PCPCC PPT Template

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Coherent ConnectionsWiring the Patient Centered
Medical Home in a Meaningful WayAugust 18, 2009

• David C. Kibbe, MD, MBA, Senior Advisor,
  American Academy of Family Physicians, and Chair,
  ASTM International E31Technical Committee and
• Principal, The Kibbe Group
• Dennis Saver, MD ltneed infogt

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The Health IT Landscape

• Meaningful Use
• Defined
• EHR Certification
• Who will certify,
• and when?

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Meaningful Use Meaningful Connections

• Identifies health IT as a critical platform of
  the PCMH.
• (Re) Conceptualizes health IT as an e-platform
  and set of tools.
• Health IT functional priorities to support a
  PCMH.
• Critical capabilities to engage consumers with
  health IT.
• Explores the current use of health IT by primary
  care physicians.

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Cross Walk HIT for PCMH withMeaningful Use
Objectives
CeHIA Meaningful Connections Report Capabilities
HIT Policy Committee Recommendations Priorities

• Ability to collect, store, manage and transmit
  health data
• Ability to communicate and exchange care
  planning
• Ability to report quality and performance
  measures
• Ability to engage decision support and
  evidence-based systems
• Ability to inform and educate patients online

• Improve quality, safety, and efficiency, and
  reduce health disparities
• Engage patients and families
• Improve care coordination
• Improve population and public health
• Ensure privacy and security protections for
  personal health information

"Health Outcomes Policy Priorities" from the HIT
Policy Committee
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Defining Meaningful Use
2011 Objective Improve quality, safety,
efficiency, and reduce health disparities.

• Eligible Providers
• - Implement drug-drug, drug-allergy,
  drug-formulary checks.
• Maintain up-to-date problem list of current and
  active diagnoses based on ICD-9 or
• SNOMED.
• - Generate and transmit permissible prescriptions
  electronically (eRx).
• Maintain active medication list and active
  medication allergy list.
• Record demographics preferred language,
  insurance type, gender, race, ethnicity.
• - Record advance directives.
• - Record vital signs height, weight, blood
  pressure, calculate and display BMI.
• - Record smoking status.
• - Incorporate lab-test results into EHR as
  structured data.
• Generate lists of patients by specific
  conditions to use for quality improvement,
• reduction of disparities, and outreach.
• - Report ambulatory quality measures to CMS
• - Send patient reminders, per patient preference
  for prev/follow-up care.
• - Implement one clinical decision rule relevant
  to specialty or high clinical priority.
• - Document a progress note for each encounter.
• - Check insurance eligibility electronically from
  public and private payers, where possible.
• - Submit claims electronically to public and
  private payers.

• . Ability of providers and practices to engage
  in decision support for evidence-based treatments
  and tests.

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Defining Meaningful Use
2011 Objective Improve quality, safety,
efficiency, and reduce health disparities.

• 2011 Measures
• - Report quality measures to CMS including
• - diabetics with A1c under control.
  hypertensive patients with BP under
• control of patients with LDL under
  control of smokers offered smoking
• cessation counseling of patients with
  recorded BMI eligible surgical
• patients who receive VTE prophylaxis of
  orders (for meds, lab tests,
• procedures, radiology, and referrals) entered
  directly by physicians through
• CPOE.
• - Use of high-risk medications (Re Beers
  criteria) in the elderly.
• - of patients over 50 with annual colorectal
  cancer screenings.
• - of females over 50 receiving annual
  mammogram.
• - of patients who received flu vaccine.
• - lab results incorporated into EHR in coded
  format.
• - Stratify reports by gender, insurance. type,
  primary language, race, ethnicity.
• of all meds entered into EHR as generic, when
  generic options exist in the
• relevant drug class.
• of orders for high-cost imaging services with
  specific structured indications
• recorded.
• - claims submitted electronically to all
  payers.

• . Ability of providers and practices to
  engage in decision support for evidence-based
  treatments and tests.

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Defining Meaningful Use
2011 Objective Engage patients and families.

