in a World of Interoperability and Quality Payment Programs? · in a World of Interoperability and...

Do we need Telehealth Programsin a World of Interoperability and

Quality Payment Programs?

Stewart Ferguson, PhDChief Technology Officer (CTO)

Alaska Native Tribal Health Consortium

2

TOPICS

1. Telehealth … Filling the Gaps

2. What’s Changed?

3. What’s going to change?

TELEHEALH … FILLING THE GAPS


2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

CHUGACH. (5)

EKLUTNA (1)

EAT (8)

APIA (4)

KENAITZE (1)

MSTC (1)

SEARHC (20)

KANA (7)

ANTHC & SCF (ANMC,PCC, …)

CRNA (5)

NSHC (15)

EYAK (1)

YAKUTAT (1)

SMC (1)

MANIILAQ (12) AICS

KETCHIKAN (1)

OPEN

ASNA (1)Anchor Tenant

Live

In Build

Planned

Quoting

EHR ExpansionOrganizations (# Sites)


Provider Comments

“Honestly, the shared domain is huge for me, especially around medically complex kids. In my opinion, [kids on the shared domain] get better, more comprehensive, and more complete care…”

“It’s like night and day. Seamless care, fewer mistakes, less guessing with shared domain. Gives the patients confidence too, that their providers know what is going on with them.”

“… the shared domain makes it much easier and predictable for getting information back to the referring provider. Given the choice, I don’t know why you would not choose a shared domain. Seriously, it’s not even close.”

5


Alternative comments …

“Honestly, [telehealth] is huge for me, especially around medically complex kids. In my opinion, [kids on telehealth] get better, more comprehensive, and more complete care…”

“It’s like night and day. Seamless care, fewer mistakes, less guessing with [telehealth]. Gives the patients confidence too, that their providers know what is going on with them.”

“… [telehealth] makes it much easier and predictable for getting information back to the referring provider. Given the choice, I don’t know why you would not choose [telehealth]. Seriously, it’s not even close.”

6


We allow …

We allow “doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient's vital medical information electronically—improving the speed, quality, safety and cost of patient care”

Definition of “Health Information Exchange” from Healthit.gov, May 12, 2014

https://www.healthit.gov/providers.../health-information-exchange/what-hie

7

https://www.healthit.gov/providers.../health-information-exchange/what-hie


We provide …

We “provide new opportunities to improve care delivery by supporting and rewarding clinicians as they find new ways to engage patients, families and caregivers and to improve care coordination and population health management.”

Objectives of the Quality Payment Program, 2016https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf

8

https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf


We have a vision …

We are “devoted to the simple vision that health data should be available to individuals and providers regardless of where care occurs. Additionally, provider access to this data must be built-in health IT at a reasonable cost for use by a broad range of health care providers and the people they serve.”

CommonWell Visionhttp://www.commonwellalliance.org/about/

9

http://www.commonwellalliance.org/about/


We have a vision …

Our vision “is to make the right health information accessible at the right place and time to improve the health and welfare of all Americans.”

Sequoia Project Visionhttp://sequoiaproject.org/about-us/

10

http://sequoiaproject.org/about-us/


Gaps we filled

• Sharing of Patient Data: “HIE” the verb

• Interoperability between and across health care systems

• Multimedia data sharing and presentation before EHR’s could support this capability

• Live audio / video even before technology evolved and matured (H.264, desktop video)

11

12

Physical Network

Hardware

Software

Training

Workflows

Business / Finance

Outcomes

Sequence of Telemedicine Program Implementations

We led the race …

We pushed the issues of technology, payment, strategy, and workflows.

13

… and now we might become

irrelevant.

Now we may lag in the issues of technology,

payment, strategy, and workflows.

14

15

Physical Network

Hardware

Software

Training

Workflows

Business / Finance

Outcomes

What is about to change …

WHAT’S CHANGED

1. Everyone got an EHR

Alaska Native Tribal Health Consortium 17

Percent of non-Federal acute care hospitals with adoption of at least a Basic EHR with notes system and possession of a certified EHR: 2008-2015

Source: http://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php


Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system by hospital type


At least 8 out of 10 small, rural, and

Critical Access hospitals adopted a Basic EHR


Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system at the State-Level for years 2008, 2011, and 2015

For all states, at

least 6 in 10

hospitals adopted a Basic EHR


WHAT’S CHANGED


2. Those EHRs started to communicate


What’s Changed in your EHR?

