FREQUENTLY ASKED QUESTIONS ON THE FINAL DEFINITION FOR MEANINGFUL USE OF EHRS IT Strategy Council, Advisory Board Company, Released August 19, 2010.

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1 ELIGIBILITY What are the eligibility requirements for an EP to qualify for Medicare incentives? In order to qualify for the Medicare EHR incentive program, an EP must meet the following criteria: The EP must furnish less than 90 percent of their allowed services in a hospital setting. Hospital-based Eligible Professionals (EPs) who furnish 90 percent or more of their allowed services in an inpatient or emergency department setting are not eligible for incentive payments. If practicing at multiple locations, have at least 50% of all patient encounters in a location using a certified EHR Be a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, who is legally authorized to practice under state law. Report successful performance against the thresholds for 20 meaningful use measures (15 core objectives and any 5 out of 10 of the menu objectives); report on six clinical quality metrics: three core measures and three measures chosen from among 38 additional measures. The following notes provide other relevant details about timeframe and incentives for EPs seeking Medicare incentive payments: 2014 is the last year for which an EP can begin receiving incentive payments for meaningful use. Incentive payments end after 2016, irrespective of the first year that the EP becomes a meaningful user of EHRs. A qualifying EP can receive EHR incentive payments for up to five years with payments beginning as early as In general, the maximum amount of total incentive payments that an EP can receive under the Medicare program is $44,000 (see Appendix C, Table 2 for detailed Medicare EP Incentives). An EP who predominantly furnishes services in a geographic Health Professional Shortage Area is eligible for a 10 percent increase in the maximum incentive payment amount. The maximum amount of total incentive payments that such an EP can receive under the Medicare program is $48,400. For the first year an EP applies for and receives an incentive payment, the EHR reporting period is any continuous 90-day period beginning and ending within the same calendar year. For every year after the first payment year, the EHR reporting period is the entire calendar year. For EPs, a payment year equals a Calendar Year (CY). Note: Under Medicare, EPs must demonstrate meaningful use for 5 consecutive years to maximize their incentive collection. EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs may participate in only one program and must designate the program in which they would like to participate. After the initial designation, EPs are allowed to change their program selection only once during payment years 2012 through However, this switch will not allow physicians to reset the clock on the meaningful use requirements i.e. physicians in their third year of adoption under Medicare will be required to demonstrate stage 2 requirements for Medicaid incentives, as opposed to starting over with Stage 1 requirements under Medicaid. Furthermore, physicians switching between Medicare and Medicaid will not be allowed to collect more than the maximum Medicaid incentive ($63,750) across all payment years (see Appendix C, Tables 3 and 4 for detailed Medicaid EP incentives). EPs collecting Medicare incentives for meaningful use will not be eligible to simultaneously collect e- prescribing incentives. What are the eligibility requirements for an EP to qualify for Medicaid incentives? In order to qualify for the Medicaid EHR incentive program, an EP must meet the following criteria: The EP must furnish less than 90 percent of their allowed services in a hospital setting. Hospital-based Eligible Professionals (EPs) who furnish 90 percent or more of his/her allowed services in an inpatient or emergency department setting are not eligible for incentive payments. Be one of the following clinicians: physicians, dentists, nurse practitioners, certified nurse midwives, and physician assistants practicing predominantly in a Federally Qualified Health Center or Rural Health Clinic (FQHC/RHC) that is directed by a physician assistant. Note: EPs practicing predominately at FQHCs/RHCs,

2 defined as having more than 50 percent of their encounters over a six-month period in the most recent calendar year occurring at an FQHC/RHC, are exempt from the hospital-based limitation, and must attest that a minimum of 30 percent of their patient encounters over any continuous 90-days period in the most recent calendar year was with needy individuals. Have 30% of their patient volumes attributable to Medicaid or, in the case of eligible professionals practicing predominately at FQHCs and RHCs, attributable to needy individual encounters over any representative continuous 90-day period in the most recent calendar year. For all Medicaid EPs except pediatricians, the patient volume threshold is 30 percent; for pediatricians, it is 20 percent. If practicing in multiple locations, have at least 50% of all patient encounters in a location using a certified EHR. Report successful performance against the thresholds for 20 meaningful use measures (15 core objectives and any 5 out of 10 of the menu objectives); report on six clinical quality metrics: three core measures and three measures chosen from among 38 additional measures. The following notes provide other relevant details about timeframe and incentives for EPs seeking Medicaid incentive payments: Medicaid EPs can start collecting incentives in With Medicaid incentives running through 2021, Medicaid EPs may demonstrate meaningful use as late as CY 2016 and still qualify for the maximum payment of $63,750 (see Appendix C, Tables 3 and 4 for Medicaid EP Incentives). Under Medicaid, an EP can collect Year 1 incentives for adopting, implementing, or upgrading EHRs. In year 2, the EP would need to demonstrate meaningful use for 90 continuous days beginning and ending within the same calendar year to qualify for incentives. For every year after the first year of demonstrating meaningful use, the EHR reporting period is the entire calendar year. For EPs, a payment year equals a Calendar Year (CY). Note: Under Medicaid, EPs do not need to demonstrate meaningful use in consecutive years to collect the maximum incentive. A Medicaid EP who has already adopted, implemented, or upgraded certified EHR technology and can meaningfully use this technology in the first incentive payment year will be permitted to receive the same maximum incentives as the Medicaid EP who merely adopted, implemented, or upgraded certified EHR technology in the first year. Furthermore, Medicaid EPs who demonstrate meaningful use could receive an additional 5 years of payment for maintenance and support expenses, not to exceed $8,500 in each year. (see Appendix C, Tables 3 and 4 for detailed Medicaid EP Incentives). Medicaid EPs will be eligible to collect e-prescribing incentives in addition to the Medicaid incentives for meaningful use. Are Medicaid volume requirements determined by individual physician or the aggregate of the practice? The final rule allows for Medicaid volume requirements to be determined either at the individual or aggregate practice level. However, if clinics or group practices choose to calculate volume at the aggregate level, they must meet the following conditions: The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for all EPs (for example, if one of the practice s EPs does not see Medicaid patients, then this is not an appropriate method) There is an auditable data source to support the clinic's or group practice s patient volume determination All EPs in the group practice or clinic must use the same methodology for the payment year (in other words, either the group determines patient volume or each individual physician determines their own patient volume some cannot use clinic data while others use individual data) The clinic or group practice uses the entire clinic or practice s patient volume and does not limit patient volume in any way. If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP s outside encounters.

