The Compliance Officer’s Role In “Meaningful Use”

The Compliance Officer’s Role in“Meaningful Use”Nancy Vogt, RHIT, CHC, CHPDirector/Deputy Chief Compliance OfficerAurora Health Care – Milwaukee, WisconsinThe journey from denial to acceptance–“who, what, me?” EHR Incentive Program is new andcomplex, with many moving parts Can be significant dollars Incentives now, penalties in 2015 Security risk assessment/mitigation 2012 OIG Work Plan1

Leadership certificationI certify that the foregoing information is true,accurate, and complete. I understand that theMedicare EHR Incentive Program paymentrequested will be paid from Federal funds, andthat the use of any false claims, statements, ordocuments, or the concealment of material factused to obtain Medicare EHR Incentive Programpayment, may be prosecuted under applicableFederal or State criminal laws and may besubject to civil penalties.Where to /CMS Specification SheetsFederal Register commentaryCMS FAQ’sONC FAQ’s (healthit.hhs.gov)Federal advisory committee meetingminutes7. EHR Information Center (888-7346433)8. EHR Incentive Programs Listserv2

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 toimprove quality of health care– To report/submit clinical quality and othermeasuresWhy?1. Improve quality, safety, efficiency, andreduce health disparities2. Engage patients and families3. Improve care coordination4. Improve population and public health5. Ensure adequate privacy and securityprotections for personal health information3

Medicare vs Medicaid Programs Medicare EHR Incentive Program:– Eligible participants must successfully demonstrate MU ofcertified EHR technology for 90-day period in first year, thena full year thereafter Medicaid EHR Incentive Program– Eligible participants may qualify for incentive payments ifthey adopt, implement, upgrade or demonstrate MU in theirfirst year Adopted acquired and installed Implemented have begun using certified EHRtechnology Upgraded expanded existing technology to meetcertification requirements– Must successfully demonstrate MU for subsequent yearsEligibility (and this is the easy part)4

And now for the nutty part Hospital Requirements– 19 measures (14 core, 5 from menu of 10-1 ofwhich 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 alternatecore, 3 of 38 additional measures)Of course we own a certified EHR (ortwo) EHR vendor certification methods:modular or complete (or both?) Using certified functionality (no goodinnovation goes unpunished) Possessing functionality for deferredmeasures (ONC FAQ 12-10-021-1) Clinical quality measure reports (ONCFAQ 3-11-024-1)5

CertificationThe measures are clear and simple,aren’t they? Hospital–––––––Testing exchangeClinical quality measuresE-copiesProtect electronic health informationSmoking statusDemographicsClinical lab test results6

The measures are clear and simple,aren’t they? EP–––––Clinical SummariesClinical quality measuresCPOEePrescriptionsVital signsChecking on the clear and simple CPOE: only licensed health careprofessionals Content of clinical summaries (“after-visitsummaries”) Offering electronic discharge instructions Drug formulary and interaction checks “on” Patient list generated Security risks addressed7

Accurate clinical quality measures? Abstracting Accurate and complete– FAQ 10589: “CMS considers information to beaccurate and complete for CQM’s insofar as it isidentical to the output that was generated fromcertified EHR technology”– AHA: results can vary from those derived throughexisting manual abstractionThe road to attestation Standing meetingsExternal counselRoutine trackingEHR policy teamReference toolsAdvocate for clearregulations8

Attesting with confidence Register early Determine the role of Compliance– Attesting individual will have access to paymentinformation– Constitutes submitting a claim Mock audit Documentation for accurate attestation Documentation and report retentionSample attestation document#Measure Information1Objective: Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed health careprofessional 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 eligiblehospital’s or CAH’s inpatient or emergency department (POS 21 or 23) have at least one medication order entered usingCPOEGoal: 30%Measure ValuesScore:95.1%Numerator: Number of patients in the denominator that have at least onemedication order entered using CPOEDenominator: Number of unique patients with at least onemedication in their medication list seen by the eligible hospital or CAH during theEHR reporting period9,85210,3659

Reports – a snapshot in timeAudit-readinessPer CMS website: Save the supporting electronic or paperdocumentation that support yourattestation. Save the documentation to support yourClinical Quality Measures (CQMs). Hospitals should maintain documentationto support their payment calculations.10

Non-numerical measure examples Screen shots to provide evidence of:–––––––Testing exchangeDrug formulary and interaction checksSmoking nomenclatureOne decision support rule (hospital)Sources of CQM dataExamples of structured clinical labPublic health exchange (we included interface transactions) E-copy process flow Security risk assessment and mitigation Sample patient list (hospital)Other Documentation EHR vendor contractReport specificationsCertification documents, if anyAttestation confirmation11

What if (oh no!) a mistake was made? Could be vendor or provider Repayments may be required if reportsover-reported compliance with a measureLessons learned Significant time requirement; varied withimplementation The value of diversity in the complianceteam – knowledge of I.T. The value of clear ownership Documentation (in case you really do gethit by a bus)12

On the horizonQuestions13

Meaningful use in a nutshell ARRA/HITECH incentive program – Use certified EHR technology – Be a “meaningful EHR user” . (Microsoft PowerPoint - The Compliance Officer\222s Role in Meaningful Use.