• Meaningful Use

– Stage 1, 2, 3

– EP, EH

– Medicaid, Medicare

• Health Information Exchange

• Patient Portals, Patient Engagement

21


Data is Suddenly Portable

• Direct Secure Messaging

– Adoption of Messaging Formats

• CommonWell

• Sequoia Project

22

Source: www.hl7.org

WHAT’S CHANGED


2. Those EHRs started to communicate

3. Those EHRs can do telehealth … better

EHR Vendor: “Types of Telemedicine”Low

-Tech

Hig

h-T

ech

eVisits

Video

Conferencing

Remote

Monitoring

Phone

Remote

Surveillance

Paper

Mail

Online

Chat

Available

Pilot

Future

Secure

Messaging

Prescribed

Education

Supervised

Self-Mgmt

Asynchronous Synchronous

VtC, S&F, RPM, eVisits … will all be integrated into the EHR very soon.

Member Portal (HealtheLife)

25

Members can:

• Access health records

• Access patient education

• Schedule appointments

• Secure messaging

• Pay bills online

• Receive personal health

reminders

• Transmit summary of care

• Rx refill & renewal requests

• Complete surveys and e-Visits

• Integrate devices

Providers can:

• Personalize and update content

• Increase patient touch points

and satisfaction

• Reduce overhead related to

faxing, calling, printing, etc.

Source: Cerner.com


Behavioral Health: Mood Trek

See your patient’s

journey through

simple tracking

tools…

This is part of a solution used by more than 270 organizations.

Source: Cerner.com


Video Visits

Patient Provider

HealtheLife

Patient Portal

HealtheLife App

PowerChart

PowerChart Touch App

Web-Based Video

OR OR

This is part of a solution used by more than 270 organizations.

Source: Cerner.com


How important is telehealth to us [Cerner]?

Source: Cerner.com


The relentless innovation in information technology

Delivering telehealth

Securing the enterprise

Leveraging “big data” and advanced analytics

The evolution of the Chief Information Officer role

Source: Cerner.com


High-Risk

Patients

Rising-Risk Patients

Low-Risk Patients

5% of patients.

Usually with complex disease(s), comorbidities.

15% - 35% of patients.

May have conditions not under control.

60% - 80% of patients.

Any minor conditionsare easily managed.

Trade high-cost

services for low-cost management.

Avoid unnecessary

higher-acuity, higher-cost spending.

Keep patient healthy,

loyal to the system.

Segment Care Management Models Based on Patient Care Needs

Source: Playbook for Population Health, © The Advisory Board Company 2013


Prioritize Investments by Patient Population

Source: Playbook for Population Health, © The Advisory Board Company 2013

High-RiskPatients

Rising-Risk Patients

Low-Risk Patients

IT• HIE• Data warehouse• Home Monitoring

• Analytics• Disease registry

• Patient Portal• Telemedicine• Call center• Text-based

communication

Network Development

• High-risk clinics• Home care• Post-acute care• Community

resources

• Medical home implementation

• Post-dischargeclinics

• Retail clinics• Urgent care centers• Worksite clinics

Workforce• High-risk care

managers

• Patient navigators• Health coaches• Physician extenders

• Call center staff• E-visit providers

Increasing number of patients

Alaska Native Tribal Health Consortium 32Source: Cerner.com

WHAT’S CHANGED

1. Everyone got an EHR2. Those EHRs started to communicate3. Those EHRs can do telehealth better4. More need/want to do telehealth


Interest and Support

34

A majority of respondents already offer remote monitoring (64%), store and forward technology (54%), and real-time interaction capabilities (52%). Additionally, 39 percent say they have services that qualify as mHealth —patient-driven apps and online portals. (Nathaniel Lacktman, Esq. Healthcare Partner, Foley & Lardner)

90% of healthcare executives reported that their organizations have implemented or are working on a telehealth program (Foley 2014 Telemedicine Survey).