3 Are hospital radiologists considered EPs? Eligibility is not based on the type of provider, but the site-of-service. Hospital-based Eligible Professionals (EPs) who furnish substantially all their services 90 percent or more of all his/her allowed services in an inpatient or emergency department setting are not eligible for incentive payments. Therefore, if the radiologist primarily conducts diagnostics and reads images from an outpatient clinic or practice, then he/she is eligible for incentives upon meeting the specific Medicare or Medicaid eligibility requirements and demonstrating meaningful use. However, if the radiologist practices primarily in the hospital s inpatient or ED, then he/she is not eligible. Would physicians working in emergency medicine qualify for incentives? As clarified above, the primary site of service determines whether or not a physician is considered eligible for MU incentives. An emergency medicine physician who furnished more than 90% of his/her services in a hospital ED, would be considered a hospital-based EP and would not be eligible for incentives. Are residents considered EPs and eligible for the respective Medicare and Medicaid incentives? While residents are not specifically mentioned within the final rule, it s unlikely that a resident would qualify for an incentive payment. The rule defines an eligible physician as a provider who is, legally authorized to practice their profession under state law, and specifies that eligible providers include doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, or chiropractors. In many states, licensure and independent practice is not possible until a physician has completed residency. Further, even if a resident was legally authorized to practice, they are typically hospital-based and therefore are not considered eligible for an incentive payment (EPs who provide more than 90 percent of their services in the hospital are considered hospital-based). Does MU apply to physicians operating in a concierge practice? EPs with adequate Medicare allowable charges or at least 30% of patients attributable to Medicaid are eligible for MU incentives from either Medicare or Medicaid based on their program selection. If a concierge practice does not see adequate Medicare or Medicaid patients to meet the eligibility requirements, the EPs in this practice are not subject to MU requirements and will not be eligible for incentives. Can employed physicians apply for Medicaid incentive payments? A hospital-employed physician can qualify for Medicaid incentive payments provided that he/she: 1) is not considered a hospital-based physician (i.e. providing more than 90% of his/her services in the inpatient or ED setting), and 2) provided that at least 30% of his/her patient volume is attributable to Medicaid. Note: Pediatricians are an exception to the 30 percent patient volume threshold; they can qualify for Medicaid incentives if they have at least 20 percent of patient volumes attributable to Medicaid. More generally, in order for a physician to receive a Medicaid incentive payment, they must meet the following criteria: Be one of the following clinicians: physicians, dentists, nurse practitioners, certified nurse midwives, and physician assistants practicing predominantly in a Federally Qualified Health Center or Rural Health Clinic (FQHC/RHC) that is directed by a physician assistant. Notably, EPs practicing predominately at FQHCs/RHCs defined as having more than 50 percent of their encounters over a six-month period in the most recent calendar year occurring at an FQHC/RHC are exempt from the hospital-based limitation provided that they can attest to at least 30 percent of their patient encounters over any continuous 90-day period in the most recent calendar year being needy individuals. Have 50 percent or more of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHRs.