• Eligible Providers
• Provide patients with an electronic copy of their
  health
• information (including lab results, problem
  list, medication
• lists, allergies) upon request.
• Provide patients with timely electronic access to
  their health
• information (including lab results, problem
  list, medication
• lists, allergies).
• - Provide access to specific educational
  resources.
• Provide clinical summaries for patients with
  each
• encounter.

• . Ability of consumers and patients to be
  informed and literate about their health and
  medical conditions and appropriately self-manage
  with monitoring and coaching from providers.

• 2011 Measures
• - of all patients with access to personal health
  information
• electronically.
• of all patients with access to patient-specific
  educational
• resources.
• of encounters for which clinical summaries were
  
• provided..

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Defining Meaningful Use
2011 Objective Improve care coordination.

• Eligible Providers
• Capability to exchange key clinical information
  (e.g.,
• problem list, medication list, allergies, test
  results) among
• providers of care and patients authorized
  entities
• electronically. per HIE workgroup
• Perform medication reconciliation at relevant
  encounters
• and each transition of care.

• . Ability of providers, patients and other
  members of the care team to communicate.

• 2011 Measures
• - Report 30-day readmission rate.
• of encounters where med reconciliation was
• performed.
• Implemented ability to exchange health
  information
• with external clinical entity (specifically
  labs, care
• summary, and medication lists).
• of transitions in care for which summary care
• record is shared (e.g. electronic, paper,
  e-Fax).

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Defining Meaningful Use
2011 Objective Improve population and public
health.

• Eligible Providers
• Capability to submit electronic data to
  immunization
• registries and actual submission where required
  and
• accepted.
• Capability to provide electronic syndromic
• surveillance data to public health agencies and
  
• actual transmission according to applicable law
  and
• practice.

• . Ability to collect, store, measure and
  report on the processes and outcomes of
  individual and population performance and quality
  of care.

• 2011 Measures
• -Report up-to-date status for childhood
• immunizations.
• reportable lab results submitted
• electronically.

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Defining Meaningful Use
2011 Objective Ensure privacy and security
protections for personal health information.

• Eligible Providers
• - Compliance with HIPAA Privacy and Security
  Rules.
• Compliance with fair data sharing practices set
  forth
• in the Nationwide Privacy and Security Framework

• . Ability to collect, store, manage and
  exchange relevant personal health information

• 2011 Measures
• Full compliance with HIPAA Privacy and
• Security Rules.
• Conduct or update a security risk assessment
• and implement security updates as necessary.

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Cross-Walk MU Requirements andCertifiable EHR
Technology Components

• Practice management/billing, w/ online
• eligibility.
• ePrescribing with alerts and reminders.
• Office-based Registry application
• -Report generator either locally or as web
  service remotely
• -Care plans based on guidelines
• Documentation module
• Patient web portal/PHR, with secure messaging and
  CCR-compliant viewing, downloading, and patient
  education/engagement capability.
• Internet access to secure web server local
  hospital, regional, national.
• HIPAA privacy officer and program.

• Access eligibility and submit claims online.
• Generate and refill ePrescriptions.
• -Meds Decision Support, e.g. drug-drug, etc.
• Maintain active patient data, structured format.
• -Demographics, Problems, Medications
• -Allergies, Vital Signs, Immunizations
• -Advance directives, Lab results, Smoking hx
• Generate progress note at each visit.
• Generate lists of patients by condition.
• Generate reports per CMS measures.
• Implement at least one CDS rule.
• Enable pts. to view/receive copy of summary data.
• Enable pts. to access education, coaching.
• Enable exchange of summary health data.
• Generate reports for public health and
  surveillance.
• Comply with all HIPAA privacy and security rules.

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• Clinical Groupware
• Modular, mobile, and modestly-priced platforms
  and software applications for physicians
  practices and hospitals that meet ONC/NIST
  certification criteria for meaningful use,
  security, and interoperability

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Dennis Saver, MDBoots on the Ground

• A view from a practicing physician

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Questions and Comments?

• Dennis Saver, MD
• David C. Kibbe, MD MBA
• The Kibbe Group LLC
• email kibbedavid_at_mac.com
• telephone [phone]
• home office 594 D Woodbury Road
• Fearrington Post
• Pittsboro, NC 27312