A Primer on Meaningful Use Understanding the federal government s EHR Incentive Program. By Elizabeth W. Woodcock, MBA, FACMPE, CPC

Transcription

1 A Primer on Meaningful Use Understanding the federal government s EHR Incentive Program By Elizabeth W. Woodcock, MBA, FACMPE, CPC

2 CONTENTS The Background... 1 Meaningful Use... 4 Certification... 7 Registration... 8 Attestation... 9 Bonus Payments and Penalties Steps to Meaningful Use of the Electronic Health Record The U.S. government is paying eligible health care professionals to automate their medical practices. The Electronic Health Record (EHR) Incentive Program a product of the American Recovery and Reinvestment Act (ARRA) passed in February 2009 earmarks several billion dollars for eligible professionals, as well as hospitals. The federal program seeks to promote the meaningful use of EHR systems that are certified by the government s designated accreditation program. Adoption of these certified EHR systems, according to the government, is an important step in enhancing the quality, safety and value of health care in the United States. To obtain the incentives the government offers, eligible health care professionals, the subject of this white paper, must do much more than merely buy an EHR, install it and start using it. In fact, the program incorporates professionals who have used EHRs for years. To gain the $44,000 to $63,750 in federal bonus payments through Medicare or Medicaid, respectively, eligible professionals must make meaningful use of a government-certified EHR. This puts everyone in the same boat: Even seasoned EHR users must understand the requirements of meaningful use, and many must upgrade or even change systems to operate a certified one. While the EHR Incentive Program isn t mandatory, health care professionals who are eligible but decline to participate, or who fail in their participation, will see reduced Medicare payments beginning in Whether it is the carrot of incentive payments or the stick of reduced Medicare reimbursement that motivates you, it s important to understand the elements of this multi-year program. One way or another, it will affect how the nation s health care professionals, their practices, and hospitals and other healthcare facilities manage patients clinical information. Knowledge is the critical first step to successful participation in the EHR Incentive Program. The Background Working closely together, two federal agencies oversee the EHR Incentive Program. The Centers for Medicare & Medicaid Services (CMS) ( cms.gov/) administers the program, including serving as the information portal for the program, registering all participants and processing the attestations from Medicare participants. The Office of the National Coordinator for Health Information Technology (ONC) ( is in charge of defining the elements of meaningful use, administering the certification process for EHR systems and coordinating assistance to eligible professionals on a regional level. The incentives are paid through the Medicare and Medicaid programs; each has slightly different rules for participation. The Medicare incentives are available to physicians only; namely, doctors of medicine, osteopathy, dentistry, podiatry, optometry and chiropractic medicine. 1 Eligible physicians include only those 1 CMS. Accessed February 25, 2011 at 1

3 who perform substantially all of their services outside of the hospital nonhospital-based physicians. 2 Through Medicaid, eligibility is extended to nurse practitioners, certified nurse midwives and physician assistants (PA) practicing in a federally qualified health center, or a rural health clinic led by a PA, in addition to physicians. 3 The incentive program does not include psychologists, physical therapists, speech pathologists, social workers or audiologists, or any other health care professional who is not specifically named as eligible. If multiple professionals work together in a medical practice, one can choose to participate and the others not or one can choose to participate in the Medicare program and the remaining members in Medicaid. In other words, the program is for eligible professionals not eligible practices. Participants who succeed in proving the meaningful use of their certified EHR in the Medicare program receive $44,000, paid over a five-year period starting in 2011 or (Note that participants can begin in 2013 or 2014, but the bonus is reduced.) Successful participants in the Medicaid program receive $63,750 paid over a six-year period starting anytime in the next six years. (See Table One for the Medicare payment timeline and Table Two for the Medicaid timeline.) TABLE ONE. Medicare Payment Timeline If a Medicare Eligible Professional Qualifies to Receive First Payment in Payment Amount $ 18,000 $ - $ - $ - $ $ 12,000 $ 18,000 $ - $ - $ $ 8,000 $ 12,000 $ 15,000 $ - $ $ 4,000 $ 8,000 $ 12,000 $ 12,000 $ $ 2,000 $ 4,000 $ 8,000 $ 8,000 $ $ - $ 2,000 $ 4,000 $ 4,000 $ - Total $ 44,000 $ 44,000 $ 39,000 $ 24,000 $ - TABLE TWO. Medicaid Payment Timeline If a Medicaid Eligible Professional Qualifies to Receive First Payment in Payment Amount CY $ 21,250 $ - $ - $ - $ - $ $ 8,500 $ 21,250 $ - $ - $ - $ $ 8,500 $ 8,500 $ 21,250 $ - $ - $ $ 8,500 $ 8,500 $ 8,500 $ 21,250 $ - $ $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 21,250 $ $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 21, $ - $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8, $ - $ - $ 8,500 $ 8,500 $ 8,500 $ 8, $ - $ - $ - $ 8,500 $ 8,500 $ 8, $ - $ - $ - $ - $ 8,500 $ 8, $ - $ - $ - $ - $ - $ 8,500 TOTAL $ 63,750 $ 63,750 $ 63,750 $ 63,750 $ 63,750 $ 63,750 2 Hospital is defined by the places of service (POS): hospital (-21) and emergency department (-23). If more than 90 percent of the services the eligible professional renders are billed to Medicare with these POS codes, the professional is considered hospital-based and ineligible for the EHR Incentive Program. 3 CMS. Accessed February 25, 2011 at 2

