Federal Programs Driving Health Information Exchange

HIE Summit West October 5, 2010Michael T. Rapp, MD, JD

Director, Quality Measurement and Health Assessment GroupOffice of Clinical Standards and Quality

Centers for Medicare and Medicaid ServicesBaltimore, MD

Better PopulationHealth

Better Healthcare for Individual

Lower Per CapitaCost

The “Triple Aim”

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Quality Aims

• Better Care for Individuals

– Six IOM Aims: Effective; Safe; Patient-Centered; Timely; Efficient; Equitable

• Better Health of Population

– Prevention and other population health activities

• Reduce Per Capita Costs

– Reduce while improving individual health care and population health

Ensuring Quality & Value:CMS Tools

• Contemporary Quality Improvement : QIO program• Transparency: Public Reporting of Quality Measure Results• Financial Incentives: To Measure and Improve Quality

– HITECH Incentive – Requires meaningful use of certified E H R’s, including Heath Information Exchange and Clinical Quality Measure reporting

– Quality Reporting Programs: Hospital, Physician, Home Health– Differential payment based on quality

• ESRD Value Based Purchasing - 2008 Medicare Legislation• Hospital Value Based Purchasing - Affordable Care Act• Accountable Care Organizations – Affordable Care Act• Physician Value Modifier – Affordable Care Act

• Regulatory vehicles : Including Conditions of Participation, Survey and Certification, Accreditation– Required Patient Assessment Instruments: MDS, OASIS

• National & Local Coverage Decisions• Demonstrations, pilots, research

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Challenges in Measuring Quality• Burden of collecting clinical data

– Clinical data preferable to claims data for quality measurement and risk adjustment

• Difficulty of collecting data across provider and professional settings of care

– Coordination of care

– Episodes of care

– Outcome measures

– Measurement of Functional Status

• E H R’s have potential to address challenges

Potential Advantages HIE/HIO

• Less burden to professionals

• HIE functions on behalf of professionals; CMS interacts with HIE

• Established protocols and configuration

• Leverages capabilities of HIE/HIO

Quality Measurement and HIE/HIO’s

• Physician Quality Reporting Initiative

– Proof of Concept HIE in bidirectional transfer of data/information

• CARE data set

– Uniform data set for different care settings

– Proof of Concept collection of data submission through HIE to CMS

Physician Quality Reporting Initiative

– 2007 initial year with bonus payments

– Affordable Care Act requires participation or penalty applied after 2014

– Current submission claims, registries, or direct EHR submission into CMS portal – claims primary mechanism

– Feedback report on satisfactory reporting and performance rates, distributed by CMS, requiring entry into CMS portal

– Limited number measures required

– Few Outcome Measures

PQRI: Research and Development (R+D) Quality Initiatives on NHIN

• CMS/OCSQ execution of a research and development effort to develop technical and business process solutions to securely exchange PII level discrete data and reports in a bi-directional fashion with HIEs on the NHIN

• Industry partners include three HIEs participating in PQRI R&D plus up to two other HIEs that are in the process of on-boarding to NHIN with ONC

• Lay groundwork for PQRI Program Year 2011 limited production implementation

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& P

QR

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PQRI NHIN R&D DesignSubmissions & Feedback Testing - 2010

NHIN Exchange

CMS PQRI

HIE 2 Gateway

OCSQ CMS

Gateway

1.Submit Quality

Measures

3. Submit Quality

Measures

EMR

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5. Send NPI Reports (pdf, Excel) via email

4. Securely Send TIN Feedback

Reports (pdf/csv)

6. Access TIN/NPI Feedback Report

1. EMR Vendor Systems generate and submit Quality Reporting Document Architecture

(QRDA) / Level 1 document payload to their HIE

2. HIE Transmits quality measures data from HIEs to CMS on behalf of their Practitioners

3. CMS Gateway routes data to CMS PQRI systems using 11 e-specified measure

specifications from PY2010 E.H.R. Submission

4. CMS systems securely batch send TIN Feedback Reports over NHIN (contains PII, SSN)

5. CMS systems batch send NPI Reports over e-mail (no PII data)

6. Provider or authorized party can securely access TIN feedback reports using tools

provided by HIE and can access NPI feedback reports by e-mail

HIE 1 Gateway

HIE 3 Gateway

EMR

EMR

2. Submit Quality

Measures

PQRI NHIN R&D Overview

Demonstrate the use of the NHIN to:1. Transmit Quality Reporting Document Architecture (QRDA) / Level 1

document payload from HIEs to CMS on behalf of their Practitioners for PQRI. Uses 11 e-specified measure specifications from PY2010 E.H.R. Submissions.

2. Distribute PQRI Feedback Reports from CMS through HIE integration in addition to the current report distribution/access methodology.

3. Integrate the PQRI process with recognized goals and objectives of leveraging the Nationwide Health Information Network (NHIN) for the exchange of electronic health records data.

4. Leverage and extend existing PQRI policies and procedure with regard to data submission and report access

5. Develop a baseline bi-directional data exchange process that has an inherent business process model that is agnostic to PQRI.