35% of employers with on-site health facilities offer telemedicine services and another 12% plan to do it within the next two years. About 70% of employers plan to offer telemedicine services as an employee benefit by 2017 (Towers Watson 2015 Employer-Sponsored Health Care Center Survey).

http://chironhealth.com/blog/telemedicine-gaining-traction-patient-attraction-growing-heres-data/

64% of Americans would attend a doctor’s appointment via video (American Well 2015 Telehealth Survey)

57% of primary care physicians are open to holding appointments with patients remotely (American Well 2015 Telehealth Survey).

http://chironhealth.com/blog/telemedicine-gaining-traction-patient-attraction-growing-heres-data/


Interest and Support … But …

“Telemedicine reimbursement poses the primary obstacle to success, but EMR-related challenges are persistent and widely noted in the survey,” said McGraw. “There is clearly a high demand in the industry for EMR integration, specifically the two-way flow of individual data elements between telemedicine platforms and EMR systems.”

http://www.clinical-innovation.com/topics/mobile-telehealth/survey-shows-growing-interest-telemedicine

35

http://www.clinical-innovation.com/topics/mobile-telehealth/survey-shows-growing-interest-telemedicine


Comparing Providers (2011)

36

High User

Medium User

Low User

500 or more cases

100-499 cases

10-99 cases

Initiator (22)

Consultant (49)

Initiator (120)

Consultant (112)

Initiator (222)

Consultant (159)


Rate the importance of EHR Integration

37

Listing patients from your EHR database (so you can select a name to start a telemed case).

4.0

Providing a patient health summary obtained from the EHR with every telemed case.

4.0

Receiving hospital discharge summaries, sent to you as a telemed case.

3.7

Providing a text summary of the telehealth case in your EHR.

4.1

Providing a link in your EHR that would open the telehealth case.

4.2

Providing the complete telehealth case with text, images and other attachments, in your EHR.

4.1

1Very unimportant

2Somewhat unimportant

3Somewhat important

4Very important

5Extremely important

WHAT’S GOING TO CHANGE

1. Federal regulations are going to drive dramatic changes.

Regulatory Changes

Medicare Access and CHIP Reauthorization Act (MACRA)Merit-Based Incentive Payment System (MIPS)

Quality Payment Program (QPP)

Certified Electronic Health Record Technology (CEHRT)

Meaningful Use Stage 3

39

Quality

Cost

Volume-Driven Healthcare

Value-Driven Healthcare


MACRA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114 10, enacted April 16, 2015), amended title XVIII of the Social Security Act (the Act) to repeal the Medicare Sustainable Growth Rate, to reauthorize the Children’s Health Insurance Program, and to strengthen Medicare access by improving physician and other clinician payments and making other improvements.

What you need to know: MACRA created MIPS/APMS and Quality Payment Programs.

40


PATHS TO PAYMENT

41

MACRA presents two alternative paths to payment

The Merit-based Incentive Payment

System (MIPS)

Advanced Alternative Payment Models (Advanced

APMs)

Shared Savings Program (Tracks 2 and 3)

Next Generation ACO Model Comprehensive ESRD Care (CEC) Comprehensive Primary Care

Plus (CPC+) Oncology Care Model (OCM)

Physicians (MD/DO and DMD/DDS) Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse

Anesthetists

MIPS Weighted Categories & Financial Impact

42

ADVANCING CARE INFORMATION (ACI)

Previously MU

CLINICAL PRACTICE IMPROVEMENT ACTIVITIES

(CPIAs)

QUALITYPreviously PQRS & MU CQM

RESOURCE USEPreviously VM

25%

15%

60%

25%

15%

50%

10%

25%

15%

30%

30%

25%

15%

30%

30%

2017+/- 4% in 2019

2018+/- 5% in 2020

2019+/- 7% in 2021

2020+/- 9% in 2022


ADVANCING CARE INFORMATION (ACI)

43

Formerly Meaningful Use (MU). Now 8 measures.

Patient Access0-10 Points

View/Download/Transmit (VDT)

0-10 Points

Patient-Specific Education

0-10 Points

Secure Messaging0-10 Points

Health Information Exchange (Summary

of Care)*0-10 Points

Patient Generated Health Data0-10 Points

Request/Accept Patient Care Record

0-10 Points

Clinical Information Reconciliation

0-10 Points

Maximum of 80 points towards total ACI score

Clinical Practice Improvement Activities (CPIA)

Expanded Practice Access

Population Management

Care Coordination

BeneficiaryEngagement

Patient Safety Practice

Assessment

AlternativePayment Models

Same day appointments for urgent needs

After hours clinician advice

Monitoring health conditions & providing timely intervention

Participation in a Qualified Clinical Data Registry (QCDR)