4 FIGURE ONE. Definition of Medicaid Encounters To qualify for the Medicaid bonuses, an eligible professional must have 30 percent or more of total patient encounters with Medicaid patients during any representative, continuous 90-day period during the year prior to reporting. For pediatricians, the floor is set at 20 percent or more. (Pediatricians between 20 and 30 percent of Medicaid are eligible for two-thirds of the full bonus of $63,750.) Eligible professional may count Medicaid enrollees who are on a panel assigned to them (for example, managed care or medical homes). A professional can also count patients for whom Medicaid is a secondary payer, and Medicaid from states other than the one to which he or she is reporting. The bonus payments are per professional, so a practice with three physicians participating in the Medicare program and two nurse practitioners in the Medicaid program stands to gain $259,500. By design, the meaningful use criteria, list of certified EHR systems and several other aspects of the program are similar for Medicare and Medicaid. An eligible professional must be a member of the program for Medicare, that means participating or non-participating (because non-participating physicians remain subject to a limiting charge); for Medicaid, only participating professionals can qualify. There are, however, some significant differences between the Medicare and Medicaid programs. The dissimilarity starts with eligibility for Medicaid, an eligible professional must have more than 30 percent of patient encounters attributable to Medicaid (20 percent for pediatricians). (See Figure One for the definition of Medicaid encounters.) Medicare requires no minimum number of encounters, charges or any other minimum measure. The payment is based on 75 percent of the physician s total allowed Medicare fee-for-service (FFS) professional charges up to an annual cap (see Table One). So, a physician participating in the Medicare program can receive a portion of the bonus even with very low volume. Medicaid, on the other hand, makes a flat payment to qualifying professionals regardless of the measurement. When a participant achieves the 30 percent bar, regardless of how much higher their Medicaid volume goes up, he or she achieves the set bonus amount. In addition to the eligible professional-based reporting methodology, a medical practice may report percentages on a group level for Medicaid program participation, if the following three conditions are met: 1) The practice s patient volume is appropriate as a patient volume methodology calculation for the physician or other eligible professionals; 2) There is an auditable data source to support the medical practice s patient volume determination; and 3) The practice and its physicians and other eligible professionals use one methodology for the full year in which they participate; that is, they cannot switch between group-level reporting and individual reporting mid-year. Source: CMS 4 The differences don t end there. The initial payment year in the Medicare incentive program requires the eligible professional to achieve meaningful use of a certified EHR for 90 days. The Medicaid incentives, on the other hand, only require that the eligible professional is adopting, implementing or upgrading an EHR during this initial payment year. Both programs require registration through the central, Internet-based CMS registration system - The Registration and Attestation System ( Medicare participants will use this same system to report meaningful use; Medicaid participants must look to their state Medicaid agency to complete the attestation process. 4 CMS. Accessed February 25, 2011 at 3

