PYA executives Linda ClenDening and Erin Phillips recently addressed the Nashville MGMA, providing regulatory updates on the CMS meaningful use attestation process. They also shared perspectives on the operational implications of “meaningful use” for physician practices.

1. Page 0August 13, 2013
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Meaningful Use:
Regulatory and Operational
Implications
Nashville MGMA
August 13, 2013

2. Page 1August 13, 2013
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Agenda
• Data and quality clinical outcomes
• Regulatory information highlights and audits
• Meaningful Use (MU) implications for
– Staffing/Roles
– Alliances/Referrals
– Meaningful data

3. Page 2August 13, 2013
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Quality Outcomes

4. Page 3August 13, 2013
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Quality Data in the Exam Room
xx% of my patients over 18 who have their tonsils
removed experience post-surgical hemorrhaging.
These outcomes are less than the national average of
yy% of patients over 18.

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Quality Data
What’s the source of the data?

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Communicating About Quality
If he’s using clinical outcomes statistics in the
exam room, where else is he using them?

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Doctor’s Lounge
Communicating with
referring physicians?

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Board Table
Quality contractual requirements between
hospitals and physicians
– Employment arrangements
– Clinical co-management
– ACOs
– Other partnerships

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Negotiating Table
Once quality metrics are
operationalized for one payor, the
provider can build on that
strength to discuss quality with
other contracting payors.

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Website
How is he attracting patients to his practice
based on quality outcomes?

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Take Away #1
• What story are you telling about the
physicians in your practice using the quality
data collected in the MU process?
• Focus on a core measure metric or clinical
quality metrics and develop the story.

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MU Statistics as of
June 2013
$-
$500,000,000
$1,000,000,000
$1,500,000,000
$2,000,000,000
$2,500,000,000
$3,000,000,000
2011 2012 2013 YTD
Medicare EP.s Medicaid EP.s
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/June_PaymentRegistration_Summary.pdf
Almost
6 billion
dollars to
EP.s to-
date

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Real World Impact of MU
• More than 458 million test results were entered into the EHR by 111,954
Eligible Providers (EP.s).
• Medication reconciliation was performed on over 40 million patient
transitions of care by 83,035 EP.s.
• More than 4.3 million patient transitions of care summaries were
generated by 24,827 EP.s.

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Meaningful Use
Headlines
• July 25, 2013 – AMA and AHA ask for flexibility in
Meaningful Use program requirements.
• July 30, 2013 – AHA and AMA, as well as CHIME
(College of Healthcare Information Management
Executives), request more time for Stage 2.
• July 30, 2013 –AHA report calls for a delay of
Eligible Hospital Stage 2 deadline of October 1,
2013.
As reported in HealthLeaders Media.

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Meaningful Use
Current Details
• Stage 2 Meaningful Use (MU) Attestation begins in calendar
year 2014 for Eligible Providers (EP.s).
– If a provider began MU in 2011, he/she will meet three consecutive
years of MU before beginning Stage 2 in 2014.
– All other providers meet two years of MU before advancing to Stage 2
in their third reporting year.
• For 2014 only, all providers – regardless of MU stage – are only
required to demonstrate MU for a 3 month reporting period.
• Beginning in 2015, Medicare eligible professionals who do not
successfully demonstrate meaningful use will be subject to a
payment adjustment.

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Public Health Reporting
Objectives:
Providers must perform at
least one test of their certified
EHR technology’s capability to
send data to public health
agencies.
Timing/Compliance:
Required in 2013 and beyond for all Stage 1 public health
objectives.
Affected Providers:
EPs, eligible hospitals, and CAHs
What It Means:
The intent of this modification is to encourage all EPs,
eligible hospitals, and CAHs to submit public health data,
even when not required by State/local law, if authorized.
Public health reporting objectives include submitting data
to: an immunization registry, a syndromic surveillance
database, OR lab results to a public health agency.
What’s New in MU Stage 1 in 2013

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What’s New in MU Stage 1 in 2013
Electronic Exchange of Key
Clinical Information:
Removal of electronic exchange
of key clinical information
objective for Stage 1 for EPs,
eligible hospitals, and CAHs
Timing/Compliance:
Removed in 2013 and beyond
Affected Providers:
EPs, eligible hospitals, and CAHs
What It Means:
Providers will no longer have to meet or attest to this objective for
the EHR incentive programs. MU Stage 2 will include a more robust
requirement for electronic health information exchange associated
with a transition of care or referral.

