On December 30, 2009, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) released documents shedding light on what physicians and hospitals must do to qualify for electronic health records (EHR) incentive payments under the HITECH Act. To qualify for incentives, physicians and hospitals must be using "certified EHR technology" in a "meaningful manner."
These documents give us the clearest picture yet on what features physicians and hospitals need to look for in their EHR technology. They also tell us how that technology needs to be used to meet the definition of meaningful use during the Stage 1 (2011) EHR adoption period.
Among other things, these documents show us:
- How physicians and hospitals can achieve meaningful use;
- What software features you need; and,
- What the final rulings mean for CCHIT certification.
We'll also look at a few points that the rulings didn't address.
How to Achieve Meaningful Use in Stage 1
In the table below, we've combined the meaningful use objectives for both eligible professionals (physicians) and hospitals for the Stage 1 adoption year, the required EHR technology criteria to accomplish those objectives and what criteria the government will use to measure meaningful use.
CMS defines "meaningful use" as using an EHR for the objectives listed in the first column. The objectives fall under these general topics:
- Improving quality, safety, efficiency, care coordination, population and public health;
- Reducing health disparities;
- Engaging patients and their families; and,
- Ensuring adequate privacy and security protections for personal health information
For the first time, CMS has also outlined specific measurements for how the government will determine if an EHR is being used in a meaningful manner for the Stage 1 (2011) adoption year. Updated definitions of meaningful use for Stage 2 (2013) and Stage 3 (2015) EHR adoption periods will be released in the year before those periods begin.
This table outlines what Stage 1 objectives define meaningful use, what software features are necessary to accomplish those objectives and what criteria the government will use to measure meaningful use. EP refers to eligible professional.
|Meaningful Use Objectives||Corresponding EHR Software Features||Meaningful Use Measures
|Use Computer Provider Order Entry (CPOE)||Enable a user to electronically record, store, retrieve, and manage, at a minimum, the following order types: Medications; Laboratory; Radiology/imaging; Provider referrals; Blood bank; Physical therapy; Occupational therapy; Respiratory therapy; Rehabilitation therapy; Dialysis; Provider consults; and Discharge and transfer. ||CPOE is used for at least 80% of all orders; 10% for hospitals
|Implement drug/allergy checks||(1) Real-time, alerts at the point of care for drug-drug and drug-allergy contraindications; (2) Electronically check if drugs are in a formulary or preferred drug list; (3) Provide certain users rights to deactivate, modify, and add rules for drug-drug and drug-allergy checking; (4) Track number of alerts users respond to||Function is enabled
|Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®||Electronically record, modify, and retrieve a patient’s problem list over multiple visits||At least 80% of all unique patients have at least one entry or an indication of none recorded.
|E-prescribing (EP only)||Electronically transmit prescriptions||At least 75% of all permissible prescriptions written by the EP are transmitted electronically
|Maintain active medication/allergy list||Electronically record, modify, and retrieve a patient’s active medication/allergy list||At least 80% of all unique patients have at least one entry or an indication of “none”
|Record demographics||Electronically record, modify, and retrieve patient demographic data||At least 80% of all unique patients have demographics recorded
|Record and chart changes in vital signs||(1) Enable a user to electronically record, modify, and retrieve a patient’s vital signs; (2) Automatically calculate and display body mass index (BMI); (3) Plot and electronically display, upon request, growth charts for patients 2-20 years old. ||For at least 80 percent of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20
|Record smoking status for patients 13 years old or older ||Electronically record, modify, and retrieve the smoking status of a patient||At least 80% of all unique patients 13 years old or older have “smoking status” recorded
|Incorporate clinical lab-test results into EHR as structured data||(1) Electronically receive clinical laboratory test results and display such results in human readable format; (2) Electronically display in human readable format any clinical laboratory tests that have been received with LOINC® codes; (3) Electronically display all the information for a test report; (4) Electronically update a patient's record based upon received laboratory test results||At least 50% of all clinical lab tests results are incorporated as structured data
|Generate lists of patients by specific conditions ||Electronically select, sort, retrieve, and output a list of patients and patients’ clinical information ||Generate at least one report listing patients with a specific condition
|Report ambulatory quality measures to CMS or the States (EP only)||(1) Calculate and electronically display quality measure results as specified by CMS or states; (2) Electronically submit calculated quality measures||For 2011, an EP/hospital would attest this has been done
|Send reminders to patients for preventive/follow-up care||Electronically generate a patient reminder list for preventive or follow-up care ||Reminders sent to at least 50% of all unique patients that are 50 and over
|Implement five clinical decision support rules relevant to specialty or high clinical priority||(1) Implement automated, electronic clinical decision support rules according to specialty or clinical priorities; (2) Automatically and electronically generate real-time alerts and care suggestions based upon clinical decision support rules and evidence grade; (3) Automatically and electronically track, record, and generate reports on the number of alerts responded to by a user ||Implement five clinical decision support rules relevant to the clinical quality metrics the EP/Eligible Hospital is responsible for