5 Eligible professionals can only participate in one program Medicare or Medicaid even if they qualify for both. It is possible to transfer between the programs, but only once during the lifetime of the EHR Incentive Program. Although the initiative is sponsored by the government, eligible professionals in either program must apply its terms to all their patients, not just those covered by Medicare or Medicaid. The qualifying meaningful use criteria are expected to be provided to patients with public, private or no insurance coverage. Meaningful Use After several rounds of revisions, the government published the criteria to meet meaningful use for 2011 and 2012 in July In addition to outlining the criteria for the program s initial two years, the government unveiled plans to expand from the current set of criteria and measurements, known collectively as Stage One, to more far-reaching, and arguably more difficult to achieve, criteria in future years. As the program progresses over the next few years, an eligible professional will need to do more to qualify for an incentive payment than in 2011 or Although the details have yet to be released, Stages Two and Three set progressively higher bars. In the EHR Incentive Program s initial phase, the government establishes 25 criteria for meaningful use. Of those, 15 are core criteria required of all participants. For Stage One of the EHR Incentive Program, which is 2011 and 2012, each of the 15 core criteria for meaningful use establishes a measurement, usually a percentage of active patients. The 15 core criteria in Stage One apply to both Medicare- and Medicaid-eligible professionals. (See Table Three for a listing of the 15 core criteria and measures, presented in abbreviated form.) TABLE THREE. Core Criteria and Measures for Meaningful Use, Presented in Abbreviated Format CORE CRITERIA 1 Use computerized physician order entry (CPOE) 2 Implement drug-drug and drugallergy interaction checks 3 Generate and transmit permissible prescriptions electronically CORE MEASURE More than 30% of unique patients with >1 medication in their medication list have at >1 medication order entered using CPOE Implement drug-drug and drug-allergy interaction checks More than 40% of all permissible prescriptions are transmitted electronically 4 Record demographics More than 50% of all unique patients have demographics recorded 5 Maintain an up-to-date problem list of current and active diagnoses More than 80% of all unique patients have >1 entry or an indication that no problems are known for the patient 6 Maintain active medication list More than 80% of all unique patients have >1 entry (or an indication that the patient is not currently prescribed any medication) 4

6 7 Maintain active medication allergy list 8 Record and chart changes in vital signs 9 Record smoking status for patients 13 years old or older 10 Implement one clinical decisionsupport rule 11 Report ambulatory clinical quality measures 12 Provide patients with an electronic copy of their health information, upon request 13 Provide clinical summaries for patients for each office visit 14 Ensure capability to exchange key clinical information 15 Protect electronic health information created or maintained by the certified EHR technology More than 80% of all unique patients have >1 entry (or an indication that the patient has no known medication allergies) For more than 50% of all unique patients age 2 or over, height, weight and blood pressure are recorded More than 50% of all unique patients 13 years old or older have smoking status recorded Implement one clinical decision support rule Submit the required 3 clinical quality measures (or alternate measures), plus 3 additional measures to choose from a menu of 38 More than 50% of all patients who request an electronic copy of their health information are provided it within 3 business days Clinical summaries provided to patients for more than 50% of all office visits within 3 business days Performed at least one test of the capacity to electronically exchange key clinical information Conduct or review a security risk analysis As part of the core criteria, eligible professionals must report six ambulatory clinical quality measures, generated as an output of a certified EHR: three core measures (or three alternate core) and three additional measures chosen from a list of 38 (See criterion and measure 11, in Table Three). The required clinical quality core measures are: 1. Hypertension: Blood pressure management 2. Tobacco use assessment and cessation intervention 3. Adult weight screening and follow-up If an eligible professional doesn t qualify to report on any of the above measures, the alternate core measures are: 1. Influenza immunization for patients equal to or greater than 50 years old 2. Weight assessment and counseling for children and adolescents 3. Childhood immunization status In addition to these three measures, another three must be chosen from the government-provided list of 38 ( ElectronicSpecifications.asp). The eligible professional must also choose an additional five criteria from a list of 10 that the government provides. The 10 menu-based criteria, along with the associated measures, are presented in abbreviated format in Table Four. 5