Timely communication on test results

Timely exchange of clinical information with patients and providers

Use of remote monitoring

Use of telehealth

Establishing care plans for complexpatients

Beneficiaryself-management assessment and training

Employing shared decision making

Use of clinical checklists

Use of surgical checklists

Assessments related to maintaining of certification

Participation in an APM will also count for CPIA

CMS proposes more than 90 activities

Resource Use

45

Highest Points = Most Efficient Resource Use

CMS calculates scores based on Medicare claims

No additional reporting 40+ Episode-specific measures Measures worth 10 points each

The Resource Use performance category values clinicians delivering more efficient, high quality care…

Composite Performance Score

46

MIPS performance category points are added up to create the Composite Performance Score…

Performance Category Max. Points % MIPS Score

Advancing Care Information 100 Points 25%

Quality 80 to 90 Points 50%

Resource UseAverage score of all cost measures that can be attributed

10%

CPIAs 60 Points 15%

…which is compared to the “MIPS Performance Threshold” to determine the adjustment % the eligible clinician will receive

Financial Impact

47

Payment adjustments will take place 2 years following the performance year …

Payment Adjustment

+4% +5%

MAXIMUM +/- ADJUSTMENT

+7% +9%-9% -7% -5% -4%

…plus potential bonuses x3 for top performers

2019

2020

2021

2022

2017 Reporting Options“Pick Your Pace”

No Submission Test ProgramPartial/Full Submission

APM Participant

Non-Participant in MIPS

Testing MIPS Reporting MIPS Advanced APM Participant

Does not report on any measures for at least 90 days.

Receives a negative 4% payment adjustment in 2019.

Only reports onemeasure in one category.

Avoids Negative Payment Adjustment

Testing ACI = all base measures

Either a Full or Partial (90 days or more) reporting period.

Report all requiredmeasures across all categories.

Achieves QP Status(receives a 5% incentive payment in 2019)- or –

Achieves Partial QP Status (can elect to participate or not in MIPS)

- 4% 0% 0% to +4% +5%

48


CEHRT, MIPS & MU Sequence

Calendar Year

(EH & EP)

Eligible Hospitals (EH) and Critical Access Hospitals

(CAH)

EligibleProfessionals (EP)

(Medicaid)

Eligible Clinicians (EC)

(Medicare)

2014 Stage 1 or Stage 2 Stage 1 or Stage 2 Stage 1 or Stage 2

2015 Modified Stage 2 Modified Stage 2 Modified Stage 2

2016 Modified Stage 2 Modified Stage 2 Modified Stage 2

2017Modified Stage 2 or

Stage 3 (90 Days)Modified Stage 2 or

Stage 3 (90 Days)MIPS

(90 Days-ACI)

2018 Stage 3 (Full Year) Stage 3 (Full Year)MIPS

(90 Days-ACI)

49

2014 Certified EHR

2014 or 2015 Certified EHR

2015 Certified EHR


Meaningful Use (MU)

Meaningful Use is at the core of the EHR Incentive Payment Programs.

Previous rulemaking established three stages of Meaningful Use:

STAGE 1 - Data Capture and Information Sharing STAGE 2 - Advanced Clinical Processes STAGE 3 – Improved Outcomes

50

Meaningful Use Stage 3 is about provider behavior.

2015 Certification Rule is about the technology to support that behavior.


EHR Incentive Programs Stage 3 Meaningful Use Objectives

Objective 1: Protect Patient Health InformationObjective 2: Electronic PrescribingObjective 3: Clinical Decision SupportObjective 4: Computerized Provider Order EntryObjective 5: Patient Electronic Access to Health

InformationObjective 6: Coordination of Care through Patient

EngagementObjective 7: Health Information ExchangeObjective 8: Public Health and Clinical Data

Registry Reporting51

52https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medicaid_Stage3.pdf

80% OF PATIENTS WILL BE ON A PORTAL


25% OF PATIENTS WILL MESSAGE TO A PROVIDER


50% OF TRANSFEROF CARE WILL OCCUR VIA DSM AND CCDA


QPP in the words of CMS

The Quality Payment Program provides new opportunities to improve care delivery by supporting and rewarding clinicians as they find new ways to engage patients, families and caregivers and to improve care coordination and population health management.

https://qpp.cms.gov/docs/QPP_Key_Objectives.pdf

55

https://qpp.cms.gov/docs/QPP_Key_Objectives.pdf



2. Telehealth can integrate with EHRs.

2015 Edition Final Rule Health IT Goals

57

Improve Interoperability Facilitate Data Access and Exchange

Use the ONC Health IT Certification Program to

Support the Care Continuum

Support Stage 3 of the EHR Incentive Programs

Improve Patient Safety

Reduce Health Disparities

Ensure Privacy and Security

Capabilities

Improve the Reliability and Transparency of Certified Health IT

2015 Base EHR Definition

58

Base EHR Capabilities Certification Criteria

Includes patient demographic and

clinical health information, such as

medical history and problem lists

Demographics § 170.315(a)(5)

