Meaningful Use: Compliance Management Best Practices David Morton, Adventist Health Jay Fisher, Meaningful Use Monitor May 20, 2015
Theme 1. The risks associated with Meaningful Use are largely in the future, and largely based on actions taken in the past. 2. How Adventist has evolved from projects around new regulations, to ongoing operational management of a (probable perpetual) Federal Program.
When is Meaningful Use Done? a) As soon as we receive all our Stimulus Payments b) After two years of Stage 3 Attestations c) Some future date in the Regulations (i.e., 2021) d) Other Answer (c or d): Stage 2 Federal Register identified activities through 2021, But no explicit sunset date has been published
Context: ADVENTIST Volumes Physicians Hospitals EHR products MU staff Initial program entry dates and volumes
Impact of an Audit Event Why is MU a Risk Conversation? Install EHR Achieve MU Attest to MU Receive Stimulus! CMS Audit CMS Recoups Stimulus CMS Imposes Penalties Adverse Audit = Unpleasant Surprise Hospital audits have potential large single impact (6 or 7 digit recoupment plus penalty) Physician audits financial impact is less but document management is large Most likely audit failure is inadequate documentation, rather than lack of compliance Created outside the reporting period / cannot reproduce exact attestation results Missing EHR system logo and/or hospital/clinic identification Documentation that requires explanations or is not self explanatory
Impact of an Audit Event What is the Adventist Adverse Impact? Install EHR Achieve MU Attest to MU Receive Stimulus! CMS Audit CMS Recoups Stimulus CMS Imposes Penalties Financial Exposures in Adventist terms $80,000,000.00 hospital Stimulus payments over 4 years $6,000,000.00 ambulatory Stimulus payments over 4 years Meaningful Use Penalty exposure varies from $200,000.00 to $1,000,000.00 annually as penalty moves from 1% to 5% of Medicare billings for EP s Damage to Reputation
Evolution of Meaningful Use First 2 years Meaningful Use Projects: Project Managers EHR Implementation or re-implementation (even for HIMSS EHR Adoption Model winners) Physician Education and Monitoring Data management was spreadsheet based 2014 Projects Threw us all for a loop 2015 Projects In turmoil around what measures, what timeline, what EHR Versions Last 2 years have Operationalized Meaningful Use: Meaningful Use Coordinators Hospitals centered on documentation and audit simple job with big consequences Big physician groups = bigger management of data Data volume and complexity The business problem around Meaningful Use has evolved from Achieving It to Reporting and Documenting It
MU Coordinator Manages Part-time Relationships Coordinate CMS Audits Plan Audit Appeals Analyze Regulations for configuration and workflow changes. Mock Audit (manage Or conduct) Run Meaningful Use Reporting from EHR Internal Audit CFO IT Analyst Share results of Security Risk Assessment Test and sustain Public Health Connectivity Proof Execute Quality Reports Evaluate individual provider CQM Compliance Data Communications Quality Reporting Arrange and document Existence of correct CEHRT CIO Post MU Payments From Medicare and Medicaid Meaningful Use Coordinator Revenue Cycle Staff Track expected Stimulus and Penalty data Physician Contracting Financial Manager IT Security Manage PECOS Proxies Register EP s in PECOS Receive initial audit request Obtain prior employer MU Documentation For current and prior years Clarify responsibilities for failed audit (with Providers new to the practice)
MU Coordinator Manages Mountains of Data Annual Audits: One per 20 EP s (on average) Audits Body of Evidence: 2-3 documents per Measure per EP Meaningful Use Quantitative Measures: 11 13 per EP, per report cycle Analyze Regulations for configuration and workflow changes: A few hundred pages of Federal Register per year, plus 300+ FAQ s Security Risk Assessment: one per location per year PECOS Registrations: One per EP Public Health Connectivity Proof: One per Public Health Measure, Per EHR Per Public Health Jurisdiction Meaningful Use Coordinator Meaningful Use Payments: One per EP per reporting year Execute Quality Reports: 9 Per EP across 3 domains, but Most organizations run 20+ CQM s To assure coverage Arrange and document Existence of correct CEHRT: One per major EHR Release For a population of 60 EP s, one MU Coordinator manages over 4,000 elements of information
MU Coordinator Manages An Evolving (sometimes Revolving) Position Office Manager With Meaningful Use Responsibilities Original Dedicated Meaningful Use Coordinator Meaningful Use Startup Consultant Replacement Meaningful Use Coordinator
Not much of a Support Group Quality of Industry Advice is Questionable Consulting firms have no real stake in accuracy of advice Decisions and strategies decided today may not be tested for years after consultants have departed CMS advice and interpretations difficult to obtain and are not always supported by body of regulation Newness of regulations means there is little reliable case law to rely on We had to become self-sufficient on Regulations and interpretation