7 TABLE FOUR. Menu-Based Criteria and Associated Measures, Presented in Abbreviated Format MENU-BASED CRITERIA MENU-BASED MEASURE 1 Implement drug-formulary checks This functionality has been enabled, and the eligible professional has access to >1 internal or external drug formulary 2 Incorporate clinical lab test results as structured data 3 Generate lists of patients by specific conditions 4 Send reminders to patients for preventive/follow-up care 5 Use certified EHR technology to identify patient-specific education resources 6 Provide patients with timely electronic access to their health information More than 40% of all clinical lab test results whose results are either in a positive/negative or numerical format are incorporated in the EHR Generate at least one report listing patients with a specific condition More than 20% of all unique patients 65 years old or older or 5 years old or younger are sent an appropriate reminder More than 10% of all unique patients are provided patient-specific education resources More than 10% of all unique patients are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information 7 Perform medication reconciliation The EP performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP 8 Provide summary care record for each transition of care and referral 9 Ensure capability to submit electronic data to immunization registries 10 Ensure capability to submit electronic syndromic surveillance data EPs who transition or refer their patients to another setting of care or provider of care provide a summary of care record for more than 50% of transitions of care and referrals Performed at least one test of capacity to submit electronic data to immunization registries and follow-up submission if the test is successful Performed at least one test of capacity to submit electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful An important note for eligible professionals considering the Medicaid EHR Incentive Program: the government allows states the latitude to add up to four criteria from the menu to the core of 15 criteria for meaningful use to create a required set of 19 for Medicaid participants in their state. At least one of the five criteria selected from the menu-based list of 10 must be public health-oriented, in essence creating the need for participants to choose four of eight from the menu, and one of the two public-health criteria. The criteria that fit this requirement are the capability to submit electronic data to immunization registries, and the capability to submit electronic syndromic surveillance data to public health agencies. The government allows exemptions from some of the criteria, but the exemptions are narrowly drawn. For example, the eligible professional might not have any patients who qualify for one of the core criteria. A pediatrician who does not treat patients over age 13 would not be required to electronically record 6

8 smoking status for patients 13 years and older. Likewise, an eligible professional who performs an insufficient number of actions during the year, such as not prescribing medications, would not need to generate and transmit prescriptions electronically. Eligible professionals who are exempt from a criterion are not required to substitute another one. Although the government establishes exemptions for 13 of the 25 Stage One criteria, the spirit of the program is for participants to perform as many of the criteria as reasonably possible. This makes sense, since all criteria will likely become mandatory as the EHR Incentive Program progresses in later stages. At the end of the reporting period, each eligible professional is required to formally report which the government calls attestation compliance with each criterion. Again, to emphasize: Although the meaningful use criteria are the same for Medicare and Medicaid, professionals participating in the Medicaid program don t have to attest to meaningful use in their initial payment year. To qualify for their first-year Medicaid incentive payment, eligible professionals need only demonstrate that they are making an effort to adopt, implement or upgrade certified EHR technology. Certification Eligible professionals must be meaningful users of an EHR, and the government launched a certification process to ensure that systems give them that capability. To achieve certification, an EHR system must meet standards designated by the ONC, but the technology may be an entire system or just a module to fit within a larger system. Thus, eligible professionals can implement a single system that qualifies in its entirety or compile multiple modules to create a custom whole system. Regardless of the type of technology, the products are required to support meaningful use in order to gain certification. The certification process for complete EHR systems, as well as modules, began soon after the ONC outlined the standards, implementation and specifications in July Instead of granting the certifications itself, the ONC chose accreditation and testing certification bodies (ATCBs) to certify systems. 5 The ATCBs, which now number six, began receiving applications from vendors soon after being appointed. By the time that the EHR Incentive Program officially opened for registration in January 2011, hundreds of complete systems and modules were certified. Another of ONC s key functions is helping physicians and other providers adopt EHRs for their practices. The government provided grants to 62 Regional Extension Centers designed to help eligible professionals select EHR vendors, understand meaningful use and implement EHR systems. Many of the centers services and educational programs cost providers little or nothing. The Regional Extension Centers geographic distribution allows most professionals to have access to these services. 5 Health Information Technology: Initial Set of Standards, Implementation, Specifications, and Certification Criteria for EHR Technology. Final Rule. Released July 13, Published July 28, 2010 in Federal Register. Accessed February 25, 2011 at 7