|Check insurance eligibility electronically ||Electronically record and display patients’ insurance eligibility, and submit insurance eligibility queries|| Insurance eligibility checked electronically for at least 80% of all unique patients
|Submit claims electronically to public and private payers. || Electronically submit claims ||At least 80 % of all claims filed electronically
|Provide patients with an electronic copy of their health information upon request||Enable a user to create an electronic copy of a patient’s clinical information and provide to a patient on electronic media, or through some other electronic means||At least 80% of all patients who request an electronic copy of their health information are provided it within 48 hours
|Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request (Hospital only)||Enable a user to create an electronic copy of the discharge instructions and procedures for a patient, in human readable format, at the time of discharge to provide to a patient on electronic media, or through some other electronic means||At least 80% of all patients who are discharged from an eligible hospital and who request an electronic copy of their discharge instructions and procedures are provided it
|Provide patients with electronic access to their health information within 96 hours of the information being available (EP only)||Enable a user to provide patients with online access to their clinical information||At least 10% of all unique patients are provided timely electronic access to their health information
|Provide clinical summaries to patients for each office visit. (EP only)||(1) Enable a user to provide clinical summaries to patients (in paper or electronic form) for each office visit; (2) If the clinical summary is provided electronically (i.e., not printed), it must be provided in: 1) human readable format; and 2) and on electronic media, or through some other electronic means. ||Clinical summaries provided to patients for at least 80% of all office visits
|Exchange key clinical information among providers of care and patient authorized entities electronically and provide summary care record||(1) Electronically receive a patient summary record, from other providers and organizations; (2) Electronically transmit a patient summary record, to other providers and organizations||Provide summary of care record for at least 80 % of transitions of care and referrals; Perform at least one test of certified EHR technology's capacity to electronically exchange key clinical information
|Perform medication reconciliation at relevant encounters and each transition of care and referral||Electronically complete medication reconciliation of two or more medication lists into a single medication list that can be electronically displayed in real-time||Perform medication reconciliation for at least 80 % of relevant encounters and transitions of care
|Submit electronic data to immunization registries and actual submission where required and accepted||Electronically record, retrieve, and transmit immunization information to immunization registries ||Performed at least one test submission to immunization registries and public health agencies
|Provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received (Hospital only)||Electronically record, retrieve, and transmit reportable clinical lab results to public health agencies||Performed at least one test of certified EHR technology capacity to provide electronic submission of reportable lab results to public health agencies
|Provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice ||Electronically record, retrieve, and transmit syndrome-based (e.g., influenza like illness) public health surveillance information to public health agencies||Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies
|Protect electronic health information through the implementation of appropriate technical capabilities || (1) Assign unique user names; (2) Permit certain users to access health information in an emergency; (3) Terminate an electronic session after a predetermined time of inactivity; (4) Encrypt and decrypt electronic health information that is stored and exchangd; (5) Record actions (e.g., deletion) related to electronic health information; (6) Track alterations of electronic health information; (7) Set up user verification measures; (8) Record disclosures made for treatment, payment, and health care operations||Conduct or review a security risk analysis and implement security updates as necessary
How long does EHR software have to be used in a meaningful manner to qualify for incentive payments? In the first year of adoption, CMS states that a physician or hospital must be using an EHR in a meaningful manner for a minimum of 90 days in order to qualify for incentives. In subsequent years, the EHR must be used in a meaningful manner for the entire year.
The ONC's interim final ruling details what software features EHR technology must have to become certified. Those criteria are listed in the second column. These criteria form the basis for the definition of "certified EHR technology," which we discuss next.
To summarize, the government now has told physicians and hospitals what tasks they should be using their EHR for (meaningful use); what EHR software features are needed to accomplish those tasks (certified EHR technology); and how the government is going to measure those tasks to determine whether or not they are being performed to their satisfaction.
What EHR Technology Will be Certified?
Here is the ONC's latest definition of certified EHR technology:
"A Complete EHR or a combination of EHR Modules, each of which (1) meets the requirements included in the definition of a Qualified EHR; and (2) has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the [ONC]."
In a nutshell, as long as the EHR software meets the software certification criteria laid out in the table above, an integrated EHR software suite or combination of best of breed EHR modules is going to fall under the ONC's definition of "certified EHR technology."
Within the available EHR universe are a number of EHRs certified by the Certification Commission for Health Information Technology (CCHIT). The ONC feels that 90% of the EHRs that are CCHIT-certified (~80) will become certified under their proposed certification criteria. The ONC also feels that a significant number of the remaining EHRs will require only minor upgrades to comply.