4 What will become of new physicians entering the system in 2015? Physicians starting to practice in 2015 will not be eligible for an incentive payment. However, given that this group of physicians will learn to use EHR technology from the beginning of their medical career, it s unlikely that EHR adoption will be a significant challenge for these providers in fact, it s more likely that they ll be reticent to work in a practice or hospital without IT capabilities. Must the emergency department of the hospital participate to be eligible for incentives? The rule specifies that patient volume from both the inpatient setting and emergency department will be included in the denominator for assessing performance on MU measures, when determining MU achievement. Given the addition of ED volumes to the denominator for each measure, organizations will find it challenging to meet the MU performance thresholds without requiring MU compliance in the ED. Are inpatient rehabilitation and psychiatric services included in the denominator for measures pertaining to inpatient services? Whether or not a service is eligible for inclusion is based on its Point of Service (POS) code, the two-digit code used in claims reporting to indicate the setting in which the service was provided. The rule looks specifically at services in the inpatient setting and emergency department, POS 21 and 23 respectively. Therefore, if the aforementioned services are identified as POS 21 or 23, they would be eligible for inclusion in the denominator for MU reporting. Can an eligible hospital who satisfies the meaningful use requirements receive both the Medicare and Medicaid incentive payments? Acute care hospitals are eligible for meaningful use incentives from both Medicare and Medicaid, provided they demonstrate meaningful use of certified EHRs and report against the prescribed set of clinical quality metrics. For the purposes of this ruling, CMS defined an acute care hospital as one with an average length of stay under 25 days. To be considered a Medicaid eligible hospital, in addition to being an acute care hospital or a critical access hospital with average length of stay less than 25 days, the eligible hospital must have at least 10% of its volumes attributable to Medicaid. Children s Hospitals are an exception, as they do not have a minimum volume threshold to be eligible for Medicaid incentives, but they do not qualify for Medicare incentives. Can a hospital collect incentive payments for owned or affiliated practices? The final rule specifies that an EP may reassign their incentive payment to their employer or an entity with whom they have a contractual relationship by providing the hospital s CCN as the beneficiary of the incentive. The arrangement must be consistent with rules governing reassignments and based on this rule, the incentive can only be reassigned to any one hospital even if the physician practices at more than one hospital. IT Strategy Council recommends explicitly requiring physicians to reassign incentives to the hospital by signing appropriate contracts with them, in advance of registration for MU incentives. For an eligible hospital to meet eligibility for Medicaid incentive payments is the 10% volume requirement for inpatient only or does it include ED volumes as well? To be considered a Medicaid eligible hospital, in addition to being an acute care hospital or a critical access hospital with average length of stay less than 25 days, the eligible hospital must have at least 10% of volume attributable to Medicaid. The rule provides the following clarification for what is considered a Medicaid encounter for eligible hospitals, indicating that both inpatient and ED volume may be considered when determining the volume of Medicaid patient encounters: 1. Services rendered to an individual per inpatient discharges where Medicaid or a Medicaid demonstration project under section 1115 paid for part or all of the service; 2. Services rendered to an individual per inpatient discharge where Medicaid or a Medicaid demonstration project under section 1115 of the Act paid all or part of their premiums, co-payments, and/or cost-sharing;

5 3. Services rendered to an individual in an emergency department on any one day where Medicaid or a Medicaid demonstration project under section 1115 of the Act either paid for part or all of the service; or 4. Services rendered to an individual in an emergency department on any one day where Medicaid or a Medicaid demonstration project under section 1115 of the Act paid all or part of their premiums, copayments, and/or cost-sharing. We wanted to adequately reflect what an encounter looked like for a hospital and apply these concepts consistently across the numerous areas of this final rule. We used inpatient discharges and emergency department services for the hospitals because this is consistent with how we will make hospital-based determinations for EPs and how we collect meaningful use information for hospitals. We decided that services rendered on one day would be an encounter. An emergency department must be part of the hospital under the qualifying CCN. INCENTIVE PAYMENTS In order to participate in the Medicare and Medicaid incentive program, what must an EP do? CMS provided the following response in their August 10, 2010 teleconference on the Medicare and Medicaid EHR Incentive Program: Specifics of the Program for Eligible Professionals: All providers must: o Register via the EHR Incentive Program website o Be enrolled in Medicare FFS, MA, or Medicaid (FFS or managed care) o Have a National Provider Identifier (NPI) o Use a certified EHR technology (Medicaid providers may adopt, implement, or upgrade in their first payment year). All Medicare providers and eligible hospitals must be enrolled in PECOS o Registration: Medicaid Specific Details o o States will interface with/to the EHR Incentive Program registration site States will ask providers to provide and/or attest to additional information in order to make accurate and timely payments, such as: Patient Volume Licensure A/I/U or Meaningful Use Certified EHR Technology Registration requirements include: o Name of eligible professional o NPI o TIN to which the provider would like their incentive payment made o Medicare or Medicaid program selection (may only switch once after receiving an incentive payment before 2015) for EPs o State selection for Medicaid providers Certified EHR Technology required in order to meet MU In order to participate in the Medicare and Medicaid incentive program, what must a hospital do? CMS provided the following response in their August 11, 2010 teleconference on the Medicare and Medicaid EHR Incentive Program: Specifics of the Program for Hospitals: All providers must: o Register via the EHR Incentive Program website o Be enrolled in Medicare FFS, MA, or Medicaid (FFS or managed care) o Have a National Provider Identifier (NPI)

