Introduction to E-Health

Hello, my name is Rob Tagalicod and I am the Director for the Office of E-Health Standards and Services at the Centers for Medicare & Medicaid Services Today, I would like to talk with you about how we are building an e-health environment through strategic alignment of e-health initiatives, reducing provider burden, and developing innovative policy like Administrative Simplification, generally known as Admin Simp Administrative Simplification is not only foundational for health care reform, but is a cornerstone of several integrated programs like the Medicare & Medicaid Electronic Health Record Incentive Programs, and the Physician Quality Reporting System that build toward a modernized health care system and work in concert to achieve better care, better health, and lower costs. Together, they move Americas health care system towards: Better coordinated care through greater interoperability and ease of transmitting electronic data; Better quality measurement and reporting of clinical outcomes data; and Lower costs achieved through operational efficiencies Currently, physicians spend a reported 43 minutes per day on averagethe equivalent of three hours per week and nearly three weeks per yearon interactions with health plans consuming time and resources that would otherwise be spent on patient care (Casalino et al., 2009) Administrative Simplification is aimed at reducing administrative costs and burdens in the health care industry by adopting and requiring the use of standardized, electronic transmission of administrative and financial data Administrative Simplification standards also educate patients about their coverage and costs, such as copayments and deductibles, at the point of service Administrative Simplification also provides significant qualitative improvements in care services through support of greater detailed, standardized clinical information capture, rationalized care cost, better clinical decision-making, data exchange, and payer-provider integration By streamlining and standardizing routine business processes, administrative simplification can help to reduce unnecessary and duplicative transaction costs and thus reduce overall health care expenditures Today, we will explore the benefits of Administrative Simplification and discuss: Rising health care costs and how administrative simplification can reduce those costs Building blocks for achieving administrative simplification New requirements, policies, and tools to implement these operational efficiencies within your organization And now, we’ll bring in Denise Buenning who will be talking about Administrative Simplification- Reducing Administrative Health Care Cost Hello my name is Denise Buenning and I am the Deputy Director for the Office of E-Health Standards and Services at the Centers for Medicare & Medicaid Services. For this segment of the broadcast, we will discuss how administrative simplification reduces administrative health care cost The Healthcare Administrative Simplification Coalition, or HASC, found that about 25 percent of the nation’s health care costs — estimated at more than $2 trillion in 2007 — go toward administrative functions, such as billing and payment tasks. For example, an average of 26 cents of each health care dollar is spent on administrative overhead The health care industry needs to become more efficient, and one way to do that is to standardize the way information is exchanged. According to UnitedHealth Groupapproximately $332 billion in administrative costs could be saved over 10 years from simplification efforts (UnitedHealth Center for Health Reform and Modernization, 2009). Section 1104 of the Affordable Care Act focuses on reducing those costs by reorganizing and streamlining policies and processes to make it cheaper, better, and faster The Administrative Simplification provision under Section 1104 of the Patient Protection and Affordable Care Act (the Act) intends to improve the standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA). The intent of this provision is to reduce administrative costs by adopting a set of operating rules for each transaction and to create uniformity in implementing electronic standards for items such as: – Processing Claims – Enrolling an individual in a health plan – Paying health insurance premiums – Checking eligibility – Obtaining

authorizations for patient referrals – Notifying a provider about the payment of a claim Why do we need health care transaction standards? Reduce Standardize Exchange Benefits of Administrative Simplification Lowered administrative costs and lowered overall health care costs Enhanced accuracy of data and reports Reduced cycle time for processing of claims and payments Better cash management Improved data privacy and security Improved ability to detect fraud and abuse, thus reducing overall industry costs Increased consumer satisfaction And now, we’ll bring in Christine Stahlecker who will be discussing Building Blocks to Achieve Administrative Simplification My name is Christine Stahlecker and I am the Director for the Administrative Simplification Group in the Office of E-Health Standards & Services at the Centers for Medicare & Medicaid Services. To support industry opportunities for savings, we have developed regulations in collaboration with industry that promote best practices and socialize the idea of blending e-health and administrative simplification to achieve seamless processing of transactions. Our progressive administrative simplification policy supports interoperability, automation, and establishes the platform for new and future technologies There are four broad categories or building blocks to achieve administrative simplification They will each be presented by members of the administrative simplification group: 1. Standardized Transactions & Operating Rules will be presented by Matt Albright 2. Standardized Code Sets will be presented by Denesecia Green 3.Unique Identifiers will be presented by Kari Gaare 4. Compliance and Enforcement will be presented by Denesecia Green There are three members of our team that you will not meet today: Gladys Wheeler who is responsible for enforcement, Rosali Topper and Geanelle Herring who are responsible for outreach and communications And now, Matt Albright will talk about the Standardized Transactions & Operating Rules Hello, my name is Matthew Albright, and I am lead health insurance analyst for the Administrative Simplification Team in the Office of E-Health Standards and Services at the Center for Medicare & Medicaid Services Today, Ill talk for a moment about a new administrative simplification initiatives mandated by the Affordable Care Act, namely operating rules Operating rules are business rules and best business practices that health care entities must use when they transmit administrative transactions electronically Now, administrative transactions are communications between health plans and providers about health care claims and the billing of health care services in other words, administrative transactions are the back and forth between insurance companies and your doctor so that your doctor can get paid for providing health care These operating rules will make it easier for providers and health plans to conduct their administrative transactions electronically, as opposed to more costly manual and paper-based communications. The idea is to move the health care industry to using electronic transactions, as so many other industries use in their billing and accounts receivable processes To date, the Department of Health and Human Services has adopted operating rules for three distinct electronic administrative transactions, and more are planned for adoption The first two sets of operating rules are for the eligibility for a health plan transaction that is, when a provider electronically queries a health plan to check to see if a patient is covered or has benefits and the health claim status transaction thats when a provider electronically queries a health plan to check on the status of a submitted claim Entities should be complying with these two sets of operating rules as of January 1, 2013. However, input from industry resulted in authorization from HHS for a 90 day enforcement discretion period which runs through March 31, 2013 The third set of operating rules are for the health care electronic funds transfers (EFT) and remittance advice transaction that is, the electronic payment of claims from the health plan to the provider, the EFT, and the communication of why the payment is different from the amount the provider originally billed. This operating rule set has a compliance date of January 1, 2014 Aside from operating rules, a proposed rule is in development for a certification of compliance process. Through this process, health plans