9 Registration Each eligible professional must register through CMS Registration and Attestation System ( which opened on January 3, The Internet-based portal allows eligible professionals to enroll in the EHR Incentive Program for either the Medicare or Medicaid incentives. The registration process is fairly straightforward and, if armed with the necessary information, takes only minutes. Although group registration may be available in the future, eligible professionals must now register individually. Before registering, participants should review: Registration User Guide for Eligible Professionals for Medicare ( gov/ehrincentiveprograms/downloads/ehrmedicareep_registrationuserguide. pdf) or the corresponding guide for Medicaid ( EHRIncentivePrograms/Downloads/EHRMedicaidEP_RegistrationUserGuide.pdf). Eligible professionals can address questions to CMS EHR Information Center Help Desk at (888) Eligible professionals who want to register for the program need a National Provider Identifier (NPI), available through the National Plan and Provider Enumeration System (NPPES) website ( Welcome.do). They also need an NPPES user name and password. Enrollment in the government s Provider Enrollment, Chain and Ownership System (PECOS) is required for professionals registering for the Medicare incentive program, but not for the Medicaid incentives. Although a certified EHR system is not required to register for the EHR Incentive Program, eligible professionals can proceed with submitting the vendor certification number. This 15-digit number is available from the ONC, and can be found by querying the professional s chosen system on the ONC s Certified Health IT Product List ( The number is referred to as the CMS EHR Certification ID. Although it s not necessary to register with their certified system, eligible professionals need a certified system to attest. During the registration process, the eligible professional is asked to define the payee. If the practice expects to receive the payment, the registering professional must include the group NPI in order to reassign the payment. Unless this is done, the money goes directly to the eligible professional. When the registration process for the Medicare EHR Incentive Program launched January 3, 2011, only 11 states Alaska, Iowa, Kentucky, Louisiana, Michigan, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee and Texas were prepared to launch theirs in concert. Kentucky and Oklahoma even paid the initial-year bonuses to successful Medicaid participants within 30 days after registration opened. In April, Alabama and Missouri joined the roll of states that commenced their registration process; the federal government announced that the remaining 37 states will launch registration soon. 8

10 Before registering for either incentive program, eligible professionals participating in the Medicare program must be aware that they cannot also receive the electronic prescribing (erx) ( bonus available through Medicare. Although the erx bonus of one percent for 2011 isn t available, the government has made it clear that professionals must still participate in the erx program from January 1 to June 30, 2011, to avoid the one percent penalty applied to Medicare reimbursement for non-participants starting in Eligible professionals seeking the Medicaid program bonuses can still attain the erx bonus through Medicare. All professionals can still participate and receive bonuses through CMS Physician Quality Reporting System (the new name for the Physician Quality Reporting Incentive, or PQRI) ( gov/pqrs). Attestation CMS launched the attestation process for Medicare participants on April 18, Available on the Registration and Attestation System ( cms.gov), eligible professionals can attest that is, report that they achieved meaningful use on a certified EHR system. Eligible professionals must report the numerator and denominator, if applicable, as well as any exclusions, for each element of meaningful use. A successful attestation includes the completion of the 15 core measures, five menu-based measures (including one of the two that are public-health oriented) and the six clinical quality measures (three core, or alternate core, and the three additional criteria chosen from the list of 38). Note that some criteria require only a response to a Yes / No question. For example, Have you enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period? Because the attestation process allows professionals to start and stop a professional can return to modify or finish an incomplete application an eligible professional can view the details of the attestation process to understand the elements of each question before completing the process. After the eligible professional completes the attestation process, the system generates a summary of measures page. On that page, each meaningful use criteria is declared: accepted or rejected. Thus, eligible professionals will know whether their attestation has been successful or whether it has failed. Because CMS allows attestations to be resubmitted in the case of a rejected one, eligible professionals can, in essence, try again. Attestation through CMS Registration and Attestation System ( ehrincentives.cms.gov) is for Medicare participants only. The Medicaid program does not require participants to attest to meaningful EHR use for the first payment year. Indeed, proof of adopting, implementing or upgrading is all that is required for the initial-year bonus. For the Medicaid program, even if eligible professionals have not yet installed a certified EHR, they can demonstrate adoption, implementation or upgrading by: 6 CMS. Accessed February 23, 2011 at 9