6 o Use a certified EHR technology (Medicaid providers may adopt, implement, or upgrade in their first year). All Medicare providers and eligible hospitals must be enrolled in PECOS o Registration: Medicaid Specific Details o o States will interface with/to the EHR Incentive Program registration site States will ask providers to provide and/or attest to additional information in order to make accurate and timely payments, such as: Patient Volume Licensure A/I/U or Meaningful Use Certified EHR Technology Hospital registration requirements include: o Name of the hospital or CAH o NPI o Business address and business phone o TIN to which the provider would like their incentive payment made o CCN o State selection for Medicaid providers Certified EHR Technology required in order to meet MU What are the formulas for determining incentive payments? We created a worksheet outlining the incentive payment calculations under both Medicare and Medicare for eligible hospitals and EPs, which can be found in Appendix C How will the payment be distributed? Under the Medicare program, payment will be disbursed as follows: For eligible professionals: An Integrated Data Repository (IDR) will track allowed charges according to the EP s National Provider Identifier (NPI) Payments will be made on a rolling basis once: o CMS has determined that the EP has successfully demonstrated MU for the reporting period (90 days for the first year or a calendar year for subsequent years), and o Once the EP s allowed charges have reached the threshold that qualifies an EP for maximum incentive payment, for the relevant payment year The National Level Repository (NLR) will calculate an incentive payment The payment will be made by a single payment contractor and disbursed to the TIN provided during registration (note: an EP can provide a hospital s CCN is they wish to reassign the payment to the hospital based on pre-determined contractual agreements) CMS anticipates that the EPs will receive payment days after successfully attesting to MU The reporting period for EPs is based on the calendar year, with 2011 as the first year in which the EP can qualify for incentives For eligible hospitals: Fiscal intermediaries(fis) and the Medicare Administrative Contractor(MAC) will calculate hospital incentive payments Similar to incentive payouts for EPs, a single payment contractor will issue payments to hospitals demonstrating MU (use of certified EHR technology, required performance on meaningful use measures, and reports on clinical quality measures)

7 While hospitals reporting period coincides with the federal fiscal year (i.e. Fiscal Year 2011 starts Oct through Sept 30, 2011), hospitals can only register for meaningful use incentives starting in January 1, 2011, and after demonstrating meaningful use for 90-continuous days, they will be eligible for incentives. CMS expects incentive payments for FY 2011 could be made as early as May For FY 2011, initial incentive payments will be made on a monthly payment cycle beginning shortly after the hospital is determined to be a meaningful user; with incentive payouts made on a rolling basis, qualifying providers who demonstrate MU sooner during the reporting period will receive their interim incentive payments sooner In subsequent years, hospitals need to demonstrate MU for the entire year and incentive payments will be made in the following year; while payments will be made through a MAC, CMS will instruct the MAC to disburse payments to eligible hospitals in a single initial payment Under the Medicaid program, payment will be disbursed as follows: For eligible professionals: State Medicaid agencies (or their contractors) will be responsible for administering and disbursing incentive payments to Medicaid eligible providers EPs must select to participate in either the Medicare or Medicaid EHR incentive program The EP must choose which state they intend to receive payments from for the given year The EP will enroll in the Medicaid incentive program through a single provider election repository Reporting timeframe: o In the first payment year, if applying for incentives to adopt, implement or upgrade EHRs, there is no reporting timeframe requirement. However if the EP is not applying for first year incentives for adopting, implementing, or upgrading EHRs, he/she can collect the same incentive for demonstrating meaningful use for any continuous 90-day period within the same calendar year. o Medicaid providers in their second year of participation (if they collected incentives for adoption, implementation or EHR upgrades in the first payment year) must demonstrate meaningful use over a continuous 90-day period to qualify for incentives o The reporting period will expand to 12-months for subsequent payment years States are expected to process payments on a rolling basis, but will not be permitted to make payments until January 2011; CMS intends to issue further guidance regarding expectations for timely payments For eligible hospitals: State Medicaid agencies (or their contractors) will be responsible for administering and disbursing incentive payments to Medicaid eligible providers States will use auditable data sources to calculate incentive amounts, including the following sources: o Medicare cost reports o State-specific Medicaid cost reports o Payment/utilization information from the State s Medicaid Management Information System (MMIS) o Hospital financial statements and accounting records States will calculate eligible hospital s aggregate incentive amounts on the Federal Fiscal Year (FFY) to align with requirements for the Medicare incentive program; the FFY begins on October 1 st and ends on September 30 th of each calendar year Reporting timeframe: o In the first payment year, if applying for incentives to adopt, implement or upgrade EHRs, there is no reporting timeframe requirement. However if the hospital is not applying for first year incentives for adopting, implementing, or upgrading EHRs, it can collect the same incentive for demonstrating meaningful use for any continuous 90-day period within the same calendar year. o Medicaid eligible hospitals in their second year of participation (if they collected incentives for adoption, implementation or EHR upgrades in the first payment year) must demonstrate meaningful use over a continuous 90-day period to qualify for incentives o The reporting period will expand to 12-months for subsequent payment years