What must the MU Coordinator Know? How to apply regulations to operations Where to Look Date Pages What to look for H.R. 1 - ARRA of 2009 (Legislation) 2009 400 Initial law authorizing CMS to regulate MU Stage 1 Meaningful Use F.R. 07/2010 276 Defined stages, payments, and initial criteria 2011 Edition EHR Certification F.R. 07/2010 200 EHR Vendor Certification The source of truth is The Federal Register And there are no Short Cuts Stage 2 Meaningful Use F.R. 09/2012 196 Elaborated stages, finalized penalty process 2014 Edition EHR Certification F.R. 09/2014 52 Mandatory EHR upgrade criteria and vendor certification 2014 Flexibility Rule F.R. 09/2014 25 Allow flexibility for providers to remain in Stage 1 under some circumstances Hardship Exception Final Rule 11/2014 196 Rules under which providers can claim hardship exceptions Stage 3 Notice of Proposed Rulemaking F.R. 03/2015 73 Stage 3 plus electronic submission of CQM s 2015 Edition EHR Certification 03/2015 118 Certification criteria for 2015 Edition CEHRT F. R. Modifications in Meaningful Use from 2015-2017 04/2015 55 Elaborates statutory provision for increasingly stringent use of CEHRT 300+ FAQ Entries Elaboration, clarification or sometimes changes to Federal Register content Voluntary 2015 Edition Electronic Health Record (EHR) Certification Criteria 02/2014 68 Optional CEHRT certification criteria Spread over years, the learning curve is steep, but manageable. All at once for new staff it is daunting. We need to be able to retain our knowledgeable team
Evolving Physician Contracting Scenarios CMS Auditor reviews prior year (from another employer) Physician Contracting Physician enters from another practice With Meaningful Use History Meaningful Use Coordinator Audit fails when prior Employer documentation unavailable Contracting and Physician Relations Issue: Failed Audit with Physician in Transition CMS Recoups $18,000 From physician personally
Evolving Physician Contracting Scenarios Physician not re-registered to new employer in PECOS Physician Contracting Physician enters from another practice With Meaningful Use History Financial Manager No notice to internal PECOS Registrar Meaningful Use Coordinator Physician successfully achieves Meaningful Use Year 2! Contracting and Physician Relations Issue: Meaningful Use Re-Registration Dropped Ball Previous employer receives $12,000 Stimulus payment for year 2
Meaningful Use Best Practice Model Operational Best Practice Model for Meaningful Use Coordinators As-Is / Current State Functional Activity People Current storage Future storage 1 Add new EPs to the practice (or to Meaningful Use) a Acquire PECOS Proxy b Register provider clinic for Meaningful Use in PECOS; or c Re-register EP to new employer in PECOS d Capture prior attestation history summaries e Capture any partial year metrics from prior employer for current / transition year f Request detail documentation supporting prior years attestations from prior employer(s), and store into compliance database g Determine menu items for current year 2 Manage departing EPs a Create and store partial year documentation on all measures b Flag Meaningful Use financial records Tracking Inbound and Outbound EP s has evolved to a big (and important) job
Meaningful Use Best Practice Model Operational Best Practice Model for Meaningful Use Coordinators As-Is / Current State Functional Activity People Current storage Future storage 3 Manage Attestation a Determine program eligibility, as necessary (i.e., Medicaid patient volume, registration) b Provide data on quantitative Meaningful Use measure compliance (numerator / denominator content) c Provide CQM reporting for relevant reporting period d Comply with Security Risk assessment for each pertinent location e Evaluate system configurations for relevant yes / no measures by EHR instance f Assemble data on interoperability compliance (other providers and repositories) g For providers achieving measure thresholds, evaluate performance against pertinent reporting periods h Determine which EP's are ready to attest and schedule attestation work i Attest with state or CMS j Flag EP as attested, pending payment receipt 4 Maintain Compliance Body of Evidence a Develop and maintain ongoing documentation strategy b Analyze existing process, policy and workflow information for evidence of Meaningful Use Compliance c During reporting period, capture time-sensitive content d After reporting period capture and organize all remaining documentation e Schedule and conduct annual Mock Audit Reporting and Documenting compliance has evolved to a tedious (and risky) job
Meaningful Use Best Practice Model Operational Best Practice Model for Meaningful Use Coordinators As-Is / Current State Functional Activity People Current storage Future storage 5 Monitor Regulatory updates a Research annual Federal Register publications for changes to measure definition and update strategies, workflows, technology and compliance database as needed b Monitor CMS FAQs and update strategies, workflows, technology and compliance database as needed c Communicate changes to technical and clinical staff as needed c Support planning for technology, process and workflow updates derived from Regulatory change 6 Account for Payments and Penalties a Medicare estimate stimulus payments based on attesting EPs and their point in Meaningful Use stage cycle b Medicare on a quarterly basis, use CMS spreadsheet to identify payments to your EPs, and update compliance database. Follow up with CMS on discrepancies. c Medicaid update compliance database from State Medicaid remittance data as payments are made to your account (if available). Periodically analyze and follow up with State on discrepancies d Adjust financial model for any EPs failing to attest in a given year. Delete stimulus payment for non-attesting year Recognize expected penalty for second following year and notify finance management 7 Respond to CMS (or State) Audit a Record audit request for provider / year in compliance repository b Assemble and submit documentation as requested by auditor c Record audit correspondence, including final results d In the case of failed audit: Analyze cost / benefit of submitting an appeal to CMS Submit appeal, if appropriate Adjust financial model to reflect recoupment Adjust financial model to calculate and reflect penalty in second year following failed reporting period, and notify finance management The Pseudo-Legal and Financial and components have evolved as a daunting (and risky) job