are required to demonstrate to the Department of Health and Human Services that they are compliant with the electronic standards and operating rules. We expect that rule to be published in early 2013 And now we will have Kari Gaare on End-to-End Testing Hello. My name is Kari Gaare and I am a Health Insurance Specialist in the office of E-Health Standards and Services at the Center for Medicare & Medicaid Services Given the past challenges experienced implementing the National Provider Identifier and Version 5010 AND the number of upcoming Administrative Simplification requirements, such as operating rules, Icd-10, and HPID, CMS has engaged National Government Services (NGS) to develop a process and methodology for end-to-end testing of the Administrative Simplification requirements based on industry participation and feedback The intended outcome of the project is to provide documents for all industry segments outlining the critical checkpoints to ensure compliance, a universal testing process and methodology that can be adopted by all industry segments, and a framework with definitions for end-to-end testing, readiness, and compliance There will be a pilot of the process using ICD-10 as a test case, and we will be partnering with the HIMSS/WEDI ICD-10 National Pilot Project to receive feedback on the process and associated documents Please visit the CMS End-to-End testing webpage [place link on slide] or contact ngs.compliancetesting@wellpoint.com for more information Now we will have Denesecia Green on the Standardized Medical Code Sets for the ICD-10 Implementation Hello my name is Denesecia Green and I am the lead health insurance specialist for ICD-10 implementation in the Office of E-Health Standards & Services at the Centers for Medicare & Medicaid Services . The ICD10 code sets provide flexibility to accommodate future health care needs, facilitating timely electronic processing of claims by reducing requests for additional information to providers. ICD10 also includes significant improvements over ICD9 in coding primary care encounters, external causes of injury, mental disorders, and preventive health The ICD10 code sets breadth and level of detail reflect advances in medicine and medical technology, as well as accommodate the capture of more detail on socioeconomics, ambulatory care conditions, problems related to lifestyle, and the results of screening tests Physician specialty groups in the United States provided extensive input into the development of ICD-10-CM. Many of these areas are important to patient care, health services research, and overall public health Implementation Strategy CMS has developed a comprehensive ICD-10 implementation strategy that integrates and aligns with other CMS programs like the Medicare & Medicaid EHR Meaningful Use Programs and the Physician Quality Reporting System. CMS has also established an Agency-wide Steering Committee and an Inter-Agency HHS Enterprise Workgroup to identify shared services for ICD-10 implementation Technical Assistance & Training CMS is providing technical assistance and training and has established communities of practice; a collaborative network, to share best practices for mapping and coding for common categories of health conditions. CMS has developed three Medscape continuing medical education (CME) programs which trains about 16,000 providers, nurses, and staff each quarter. CMS is developing the ICD-10 mainframe and PC software for v30 ICD-10 MS-DRG groupers to be issued soon. Details will be posted on the ICD-10 webpage Outreach & Education Conducts extensive industry education and outreach, webinars, and conference calls Distributes weekly email updates that reach more than 93,000 subscribers with practical implementation tips Offers educational resources through the cms.gov/ICD10 website Paid media campaign featuring 1) print and online ads in trade journals and 2) search engine marketing Continued collaboration with public and private sector stakeholders Readiness Assessments Conducts focus groups and interviews with providers, payers, and vendors to assess awareness Conducts quarterly readiness assessments with State I will now we will turn it back to Kari Gaare with the Unique