8 States are expected to process payments on a rolling basis, but will not be permitted to make payments until January What timeframe will be used to determine whether a provider is meeting the minimum allowable charges for Medicare and Medicaid incentive payments? Medicare For Medicare, eligibility is based on allowable charges: Eligible Hospitals: The hospital s preliminary incentive payment will be determined based upon discharges, which will be calculated using discharge and other data from a hospital s most recently filed 12-month cost report that ends in the year prior to the payment year. Subsequently, the hospital s incentive payment will be reconciled based on the 12-month cost reporting period that begins after the start of the payment year (the federal fiscal year) for which the hospital is applying for incentives. EPs: The amount of the EHR incentive payment is based on the estimated allowed charges for all covered professional services furnished by an EP during the payment year, based on claims submitted to Medicare no later than 2 months following the end of the relevant payment year. Medicaid For Medicaid, provider and hospital eligibility will be based on volume, not charges, as illustrated in the table below. To estimate Medicaid patient volume, CMS will look at the total number of Medicaid patient encounters in any representative continuous 90-day period in the preceding calendar year. Entity Minimum 90-day Medicaid Patient Physicians 30% Pediatricians 20% Dentists 30% Certified nurse midwives 30% Physician Assistant when practicing at an 30% FQHC/RHS led by a physician assistant Volume Threshold Nurse Practitioner 30% Acute Care Hospital and CAHs 10% n/a Children s Hospital n/a n/a Or the Medicaid EP practices predominantly in a FQHC or RHC 30% needy individual patient volume threshold Will an EP lose PQRI incentive payments if he or she achieves meaningful use? There is no indication in the final rule that an EP who receives MU incentives will forfeit PQRI incentives as a result. CMS further acknowledges that there will be duplicative reporting between the two programs and, in future rulemaking anticipate[s] efforts to avoid redundant and duplicative reporting in PQRI of the same clinical quality measures as required in the EHR incentive program. What about physicians who participate in the Medicare EHR demonstration project? Will they be able to participate in the Medicare incentive as well? The rule does not include any language that excludes physicians participating in the Medicare EHR demonstration project from receiving Medicare incentives if they demonstrate that they are meaningful users of EHR. That said, the rule explicitly states that once an EP collects Medicare EHR incentives, he/she will no longer be eligible for e- prescribing incentives.

9 REPORTING REQUIREMENTS What is a unique patient? The final rule defines a unique patient as the following: To further describe the concept of unique patient we mean that if a patient is seen by an EP or admitted to an eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) more than once during the EHR reporting period then for purposes of measurement they only count once in the denominator for the measure. The rule goes on to clarify that measures requiring a count of unique patients should rely solely on information contained in the patient s medical record, to minimize the burden of unnecessary manual data collection: All the measures relying on the term unique patient relate to what is contained in the patient s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period. What is a CCN? A CMS Certification Number, or CCN, is a hospital identification number linked to its Medicare agreement (it was once called a provider number ). 1 It is not the same as an organization s tax identification number. The final rule defines an eligible hospital for purposes of meeting meaningful use criteria and receiving incentive payments based on unique CCNs. What is the relevance of the 23,000 discharge cap per CCN? An individual hospital s Medicare and Medicaid incentive payment is determined, in part, by a base incentive and the volume of annual discharges, adjusted for the hospitals Medicare/Medicaid share. A hospital receives an additional incentive payment for every discharge between 1,150 and 23,000, at which point the incentive payment is capped regardless of the total number of annual discharges. This bears particular significance for multi-facility health systems that operate under a common CCN given that they are considered to be a single entity for the purposes of meaningful use demonstration and incentive calculation (with a 23,000 discharge cap placed on the whole system, rather than for each separate facility within the system). NOTE: a recent bill introduced in Congress challenges this incentive restriction on multi-facility systems operating under a single CCN. Passage of this bill could alter the incentive potential and meaningful use demonstration requirements for multi-facility systems under the same CCN. How must providers report compliance in order to receive incentive payments? For 2011, EPs and eligible hospitals will be required to log into a CMS-designated portal to report the numerators, denominator, and exclusions for the meaningful use measures as well as the clinical quality measures. These numerators and denominators must be generated from the certified EHR and attested as such to demonstrate compliance with MU. Furthermore, EPs and eligible hospitals must attest to having implemented the MU objectives that do not have a performance threshold but simply require a yes/no validation for MU. In 2012, EPs and hospitals will continue to attest to meaningful use measures but will be required to electronically report clinical quality measures to CMS. In order to receive the incentives, hospitals must register with CMS, providing a CCN (which identifies the eligible hospital) and a tax identification number (TIN). Similarly, EPs should provider either a SSN or TIN if the payment should go to the physician or practice (or a CCN is the payment should go to a designated hospital). 1 Frequently Asked Questions about Accrediting Hospitals in Accordance with their CMS' Certification Number (CCN), Joint Commission, available at (Accessed July 29, 2010).