Meaningful Use Best Practice Multiple Discrete Layered Defense We measure our Diligence regularly oriented towards: Audit Prevention Mock audit Ready-Team for Actual Audit Appeals team
Book of Evidence Audit documentation guidelines from CMS are almost Non-Existent Book of Evidence Documentation Strategies Summary (Certified) EHR Data is only a starting point Additional details by Physician (or Hospital) and Measure Checklists Our Book of Evidence for an EP averages 500 pages; for a Hospital 750 pages
Supporting technologies and processes In the beginning Initial heavy reliance on EHR based tools quickly generated lots of supplemental tools Access Databases Physician Master Data Clinic Data Hospital Data Share Point Document Repositories Spreadsheets for Measurement and Lots of Overtime as the job(s) emerged
Supporting technologies and processes In the beginning Stimulus payments will begin to tail out in the next few years Keys to success Automate where possible to gain staffing efficiencies Leverage high-quality information on regulations, their impact, and our compliance strategies Rely on cost-effective vendors to manage the creation and sustaining of tools Leverage our deeply knowledgeable staff to manage strategy and protect our funds and reputation (externally as well as with our EP staff) but Compliance Activities will not go away
Supporting technologies and processes In the beginning Maintaining our own tools started to get in the way of doing the job Spreadsheets get overwhelmed Become cumbersome with size over time Lack the transaction controls of Operational Data Store tools Do little to automate repetitive processes Each owner puts their own stamp on design and usage, reducing institutional value Share Point Document Repositories Good as simple document repositories Lacking in checklists for documentation, process or regulation content They don t really provide expert assistance to users Access Databases A good start, but difficult to maintain with limited resources Meaningful Use compliance jobs are still evolving, and functionality needs to evolve with it Our scarce and valuable MU resources needed to do the job, not build tools
Market Review of Third Party compliance tools Still a young market with maturing tools but they do exist and provide good value Price and functionality vary quite a bit They can be a little bit hard to find there is not a common vocabulary to describe this kind of product EHR Vendors assert capabilities, but lack: Automated Attestation Comprehensive Documentation Repository Annual history of each provider s attestation history Integrated Financial tracking Managing information on Physicians in Transition (in and out) Comprehensive tracking of all Meaningful Use criteria Multi-CEHRT vendor compliance tracking MUM or Meaningful Use Monitor is a cloud-based product by C3 Partners, LLC. It supports ambulatory and inpatient domains, and is supported by Meaningful Use Help Desk, an educational portal, and mock audits associated with each subscription. The URL is MeaningfulUseMonitor.com, and its Help Desk site is MeaningfulUse.Guru. SA-Ignite markets a product called MU Assistant, originally deployed and used by a number of Regional Extension Centers (RECs) for small physician practices, and is oriented toward Eligible Professionals. The URL is SAignite.com. Iatric has a product based on its strong Meditech relationships, primarily in hospitals. Their Meaningful Use Manager is typically installed on-site, and has the benefit of reproducing Meaningful Use reporting that is typically weak in Meditech installations.
Incorporating a Tool into Adventist Converting History helped us clean up our own data Vendor had to be flexible with reporting and new functionality to support our size and diversity Multi-EHR vendor and version had to be easy and quick Our vendor had some new concepts we needed to learn and agree with The Job of the Meaningful Use Coordinator team is still evolving our vendor needs to commit to new functionality as the regulations change, and our needs evolve Meaningful Use will probably only be a part of the long-term CMS Compliance strategy. We envision adding: ACO Value Based Modifier Tracking PQRS / GPRO Quality Measure Compliance Tracking Others, that we don t yet see, but leverage use of some of the same core data
Future of MU Meaningful Use Attestation is Required at least through 2021 Audit Retention Cycles through at least 2027 CMS develops Regulations in support of Legislation Regulation subject to administrative change Audit standards are regulatory, not legislative Current Administration created the Stimulus and Audit program Current auditors do not dig as deeply as their rights allow Flexibility Self Sufficiency Leverage Common Data Across Multiple Programs