Identifiers Thank you Denesecia On September 5, 2012, a final rule was issued that adopts a standard health plan identifier the (HPID). The primary purpose of the HPID is to create a standard identifier that will be used to identify health plans in the standard transactions. The final rule also adopts an other entity identifier (the OEID) which is a voluntary identifier for entities like third party administrators that need to be identified in the standard transactions and are not eligible to obtain a National Provider Identifier (NPI), an HPID, and they are not an individual The only required use of the HPID is that all covered entities must use the HPID to identify a health plan in the standard transactions. While this is the only required use, the HPID may be used for any other lawful purpose, for instance a health plan may choose to put its HPID on a health plan id card In terms of compliance dates, all health plans, except small health plans, must obtain an HPID by Nov. 5, 2014. Small health plans have until Nov. 5, 2015. All covered entities will be required to use an HPID when identifying a health plan in the standard transactions beginning November 7, 2016 Applications for the HPID and OEID will be available in March 2013 in the Health Plan and Other Entity System, which we are calling HPOES Since October 1, 2012 entities have been able to register for an account in HPOES where they can access educational material and receive email notifications about webinars We encourage those interested in the HPID and OEID to visit the CMS HPID website (http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative- Simplification/Affordable-Care-Act/Health-Plan-Identifier.html) or register for an account in HPOES Now, back to Denesecia Green who will be presenting Compliance & Enforcement CMS has instituted program safeguards to ensure that all covered entities are compliant with the HIPAA and ACA requirements. We are developing tools, resources, and guides to help providers, health plans, clearinghouses, and payers achieve compliance Currently, CMS is enhancing the functionality and features of the Administrative Simplification and Testing Tool (ASETT) to include a module for free transaction testing ASETT also provides modules for filing complaints against entities that are not operating within the new requirements We envision ASETT as a one-stop shop for compliance and enforcement resources that help entities navigate through steps to achieve compliance and fully realize the operational efficiencies that can be achieved through administrative simplification Hello. My name is Elizabeth Holland, and I am the Director of the Health I-T Initiatives Group in the Office of E-Health Standards and Services, at the Centers for Medicare & Medicaid Services. For this segment of the broadcast, we will discuss the Medicare and Medicaid EHR Incentive Programs and how the meaningful use of an EHR can be used to improve outcomes An electronic health record or EHRwhich is sometimes called an electronic medical record or EMRallows healthcare providers to record patient information electronically instead of using paper records However, EHRs are often capable of doing much more than just recording information. The Medicare and Medicaid EHR Incentive Program asks providers to use the capabilities of their EHRs to achieve benchmarks that can lead to improved patient care In order to capture patient data in a way that is efficient and allows the data to be shared with other healthcare providers, you need an EHR that stores data in a structured format. Structured data allows patient information to be easily retrieved and transferred, and it allows the provider to use the EHR in ways that can aid patient carefor example, by sorting information based on chronic diseases like diabetes, or by enabling clinical decision support rules that can improve patient safety. Through the EHR Incentive Programs, CMS and the Office of the National Coordinator for Health Information Technology (O-N-C) have established standards and other criteria for structured data that EHRs must use However, its not enough just to have an EHR. The EHR Incentive Programs

also establish certain objectives that all providers must meet in order to show that they are using their EHRs in ways that can positively affect the care of their patientsin other words, so that providers can demonstrate what we call meaningful use Some of the objectives have a minimum percentage that providers have to meet. Other objectives specify an action that must be taken or a functionality of the EHR that must be enabled for the duration of the reporting period. But all of the objectives focus on areas that are critical to improving outcomes Many of the objectives you will have to meet focus on recording a minimum set of information about patients that can not only be shared with other providers but also used in clinical assessments, such as: * Basic demographic information, like gender and race * Vital signs, such as height, weight, and blood pressure * Smoking status * And clinical information that most providers already maintain now, as part of a paper record, such as a problem list of current diagnoses, an active medication list, and a medication allergy list Other objectives focus on the ways an EHR can be used to improve patient care, improve outcomes, and reduce overall healthcare costs: * Computerized Provider Order Entry, or C-P-O-E, and electronic prescribing allow better tracking of medication orders and also permit clinical decision alerts that can warn providers about potential drug or allergy interactions * Electronic copies of, or online access to, a patients health records can not only reduce repeated requests for information but also improve the coordination of care between multiple providers * Information shared with immunization registries and other public health databases can be used to help improve overall population health * Patient reminders for follow-up care reduce the number of no-show appointments, and patient education provided through an EHR can also encourage patients to take an active role in their own care Clinical quality measurement is also a central requirement of the Medicare and Medicaid EHR Incentive Programs. With structured, electronic data, providers can use their EHRs to quickly measure the quality of the care they provide in multiple areasand then use that information to make adjustments to patient care and clinical workflow Finally, a central component of the EHR Incentive Programs is the electronic exchange of information. Once everyone is using data that is structured identically, and once that data is available in an electronic format, exchanging that information with other providers becomes much easier. Not only can a freer exchange of patient information improve care coordination between, say, a primary care provider and a specialist, it can also help reduce the need for duplicative tests or procedures Thank You