10 Notably, the rule identifies two alternative reporting arrangements to the CMS-designated portal: 1) The EP, eligible hospital, or CAH can submit data directly from the certified EHR to a Health Information Exchange (HIE) or Health Information Organization (HIO) provided that the HHS Secretary can collect data through this network 2) CMS will accept submissions through registries dependent upon the development of the infrastructure necessary to do so through certified EHRs. Currently, CMS is not able to accept electronic transmissions of such data from HIEs, registries or providers directly and so for the foreseeable future, we expect all reporting for MU to be completed using the CMS portal. If multiple EPs share the same tax identification number (TIN) with the hospital, and work in an outpatient clinic, how should they apply? CMS states that there can be multiple incentive payments assigned to the same tax identification number (TIN). However, to distinguish one physician from another when more than one provider shares the same TIN, CMS will use the provider s National Provider Identifier (NPI) also required as part of the registration requirements for the incentive programs to ensure that duplicate payments are not made to the same provider. Note: The rule provides for an EP to use their SSN in lieu of a TIN if the EP does not have a TIN. However, if the EP intends to reassign their payment to their employer (depending on the contractual arrangement between the EP and hospital), then he/she would provide the hospital s CCN at this step. In a group, does each physician have to register, or is it done by group with a list of the physicians? While the group may calculate patient volume in aggregate, MU objectives are determined at the level of the EP, as clarified on pages 348 and 349 of the final ruling (excerpted text below with bold added for emphasis). Therefore, each individual physician will have to register and report against MU measures to receive incentive payments. Given the per EP basis for most of the objectives and their associated measures, we did not believe group reporting would provide an accurate reflection of meaningful use. In addition, as the incentives payments are calculated on a per EP basis it is unclear to us how variance of meaningful use among EPs within the group should be treated. We believe the possible reduction in burden of attesting once per group versus once per EP is outweighed by the less accurate reporting, increased possibility of duplicate payments and decreased transparency. We note that many of the measures rely on data which could easily be stored at a group level such as a patient s demographics or medication lists and any EP with access to that information about a patient in their certified EHR technology and who sees that same patient in the EHR reporting period would receive credit for that patient in their numerator and denominator. Other aspects such as the enabling of drug-drug, drug-allergy checks, using CPOE and erx could vary widely from EP to EP within the same group. We would also be concerned with EPs in multi-specialty group practices some of whom might be eligible for an exclusion, while others would not be. As requested by commenters we will continue to review this option in future rulemaking, but for this final rule we do not include the option to demonstrate meaningful use at a group level. ROLLOUT TIMEFRAME If a hospital attempts to meet meaningful use in 2011, but doesn t satisfy the requirements, can it try again and still qualify for the maximum incentive payment? Yes, an eligible hospital who misses MU in 2011 can try again and still qualify for the maximum incentive payment under both the Medicare and Medicaid programs. To qualify for the maximum allowable incentive payment under the Medicare EHR program, an eligible hospital must:

11 Meet Stage 1 requirements by 2013, given that the incentive payment will be subject to a decreasing transition factor starting in 2014, as illustrated below: Transition Factor Fiscal Year Fiscal Year that Eligible Hospital First Receives the Incentive Payment Continue to meet meaningful use requirements for each of the three subsequent years. Failure to meet the requirements in any year, based on the hospital s stage of meaningful use, will result in lost Medicare incentives that cannot be recovered in later years. Under the Medicaid program, an eligible hospital must qualify for MU by 2016 in order to receive incentive payments in later years. If the EH proceeds to demonstrate MU across the remaining years of the Medicaid incentive program (which extends through 2021), then it would qualify for the maximum incentive payment. There appears to be a discrepancy between pages 38 and 39 of the final rule. On page 38, the rule states that someone who achieves MU for the first time in 2013 would need to meet Stage 2 requirements in 2014 to receive incentive payments. The table on page 39 suggests that a provider who achieves MU for the first time in 2014 would be required to meet Stage 1 requirements in 2014 to receive incentive payments. Please clarify. CMS clarified this issue in their August 10, 2010 teleconference on the Medicare and Medicaid EHR Incentive Program: Specifics of the Program for Eligible Professionals. Panel respondents indicated that the table on page 39, which is also provided below, is correct; providers who first achieve MU in 2013 will be required to meet Stage 1 requirements in 2014 to qualify for MU incentive payments. First Payment Payment Year Year Stage 1 Stage 1 Stage 2 Stage 2 TBD 2012 Stage 1 Stage 1 Stage 2 TBD 2013 Stage 1 Stage 1 TBD 2014 Stage 1 TBD Given the differing incentive payout structure for the Medicaid and Medicare payments, which does it make sense to apply for first? If eligible for Medicaid (the eligible hospital must have at least 10% of its volumes attributable to Medicaid and the EP must have at least 30% of its volume attributable to Medicaid), we would suggest prioritizing the Medicaid incentive program because Medicaid eligible hospitals and EPs are eligible for an incentive in Year 1 for simply demonstrating tangible efforts to adopt (actual installation of EHRs), implement (trained staff, deployed tools, exchanged data), or upgrade to certified EHR technology (expanded functionality or interoperability) prior to ever demonstrating meaningful use. Notably, the incentives cannot be considered as grants to purchase technology but rather to facilitate their adoption. The eligible hospital and EP will be required to demonstrate meaningful use of EHRs in subsequent years based on Medicaid requirements to collect future incentive payments.