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What’s New in MU Stage 1 in 2013
Computerized Physician Order
Entry (CPOE):
Addition of an alternative
measure based on the total
number of medication orders
creating during the EHR
reporting period.
Timing/Compliance:
Option to choose the alternative measure in 2013 and beyond.
Affected Providers:
EPs, eligible hospitals, and CAHs
What It Means:
Providers will have the option of using the original measure or the
alternative measure to meet the CPOE objective.

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What’s New in MU Stage 1 in 2013
Record and Chart Changes in
Vital Signs:
Increase in age limit for
recording blood pressure in
patients to age 3; removal of
age limit requirement for height
and weight.
Timing/Compliance:
Optional to implement the changes in 2013; required in 2014 and
beyond.
Affected Providers:
EPs, eligible hospitals, and CAHs
What It Means:
In 2013, providers have a choice of reporting under either the
original or new age limits. However, in 2014, all providers must
report under the new age limits.

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What’s New in MU Stage 1 in 2013
Electronic Prescribing:
Additional exclusion to the
objective for electronic
prescribing for providers who
are not within a 10 mile radius
of a pharmacy that accepts
electronic prescriptions.
Timing/Compliance:
Optional to select the additional exclusion starting in 2013 and
beyond.
Affected Providers:
EPs
What It Means:
EPs may select the additional exclusion if they qualify.

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What’s New in MU Stage 1 in 2013
Record and Chart Changes in
Vital Signs:
New exclusion for EPs: If they
see no patients 3 years or older;
if all three vital signs are not
relevant to their scope of
practice; if height and weight
are not relevant to their scope
of practice; or if blood pressure
is not relevant to their scope of
practice.
Timing/Compliance:
Optional to select new exclusion criteria in 2013; replaces current
exclusion criteria starting in 2014.
Affected Providers:
EPs
What It Means:
Previously, EPs could only exclude the objective if all three vital signs
were not relevant to their scope of practice or if they saw no patients
3 years or older. Beginning in 2013, EPs can also now be excluded
from reporting blood pressure if blood pressure is not relevant to
their scope of practice, or recording height and weight if both height
and weight are not relevant to their scope of practice.

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MU Stage 1 to Stage 2
• Increase in required percentage of qualifying
unique patients in percentage-based objectives.
• All clinical quality measures (CQMs) will be
submitted electronically to CMS.
• New requirements for summary of care
documents at transition of care/referrals and
patient electronic access via secure messaging.

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Penalty Scenarios
First Year of
MU
Requirement to Avoid Penalty
2015 2016 2017
2011
Achieve MU in 2013
(365 days)
Achieve MU in 2014
(One 3-month
quarter)
Achieve MU in 2015
(365 days)
2012
Achieve MU in 2013
(365 days)
Achieve MU in 2014
(One 3-month
quarter)
Achieve MU in 2015
(365 days)
2013
Achieve MU in 2013
(Any 90-consecutive-day
period)
Achieve MU in 2014
(One 3-month
quarter)
Achieve MU in 2015
(365 days)
2014
Achieve MU in 2014 (Any
90-consecutive-day
period ending no later
than 3 months before the
end of the reporting
period)
Achieve MU in 2014
(One 3-month
quarter)
Achieve MU in 2015
(365 days)

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EHR Incentive Programs (MU)
Supporting Documentation
• Retain ALL relevant supporting documentation for SIX
YEARS post-attestation.
• Audit letters will be sent electronically from CMS email
address.
• Pre-payment audits:
– Both random and targeted (based on suspicious or
anomalous data).
– Supporting documentation will be requested prior to
payment of incentive monies.
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_SupportingDocumentation_Audits.pdf

25. Page 24August 13, 2013
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EHR Incentive Programs (MU)
Supporting Documentation (cont.)
• Post-payment audits:
– Initially conducted as “desk” (off-site) audits using
requested copies of documentation.
– Follow-up data requests and even on-site reviews in the
provider office could be done.
– Be sure to retain a report from the certified EHR to
validate all clinical quality measure (CQM) data.
– For non-percentage-based documentation, screenshots
from the EHR during the reporting period may be
required.