11 Acquiring, purchasing or securing access to certified EHR technology; Installing or using certified EHR technology that can meet meaningfuluse requirements; or Expanding the capability of certified EHR technology to meet meaningful-use requirements at the practice site, including staffing, maintenance and training, or upgrading from existing EHR technology to certified EHR technology. 6 In lieu of adopting, implementing or upgrading, Medicaid program participants can opt to attest to meaningful EHR use. In the initial payment year, state Medicaid agencies allow eligible professionals to demonstrate that they are meaningful users of certified EHR technology for the 90-day reporting period as an alternative to demonstrating that they have adopted, implemented or upgraded certified EHR technology. 7 Participants in the Medicaid program must look to their states to get the program particulars. As noted above, Medicaid professionals must register through CMS Registration and Attestation System, but the rest of the process occurs through their state Medicaid agency. Check your state s Medicaid website for more information about Medicaid attestation. Regional Extension Centers also have information on EHR implementation for Medicaid participants, as well as resources on the state s attestation process. The EHR Incentive Programs for both Medicare and Medicaid rely on goodfaith reporting. There is no electronic interface to transmit the results of meaningful use compliance the attestation process is self-reported. Nevertheless, the government plans to audit participants to reduce the possibility of fraud and abuse. 8 Bonus Payments and Penalties The federal government announced that payments for Medicare participants will begin in May The government will make the bonus for those meeting the meaningful use requirements in a single, consolidated annual payment. For Medicare, the money will come from CMS; for Medicaid, the payments will be sent from the state Medicaid agency. For the Medicare program, the initial year s bonus is available after attesting to 90 days of participation as a meaningful user. However, CMS will hold the money until the participant reaches the maximum level of total allowed Medicare charges (e.g., $24,000 in charges is needed for the maximum $18,000 bonus in 2011 or 2012, because it s calculated at 75 percent of total allowed charges up to a maximum of $18,000 in the initial payment year). If a participant in the Medicare program doesn t reach the maximum level by the end of the year, CMS will cut the check for whatever bonus he or she earned 75 percent of total allowed feefor-service Medicare professional charges. 7 CMS. Accessed February 23, 2011 at 8 Medicare and Medicaid Programs; Electronic Health Record Incentive Program. Final Rule. Released July 13, Published July 28, 2010 in Federal Register. Accessed February 23, 2011 at 10

12 This program is voluntary. However, it is worth noting that the government will impose penalties starting in 2015 a one percent reduction in Medicare payments for eligible professionals who decide not to participate. Although the penalty will start at one percent, ARRA gives the Secretary of Health and Human Services the authority to increase it to as much as five percent. Hospital-based physicians and other professionals who are not allowed to participate -- will not be subject to the reimbursement penalties that are phased in starting in 2015 for those who can, but choose not or fail to successfully participate. The EHR Incentive Program follows an important pattern set by the government s other technology-related programs for health care providers: They are voluntary, but include penalties for not participating. In the end, nonparticipation in the erx, PQRS and EHR Incentive Programs will amount to a nine percent reduction in Medicare reimbursement. (See Table Five for a summary of the penalties for failing to successfully participate in the government s current initiatives.) TABLE FIVE. Summary of Government Penalties for Non-Participation in Key Initiatives Year erx PQRS EHR Incentive Program Total % % % % % % % -1.5% -1.0% -4.5% % -2.0% -2.0% -6.0% % -2.0% -3.0% -7.0% % -2.0% up to -5% up to -9% % -2.0% up to -5% up to -9% The impact of the EHR Incentive Program will be far ranging. Successful participation will be a moving target, with the bar steadily moving upward. Medical practices, large and small, experienced in EHR or not, will be wise to carefully assess how internal processes can be automated with certified EHR technology. Every step of the patient encounter from check in at the front desk to documentation in the exam room must be evaluated for compatibility with the government s meaningful use criteria. The incentive programs for Medicare and Medicaid eligible professionals have just begun; your participation will pay off only if you can find the meaning in meaningful use. 11