12 Given that hospitals can collect incentives from Medicare and Medicaid, unlike physicians who can collect from only one of the incentives programs, once the eligible hospital proceeds to apply for Medicare incentives, they can shift their efforts to demonstrating Meaningful Use solely to CMS to qualify for both Medicare and Medicaid incentives. Hospitals demonstrating meaningful use to CMS for Medicare incentives do not need to demonstrate the same to their respective States, unless the State has explicit additional meaningful use requirements, so as to minimize duplicative reporting. For hospitals that do not go live until 2013, do they still have the 90 day window to report? Yes, for the first year that an eligible hospital demonstrates meaningful use, the EHR reporting period equals any continuous 90-day period beginning and ending within the same federal fiscal year. For every year after the first payment year, the EHR reporting period is the entire fiscal year. That said, CMS reserves the right to increase Stage 1 requirements in future rulemaking; this means hospitals that have yet to achieve stage 1 of meaningful use at that time of such future rulemaking may have a larger leap to make to collect the first year of incentives. When we start the clock, is it for all physicians or just one? While physicians can determine Medicaid patient volume as a group practice and receive payment at a group-level TIN, they are required to report compliance against MU objectives independently and therefore on their own timeframe, as outlined on pages 348 and 349 of the final rule: As requested by commenters we will continue to review [group reporting] in future rulemaking, but for this final rule we do not include the option to demonstrate meaningful use at a group level. If an EP meets MU requirements and receives a Medicaid incentive payment, but fails to in the subsequent year (year 2), can they still qualify for the maximum allowable incentive payment? Yes. Medicaid incentives begin in 2011 and end in An EP is eligible for six non-consecutive years of payment under the Medicaid program (one Year 1 incentive payment capped at $21,250, and 5 additional payments, each capped at $8,500). As illustrated below, under Medicaid, physician payments do not decline between the any second year of payment and the sixth (and final) year of payment. So as long as the EP demonstrates meaningful use for the first time before or in 2016, and he/she continues to demonstrate meaningful use for any 5 years after the first year, with 2021 being the last year for demonstrating MU, the EP can collect the maximum Medicaid incentives. Medicaid Incentive Payout Schedule for Eligible Professionals Calendar Years for Which an Medicaid EPs who begin adoption in Incentive Payment is Available $21, $8,500 $21, $8,500 $8,500 $21, $8,500 $8,500 $8,500 $21, $8,500 $8,500 $8,500 $8,500 $21, $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

13 Can the 90-day reporting period be different for each measure, or are all MU measures assessed within the same timeframe? All MU measures will be assessed in the same timeframe, and when reporting through the CMS-provided portal the EP/eligible hospital will be asked to provide the beginning and end dates for which the numerators, denominators, and exclusions apply for the first year. In subsequent years, EPs and eligible hospitals must demonstrate meaningful use across the entire calendar or fiscal year, respectively. EHR INFRASTRUCTURE Will a single EHR product be required or can we use multiple products? A single, certified EHR product is not required, but if a hospital or health system chooses to use EHR modules purchased from different vendors the onus falls to the hospital to ensure that each system is certified (if the vendor has not already pursued certification), interfaced properly with other systems, and that the systems collectively meet all the meaningful use objectives. Can the report be generated using business intelligence tools or a data warehouse, or must the report come from the native EHR? The final rule requires providers to generate and report most of the meaningful use measures and all of the clinical quality measures directly from the certified EHR. The rule explicitly states that the certified EHR must generate the aggregate numerators, denominators, and exclusions for reporting. In fact, hospitals can be required to show proof of such aggregate data generated by the certified EHR, if audited. To that end, EHR vendors will be required to demonstrate such reporting capabilities within their products to achieve certification. However, if a hospital chooses to use its data warehouse for reporting, it will either need to get the data warehouse and reporting solution certified for meaningful use reporting requirements or must transfer only aggregate numerators, denominators, and exclusions data generated by the certified EHR to the data warehouse for reporting. In summary, as long as the aggregate data on meaningful use measures and clinical quality measures is generated by a certified reporting solution, the hospital will be able to meet this meaningful use requirement. Will the Office of the National Coordinator for Health Information Technology (ONC) publish information regarding vendors progress in developing certified EHRs? ONC does not intend to publish information regarding which vendors have applied for EHR certification and their progress towards receiving it. However, they will publically report vendors that have received certification, the products that are certified, and the date and version of the product that received certification. With the delay in release of the certification requirements and guidelines, ONC estimates that certified EHRs will not be available until fall The good news, however, is that hospitals may start the reporting period for meaningful use in 2011, before upgrading to the certified version of the EHR, provided they can secure the upgrades before the end of the 90-day reporting period. Note: This leniency on timeframe to adopt certified EHRs may cease in 2012, by which point ONC expects multiple certified vendor products on the market. STAFFING AND ACCOUNTABILITY At hospitals, who is spearheading this process? When done well, successfully implementing and reporting from an EHR is a team effort. Given that implementing EHR requires significant changes in workflow, buy in and support of senior leadership is critical to driving MU compliance throughout the organization. From a technical perspective, the initiative is supported by IT staff who help implement and configure the systems, while the clinical quality reporting may be done within IT or by individuals overseeing clinical quality reporting for other programs.