Problem List § 170.315(a)(6)

Medication List § 170.315(a)(7)

Medication Allergy List § 170.315(a)(8)

Smoking Status § 170.315(a)(11)

Implantable Device List § 170.315(a)(14)

Capacity to provide clinical

decision supportClinical Decision Support § 170.315(a)(9)

Capacity to support physician

order entry

Computerized Provider Order Entry (medications, laboratory, or

diagnostic imaging) § 170.315(a)(1), (2) or (3)

Capacity to capture and query

information relevant to health

care quality

Clinical Quality Measures – Record and Export § 170.315(c)(1)

Capacity to exchange electronic

health information with, and

integrate such information from

other sources

Transitions of Care § 170.315(b)(1)

Data Export § 170.315(b)(6)

Application Access – Patient Selection § 170.315(g)(7)Application Access – Data Category Request § 170.315(g)(8)

Application Access – All Data Request § 170.315(g)(9)

Direct Project § 170.315(h)(1) or Direct Project, Edge Protocol, and

XDR/XDM § 170.315(h)(2)

Application Programming Interface (API)

59Source: Cerner Corporation

APIs enable apps for providers and consumers. This meets the needs of the government and people who want more choices.



2. Telehealth can integrate with EHRs.3. Patient data will be more portable


Two Workflow Methods

61

CCDA Sent Directly to Provider

CCDA Queried from CommonWell

Transition of Care

Direct DSM activity.Medical records request.Provider Letters

Incorporate

CommonWell XDS document exchange

Match patient.Save message.Query & retrieve –auto or manual

Direct


CommonWell Live Sites

http://www.commonwellalliance.org/providers/

http://www.commonwellalliance.org/providers/


National Initiatives

CommonWell services are essential to the exchange of health data across the care continuum.

• Person Enrollment — Enable each individual to be registered and uniquely identified in the CommonWellnetwork

• Record Location — Create a “virtual table of contents” that specifies the available locations for patient information

• Patient Identification and Linking — Link each individual’s clinical records across the care continuum

• Data Query and Retrieval — Enable caregivers to search, potentially select and receive needed data across a trusted network

63

http://www.commonwellalliance.org/services/

http://www.commonwellalliance.org/services/


CommonWell and Carequality

Together, CommonWell members and Carequalityparticipants represent more than 90% of the acute EHR market and nearly 60% of the ambulatory EHR market.

Today, over 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWellnetwork. Patients and their providers at these care sites will have access to more complete health data on which to base healthcare decisions.

64



2. Telehealth can integrate with EHRs.

3. Patient data will be more portable

4. Healthcare will become more integrated


The Goal …

“Our collective goal throughout the QPP is to support the vision of a simpler approach to technology for providers, focused on advancing information sharing and better outcomes for patients,” said Washington.

National Coordinator Dr. Vindell Washingtonhttp://healthitanalytics.com/news/will-macra-and-the-qpp-unlock-health-data-for-smarter-care

66

http://healthitanalytics.com/news/will-macra-and-the-qpp-unlock-health-data-for-smarter-care

BECOME ENGAGED


Get Involved

• It’s obvious telehealth is part of the solution.

• Not a lot of answers. Many questions.

• Stay connected to the EHR world. Cannot live in isolation in a “Telehealth world”.

• Get smart - or go home.

• Standalone telehealth systems will die.

• Engage in strategy development for QPP.

68


Get More Involved

• The opportunity is to change from checking a box (MU?) to changing health care.

– Consider the patient portal: do we just get patients to sign up? Or do we build programs to improve wellness, patient engagement, pop health.

• Look for other models of excellence, get involved early and often in EHR.

• Now more than ever, it’s all about partnerships.

69

Do we need Telehealth Programsin a World of Interoperability and

Quality Payment Programs?

We need Telehealth Programs

that leverage changes and

provide leadership

Stewart Ferguson, PhDChief Technology Officer (CTO)


in a World of Interoperability and Quality Payment Programs? · in a World of Interoperability and...

Documents

Transcript of in a World of Interoperability and Quality Payment Programs? · in a World of Interoperability and...