Planning Workgroup.
• Educate key stakeholders on ARRA and meaningful
  use issues.
• Set goals and develop a high level HIT strategic
  plan.
• Identify regional collaborative opportunities.
• Begin assessing workflow and change goals at the
  department level.
• Begin vendor evaluation and/or selection process.
• Be ready to sign contracts and begin
  implementations soon after final definitions are
  released.

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Online Tool Kits

• Stratis Health (Minnesota QIO) Toolkit for CAHs
• http//www.stratishealth.org/expertise/healthit/h
  ospitals/index.html
• Agency for Healthcare Research and Quality HIT
  Evaluation and Adoption Toolbox
• http//healthit.ahrq.gov/