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Favorite Government
Audits Techniques
• .
Audit Method IRS MU Example
Discriminant
Function
System (DIF)
Scoring
Analyze population groupings, standards and
trends for potential abnormal circumstances
based on past experience. E.g., zip code = Bel
Air; DMV tags = Lamborghini; pay interest on a
$1 million mortgage; BUT declare less than
$100,000 of income.
Hospital with certain
higher level of IP days or
discharges but low volume
on percentage based
measures
Hot-Spot
Market
Segments
Every year the IRS selects a particular industry
for compliance examinations. E.g., foreign
trusts, s-corps, restaurant servers
Certain EP specialties,
hospitals of a certain size
or location
Information
Matching
Employers, banks, brokerage firms,
independent contractors all file documents
with the IRS and send the same documents to
tax payers e.g., Forms 1099, W2.
Unusual variations in
volume of percentage
based measures among
EPs within the same TIN;
or between MU and PQRS

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MU Role in New Care Model
Development
• Consolidation/M&A
• ACOs
• Clinically Integrated Networks
• Private Payor Network
Development/Contracting
• Others

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MU & Consolidation
• Weathering the storm with a bigger ship:
– From 2000 to 2010, hospital physician employment
rose 32%.
– Hospitals directly employ about a quarter of all U.S.
physicians.
– By 2013, 2/3rds of physicians will work for hospitals or
large groups.
• Strategic Consideration:
– Affiliate or Merge with an organization without an MU
plan or at risk of a penalty?

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MU & Consolidation
• Transaction Due Diligence Consideration:
– Meaningful Use due diligence now occurs in most
health care transactions.
– Organizational readiness for Meaningful Use
Attestation requires detailed supporting
documentation.

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MU & ACOs
• Public Payor
• Medicare
• Medicaid
• Private Payor
• Private Payors (Blue Cross, United, Cigna, Aetna)
• ACOs with private insurers in effect or development at four
times the rate of Medicare ACOs
• Large Employers
• Self-Insured Hospitals and Health Systems

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MU & ACOs
• ACO 33 Quality Measures include:
– Percent of PCPs who Successfully Qualify for MU
Payment
– CQMs overlap with ACO measures

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Clinical Quality Measure (CQM) Overlap
with ACO and Other Programs
Stage 2 2014 CQM Measure Other CMS Program
Controlling High Blood Pressure Percentage of patients 18-85 years of
age who had a diagnosis of hypertension and whose blood pressure
was adequately controlled (<140/90mmHg) during the measurement
period.
ACO; EHR PQRS; Group
Reporting PQRS
Use of High-Risk Medications in the Elderly PQRS
Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention
ACO; EHR PQRS
Group Reporting
PQRS
Use of Imaging Studies for Low Back Pain
Preventive Care and Screening: Screening for Clinical Depression and
Follow-Up Plan
EHR PQRS; ACO; Group
Reporting PQRS
Documentation of Current Medications in the Medical Record PQRS; EHR PQRS
Preventive Care and Screening: Body Mass Index (BMI) Screening and
Follow-Up
EHR PQRS; ACO; Group
Reporting
PQRS

33. Page 32August 13, 2013
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2013 PQRS
• If you have EPs that meet MU, don’t leave
money on the table:
– 2013: 0.5% incentive
– 2015: 1.5% penalty
• Assess crosswalk opportunities for quality
reporting across programs.

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MU & Private Payor Contracting
• A growing number of private payers have added the
MU requirements to their P4P programs:
– Aetna, United and WellPoint
– Highmark modified "Quality Blue" program to include MU:
• Require copy of attestation
• Incorporate CQM for physician practice best practice indicator
program
• Payors not setting up proprietary mini-MU programs
– Rather use developed MU system
– Similar to using DRGs as a reference price for rates

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Take Away #2
• Incorporate MU into Compliance Program.
– Compliance Officer involvement in attestation and annual
review.
• Ensure Attestation documentation is consistent with
CMS’s recommendations.
• Prepare for more oversight – not just from CMS.
• Maximize MU attestation benefits with other payors
and alliances.