As we've noted before on the Software Advice blog, CCHIT-certified systems are a good bet if you want to qualify for incentive payments. If you want to find out more about these systems, take a look at our list of CCHIT-certified EHRs.
What was left out of the final rulings?
What body will be doing the certifying? This wasn't made clear and is already a point of contention between the ONC and many healthcare organizations.
Who will enforce the meaningful use measures? Again, this is not clear in the documents released. The measures are clearly defined. What body will enforce them is not.
This is the original post on the topic from early March 2009.
By now you've heard about the $850 billion American Recovery and Reinvestment act of 2009 – the stimulus bill recently passed by Congress. The bill is aimed at spurring economic growth across multiple industries by way of government spending.
What's in it for you?
Well if you are a healthcare provider, you can take advantage of the $51 billion that has been allocated to the health care industry, $19 billion of which will be used to incentivize medical practices to adopt and implement Electronic Health Records (EHRs), also known as Electronic Medical Records (EMRs).
How does the subsidy work?
Starting in 2011, providers deemed to be "meaningful users" of EHR systems will be eligible to receive $40,000 – $60,000 in incentive payments paid out over five years in the form of increased Medicare and Medicaid premiums.
For the first year a physician is deemed to be a meaningful user, he or she will be eligible for payments of 75% of that year's Medicare and Medicaid charges, up to a maximum of $15,000. The maximum payment is increased to $18,000 if the first year is 2011 or 2012. The incentive payments decline for each subsequent year within the five year period; $12,000 will be paid in year two, $8,000 in year three, $4,000 in year four, and $2,000 in year five.
No incentive payments will be available after 2015, and no payments will be offered to physicians who first become eligible after 2014. This creates a decreasing incentive for late adopters.
What is a "meaningful user"?
To qualify as a “meaningful user,” eligible providers must demonstrate use of a “qualified EHR” in a “meaningful manner.” The bill defers to the secretary of Health and Human Services (HSS) to set specific guidelines for determining what constitutes a "qualified EHR"; however, it does specify that e-prescribing, electronic exchange of medical records, and interoperability of systems will be determining criteria.
HSS will be working throughout 2009 to set the necessary criteria for certifying systems, and is expected to have a final report by January of 2010. Many expect CCHIT certification to play a major role in setting standards of interoperability. (See “Should CCHIT Influence Your EHR Selection” for more information). After all, HHS funded the creation of CCHIT to start certifying EHRs a few years ago.
View a list of CCHIT Certified EMRs/EHRs
How do I qualify for the maximum payment?
In order to receive the maximum payment, physicians must qualify as a meaningful user in 2011. Eligible physicians will receive a first year bonus of $18,000 (up from $15,000) and will max out the payment schedule over the next five years.
The table below illustrates the amount of a subsidy paid each year (columns) based on the year the provider first becomes eligible (rows):
No payments will be offered to physicians who first become eligible after 2014.
Practices with multiple physicians will be eligible to receive incentive payments for each provider. Remember that payments will be based on 75% of the correlating year’s Medicare and Medicaid charges. Therefore, in order to qualify for the maximum payment of $18,000 in the first year, each provider must bill Medicare or Medicaid a minimum of $24,000.
Should I purchase an EHR now or wait until 2010?
An obvious concern is whether an EHR implemented in 2009 will meet the standards set by HHS in 2010. Although a legitimate concern, waiting until 2010 to implement a system may be a mistake. Researching and selecting the right EMR can be a lengthy process, and many providers who wait may find it difficult to have a system in place in time.
Practices would be well-served to begin the research process now, allowing ample time to create a short-list of systems, perform demos with several vendors, check references, meet with vendors in person, negotiate terms, and complete the implementation and training process. To alleviate buyers' concerns, vendors may provide binding agreements, guaranteeing their system will comply with all emerging standards.
Furthermore, buyers' should consider CCHIT an important Certification relative to the requirement for "qualified EHRs." While we have discussed the many opinions for and against CCHIT, we expect it to play a critical role in the EHR subsidy qualification.
What if I choose not to purchase an EHR?
Unfortunately, for physicians who choose not to implement an EHR, the stimulus bill is a double-edged sword. Not only will they forego thousands in incentive payments, but starting in 2015, they will be penalized by way of decreased Medicare and Medicaid payments. Physicians who fail to qualify as meaningful users will face decreases of 1% in 2015, 2% in 2016, and 3% in 2017, with a maximum reduction of 5% by 2020.
Although each physician’s individual situation will dictate whether or not they choose to implement an EHR, the unique opportunity offered within the stimulus bill should not be overlooked.