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Next Steps

CMS &ONC to partner on PQRI R&D Efforts• CMS & ONC executed IAA for 1 year support began August 3rd

• CMS & ONC to test Version 3.1 of CONNECT gateway in September 2010 with 3 HIEs for PQRI R&D

• CMS & ONC to review lessons learned from PQRI R&D in December 2010

• CMS & ONC to partner to move CMS/OCSQ into Limited Production with up to 5 HIEs in 2011

• CMS & ONC on-boarding & testing of HIEs to NHIN

• CMS & ONC to discuss updated DURSA & Federal Sponsorship

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Work to Date / Lessons Learned

Work to date:• EMR Submission Design + Feedback Design• Draft Business Process Model and Memo of Understanding defining CMS and HIE

responsibilities• Submittal of Interagency Agreement (IAA) between CMS/OCSQ for ONC support to

conclude the R+D effort and provide support for limited production for PY2011

Lessons Learned:• E.H.R vendor industry sees itself and others as important intermediaries to be successful

(e.g. HIEs, clearinghouses, etc. functioning as intermediaries between the practitioner and CMS/OCSQ)

• Substantial investment in CMS/OCSQ contracted time and resources has been required to bring the E.H.R. vendors along with export capabilities for required CDA formats.

• Roles and responsibilities of intermediaries, vendors, practitioners remains largely undocumented from an enterprise perspective.

• Vendors, practitioners, etc., seek guidance related to those roles and responsibilities, security, etc.

• ONC On-boarding• Individual memos of understanding and individual program qualification processes

are required beyond the initial ONC on-boarding procedures. • Sponsorship required by ONC to onboard requires a contract or cooperative

agreement with HIEs13

CARE Data Set Continuity Assessment Record & Evaluation

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GOALS:

Develop Standards-based, Interoperable Clinical Data

Set

Uniformly Measure, Compare

Health Status, Functional Status

Collect Data Across Health Care

Settings, Over Time

Data Collected Upon

Admission, Discharge:

Paper

Electronically

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Drivers for Standardized Health Data

Sustained Congressional Interest Since 2000

Benefits Improvement & Protection Act 2000, Sec. 545 Standard Instruments, Readily Comparable, Statistically Compatible Data

Deficit Reduction Act 2005, Sec. 5008 Standardized Assessment to Support Equitable Payment across PAC Providers

Quality Improvement Organizations (QIOs) Safe Care Transitions

ARRA 2009, Sec.13101 HIT, Data Exchange & Quality Improve Health Care Quality, Reduce errors, Reduce waste Improve Care Coordination

Affordable Care Act 2010 Quality Reporting Programs: Long Term Care Hospitals, Hospices, Inpt. Rehab Facils.

Value Base Purchasing Programs: Home Health Agencies & Skilled Nrsg. Facilities

ACOs

CARE Standardized Data Set Current Medical Information

Diagnoses, Co-morbidities, Complications

Procedures (Diagnostic, Surgical, Therapeutic Intervention)

Major Treatments

Medications

Physiologic Factors (Vitals, Labs…)

Pain (Presence, Severity, Effect on Sleep & Activities)

Impairments (B&B, Sensory, Wt Bearing, Assistive Devices)

Functional Status (Mobility, Self-Care)

Plan of Care

Discharge Status (Support Needs/Caregiver Assistance)

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e Pilot

CARE-Health Information Exchange Project

Purpose: Small Scale, Limited Scope Project (June - December 2010). Test

Secure, Standards-based, Exchange of De-Identified CARE Data from HIOs to CMS.

Progress through Sept 2010: 15,000+ successful submissions from 3 HIOsCMS using CONNECT

Aligns with National Standards for Data Interoperability

Office of National Coordinator (ONC)

National Health Information Network (NHIN)

Moves CMS forward with a uniform, harmonized data set

Promotes exchange of info better communication better care coordination across settings

C-HIEP Participants

• CMS: Project Owners

• IBM, RTI: Contractors

• HIOs: Participants

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C-HIEP CONOPS

HIO

HIO

HIO

Provider Settings:1. Acute Hospital

2. Physicians Offices

3. Skilled Nursing Facilities

4. Home Health Agencies

5. Post-Acute Care Settings

6. Outpatient Rehab Facilities

7. Long Term Care Hospitals

High Level Process:1. Providers capture

information in their

systems

2. HIOs gather

information from their

providers

3. HIO sends information

to CMS for analysis

CMS

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C-HIEP Flow

CMS receives the document through our “NHIN CONNECT Gateway” and stores it for analysis

HIO uses their “NHIN CONNECT Gateway” to send the document to CMS using the Nationwide Health Information Network (NHIN)

HIO formats data into a “structured document” based on national standards for data and interoperability

Data captured at clinical setting within existing systems and transmitted to the HIO

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CARE &

• Align with national standards for data interoperability

• Move towards a uniform, harmonized data set

• Promotes enhanced communication better care coordination across settings

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HITECH and Health Information Exchange (HIE)

2011 – 2012 HITECH Rule• Stage 1 Objective: Improve care coordination Capability to

exchange key clinical information (ex: problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically

• Stage 1 Measure: Performed at least one test of the certified EHR technology’s capacity to electronically exchange key clinical information

• Electronic submission of data for 2012 does not require use of an HIE/HIO for clinical quality measure submission

Future• Requirements for Health Information Exchange: Future Rule Making• Strive to alignment of HITECH Clinical Quality Measure reporting

with Physician Quality Reporting Initiative for physicians and with Hospital Inpatient Reporting Program for Hospitals

• Potential role of HIE/HIO’s for Clinical Quality Measure Reporting

Conclusion

• In addition to other benefits……

• HIE’s/HIO’s have potential to facilitate submission of clinical quality data to CMS

– Address burden, episodes of care, coordination of care, outcomes

– Leverage and promote HIE/HIO infrastructure

• HIE’s/HIO’s have potential to facilitate exchange of standardized data sets among professionals and providers to promote coordination of care

Thank you

Michael T Rapp, MD, JDDirector, Quality Measurement and Health Assessment Group

Office of Clinical Standards and Quality

Centers for Medicare and Medicaid Services

Baltimore, MD

Michael.Rapp@cms.hhs.gov