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Operationalizing
to imperfect users.
Adapting a perfect
program

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Much more about the people,
than the systems.
Operationalizing

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Meaningful Use Progression
The systems
need to carry
the burden to
prompt users
to do the right
thing.
As Meaningful
Use
requirements
progress there
will be a
higher volume
of data
requirements
and more
complexity.

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We can only do so much

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Meaningful Use Attestation
Stage 1 only
Stage 1 and planning
For Stage 2 in 2014
Not yet attested

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Meaningful Use Attestation
Comments:
• Working on it [Meaningful Use attestation].
• Small office and older physician who is not going to
[attest].
• We plan on attesting for Stage 1 by the end of this
year.

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MU Staffing Changes?
Increased clerical staff
(i.e., Front Office, Billing
or Support)
Increased clinical staff
Increased IT staff
No staffing
changes made
Other (please specify)
Previous survey:
20 % increased IT

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MU Staffing Changes?
Comments:
• Increased data input demands on current staff.
• Hired dedicated quality manager.
• Shift in resources in IT department to focus on MU
readiness.
• We used outside consultants for MU attestation.

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MU Staffing Changes
Increased duties and responsibilities of
current staff, including
Administrator/Director.
Use of consultants for MU implementation
and attestation process.
New IT team members: Quality staff, EMR
analysts, and EMR trainers
Comments from
previous survey:

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New IT Staff Positions for MU?
Yes
No

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New IT Staff Positions for MU?
Comments:
• Not yet, but we are discussing these.
• Hired a portal manager.

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IT Positions Added for MU
Help
desk
staff
Clinical
data
analyst
Report
/data
specia
list
Training
/front
line
Impleme
ntation
support
staff
Information
exchange/
Network
specialist
Other -
Additional Roles not yet Determined

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Staff Positions Added in IT
Report/Data
SpecialistClinical data analyst
Help desk staff
Information
exchange/network
specialist
Training/front line
Implementation
support staff.
Other
Previous survey

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Staffing Changes
Source: 7 Hottest IT Healthcare Skills http://www.cio.com/slideshow/detail/70112#slide1 www.CIO.com October 18, 2012
EMR Build Specialists
Healthcare Analytics
Project Management
Program Management
Application Development
Data Architecture
Quality Assurance

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IT Functional Roles Changing
• Anticipate increased need of support for
– New hardware
– Networking
– Remote access
– Interoperability issues
2012 HIMSS Leadership Survey

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Staff Role Changes
Driven by MU
Increase in support/help
desk functionality within
the organization.
Increase in liaison/networking
support with healthcare
partners/alliances.
Increase in leadership/
management to support
strategic initiatives.
Other

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Referral/Alliance Decisions
Driven by MU
Our organization asks
potential referrers/
partners about MU
Our
organization
only has
referrals/
partners with
MU attested
providers
Not
considered
Other
(please specify)
Previous survey:
84% Not considered

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Partnership Strategy
with ‘Quality’ Providers
Yes – 44.4%
No – 16.7%
Unknown – 38.9%
Previous survey:
40% YES

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Biggest Barrier to
MU Success
Practice
budget/financing
Internal resources
for training
Practice culture/resistance
to change.
Complexity of
regulations and program
instructions.

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Survey Statistics
• Organization description:
– 90% Independent Physician Practices
– 10% Hospital-Owned Physician Practices
• Average practice size: 27 physicians
• Practice size range: 1 to 1,000 physicians

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Take Away #3
• Re-assess staff skills and training for EHR
usage.
• Determine possible staff duty changes.
• Document process and workflow redesign for
EHR/MU implementation.
• Update all affected policies and procedures.
• Redesign monthly reports and dashboards to
include key MU metrics.

57. Page 56August 13, 2013
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The Meaningful Use Goal
Language is the road map of a culture. It
tells you where its people come from and
where they are going.
‒Rita Mae Brown
Healthcare executives are engaged in
developing a new language.

58. Page 57August 13, 2013
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Thank you!
Linda ClenDening, MS, CMPE
Manager
PYA
lclendening@pyapc.com
615-305-5218
865-684-2735