13 STEPS TO MEANINGFUL USE OF THE ELECTRONIC HEALTH RECORD Make the federal government s EHR Incentive Program work for you. The Electronic Health Record (EHR) Incentive Program earmarks several billion dollars for eligible professionals, as well as hospitals, that make meaningful use of a certified EHR between 2011 and This program has its rewards bonuses paid through either the Medicare or Medicaid program for successful participants. It also has penalties in the form of percentage reductions in Medicare reimbursement for the eligible professionals who do not meet the government s standards for meaningful use of a certified EHR. Here are 10 steps to successful participation in the EHR Incentive Program. One: Do your homework. Decide whether the Medicare or Medicaid incentive program is best for you. The potential rewards per physician up to $44,000 through Medicare or up to $63,750 through Medicaid aren t the only differences. Each has its requirements and challenges. Two: Sign up. Register for the EHR Incentive Program through the Centers for Medicare and Medicaid Services (CMS) online Registration and Attestation System ( Make sure to obtain a National Provider Identifier (NPI) (available through the National Plan and Provider Enumeration System (NPPES) website) at ( and have the medical practice s NPI if the bonus payment is to be reassigned to the practice. If registering for the Medicare incentive program, you ll also need to enroll in the government s Provider Enrollment, Chain and Ownership System (PECOS). Three: Determine the workflow changes. Meeting the 15 required core meaningful use criteria isn t just about using the technology; it s about changing the workflow of your practice and how you manage patient information. For example: Documentation Before meaningful use: Office notes are written on paper and, perhaps, dictated later in the day. The notes and/or dictated transcript are filed in the patient s chart within a few days and the chart is returned to the medical records room until needed again. After meaningful use: The patient visit is documented in real time in the exam room; the data goes directly into the patient record as it is entered. After-visit summaries are printed and handed to patients as they exit the exam room or practice, or can be made available to patients via the practice s secure online portal within 72 hours of the visit. Laboratory tests Before meaningful use: Labs are ordered on a triple-ply paper requisition form: one page handed to the patient to take to the laboratory; another page sent to the business office for billing purposes; and the final sheet filed in the patient s chart. The lab retains the patient s copy of the requisition to subsequently match to the results in order to assure all tests are performed and results delivered. 12

14 After meaningful use: Laboratory orders are keyed directly into the EHR system. The orders transmit electronically to the lab. Results are matched automatically against physician orders to assure that no results are missed. The EHR interfaces with the practice management system to bill the payer or patient for any in-house labs that were performed. Four: Select quality measures. As part of the 15 core criteria for meaningful use, eligible professionals must report six ambulatory clinical quality measures that are to be generated as an output of the certified EHR. These include three core (or alternate core) measures and three additional measures chosen from a list of 38. Five: Read and select from the menu. Decide which five of the menu-based measures you plan to report in addition the 15 core measures. Make sure that one of them is selected from the two public health-oriented measures offered. If applicable, also assess if there is a valid basis for exclusion from any of the criteria. Six: Assess necessary exemptions. The 15 meaningful use core requirements are the same for the Medicaid and Medicare bonus programs. The government allows exemptions from some of the criteria, but the exemptions are narrowly drawn and the spirit of the program is to accomplish meaningful use, not look for exemptions. For example, a pediatrician who does not treat patients over age 13 would not be required to meet the criteria to electronically record smoking status for patients 13 years and older. Likewise, an eligible professional who performed an insufficient number of actions during the year, such as not prescribing medications, would not need to generate and transmit prescriptions electronically. An eligible professional who is exempt from a criterion is not required to substitute another one. Seven: Make sure your system is certified. To achieve certification, an EHR system or modules within a larger system must meet standards designated by the Office of the National Coordinator for Health Information Technology (ONC). The ONC s list of certified systems can be found online at Eight: Begin meaningful use. Perform internal tests of meaningful use. Take advantage of education, advice and other assistance available through the 62 Regional Extension Centers that have received federal grants to help eligible professionals select EHR vendors, understand meaningful use and implement EHR systems. Many of these centers services and educational programs cost providers little or nothing. 13

15 Nine: Attest to meaningful use. Attesting that is, reporting meaningful use of a certified EHR system officially began April 18, 2011 with the launch of the attestation section of CMS Registration and Attestation System ( Medicare participants should attest on CMS system, along with identifying the certified EHR technology they used for meaningful use. Certification is expressed through an identification number for the system (complete or series of modules). Medicaid incentive professionals can, for their first payment year at least, just demonstrate adoption, implementation or upgrading an EHR. Whether attesting to adopting, implementing or upgrading or meaningful use these reports must be made directly to the Medicaid state agency. Medicaid agencies aren t all open for reporting, however. Check with your state directly about the status of accepting attestations. Ten: Receive the incentive payment and celebrate (for a few minutes). The 15 core criteria for meaningful use and the menu selection of five more, plus quality measures apply to the first two years (2011 and 2012) of this multiyear bonus program. The current criteria and measurements, known as Stage One, will become more far-reaching and likely more difficult to achieve in future years. Expect that Stages Two and Three of the program will set the bar higher to receive the incentive payments. 14

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