14 This is a topic we ve covered in-depth in past research and publications. If you would like more information on best practices for successfully implementing systems and redesigning workflows to maximize the return on your IT investments, please contact Protima Advani at advanip@advisory.com SPECIFIC MEANINGFUL USE REQUIREMENTS: CPOE Is a PharmD qualified to enter medications into a CPOE system? The rule specifies that a licensed professional who can enter orders into the medical record per state, local, and professional guidelines, is qualified to enter orders using CPOE for the purposes of demonstrating Stage 1 MU requirements. If a PharmD meets each of these requirements, then he/she would be eligible to enter orders into the CPOE system. Is an order management an adequate tool for meeting the CPOE requirements? The final rule doesn t specifically address order management systems, though it does allow EPs and eligible hospitals to apply for EHR certification for homegrown or niche products that are not otherwise certified. We would suggest seeking certification for any product the organization intends to use to meet the MU requirements. That said, with Stage 2 requirements targeting 60% of all orders using CPOE, hospitals will be better served adopting CPOE sooner rather than later, so that they can not only achieve Stage 1 CPOE requirements but also subsequently meet the higher CPOE bar in Stage 2. If an EP is using an EMR for full e-prescribing (erx), does this satisfy the requirement for CPOE on the ambulatory side? While several ambulatory EMRs use the same functionality for order entry as they do for e-prescribing (and hence will be certified as having both those capabilities), the CPOE requirement is limited only to ordering while the erx requirement needs the system to electronically transmit the order to a pharmacy, providing distinction between the two requirements. Therefore, regardless of how the CPOE and erx requirements are operationalized, the EP will need to report distinct numerators, denominators, and exclusions for both CPOE and erx through the certified EHR in order to meet the MU requirements. CLINICAL QUALITY REPORTING For quality measures, what is the specificity of data required in the EMR for "exclusions"? CMS requires the reporting of zero as a value if a hospital or EP cannot report on any of the clinical quality measures. Physicians in particular should note that in Medicare & Medicaid EHR Incentive Program Question and Answer Session held by CMS on August 12, 2010, the CMS panel indicated that they do expect EPs to report on metrics for which they have data. If the provider reports zero on three of the 38 additional metrics, they will be asked to attest that they don t have data for any of the additional measures (remaining 35 measures). POPULATION AND HEALTH OBJECTIVES How can I comply with the population and public health objectives if my state does not support electronic receipt of population health data? In order to meet the meaningful use criteria for population and public health objectives, a provider must either meet one of the population and public health criteria outlined in the menu set or attest that they are excluded from all three population and public health criteria. Each of the three criteria provides an

15 exclusion for providers in states where there are not immunization registries or public health organizations capable of receiving such information electronically (as outlined in the table of measures below, bold added for emphasis). Note: exclusions do not count against the five deferred measures allowed in the menu set. Improve population and public health 1 EP Objective Hospital Objective Measure Capability to submit electronic data Capability to submit electronic data to Performed at least one test of certified to immunization registries or immunization registries or EHR technology's capacity to submit Immunization Information Systems Immunization Information Systems and electronic data to immunization and actual submission in accordance actual submission in accordance with registries and follow up submission if the with applicable law and practice applicable law and practice test is successful (unless none of the immunization registries to which the EP, eligible hospital or CAH submits such information have the capacity to receive the information electronically) Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology's capacity to provide electronic submission of reportable lab results to public health agencies and follow-up submission if test is successful (unless none of the public health agencies to which eligible hospital or CAH submits such information have the capacity to receive the information electronically) Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies and follow up submission if the test is successful (unless none of the public health agencies to which an EP, eligible hospital or CAH submits such information have the capacity to receive the information electronically) STATE-SPECIFIC REQUIREMENTS Do you anticipate that States will add their own unique requirements? The final rule allows States to convert the four menu objectives listed below to core objectives (making them mandatory for Medicaid eligible hospitals and/or EPs), provided these objectives support States broader efforts in achieving the population health objectives. The menu objectives that States may choose to make mandatory include the following: a. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach b. Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice. c. Capability to provide electronic submission of reportable (as required by State or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice; and d. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission in accordance with applicable law and practice.

16 While no States have added unique requirements for 2011, we wouldn t be surprised if they begin to take advantage of this aspect of the program in 2012 or from Stage 2 onwards. That said, it is important to note that hospitals eligible for both the Medicare and Medicaid programs who achieve Meaningful Use designation through the Medicare program will be deemed meaningful users for Medicaid (regardless of the State-specific definition) as outlined in the final rule: We continue to believe that allowing deeming ensures that hospitals eligible for both programs are able to focus on only one set of measures, without requiring duplication of effort or confusion regarding meaningful use standards. Thus, hospitals eligible for both Medicare and Medicaid incentive payments will be deemed for Medicaid if they have met the meaningful use definition through Medicare, even if a State has an approved State-specific definition of meaningful use. STAGE 2 REQUIREMENTS When will stage 2 requirements be published? CMS anticipates releasing rulings for subsequent stages on the following timeframe as detailed in the final rule: We expect to update the meaningful use criteria on a biennial basis, with the Stage 2 criteria by the end of 2011 and the Stage 3 criteria by the end of That said, we expect to see some early indication of Stage 2 requirements by end of 2010, based on the scheduled recommendations to CMS from the HIT Policy Committee formed as part of the stimulus legislation to advise CMS on meaningful use of EHRs. And, in the meantime, we already know several Stage 2 requirements as highlighted in the final rule for Stage 1 of meaningful use, including that all the menu objectives will be considered mandatory in Stage 2, the performance bar on all Stage 1 requirements will go up significantly, and providers will be required to actively exchange information, not just test for the exchange capability. Do you anticipate that stage 2 CPOE requirements will apply solely to medications or to all orders? The final rule explains that the purpose behind lowering the threshold and limiting the scope of the Stage 1 CPOE requirements was to allow all hospitals to gain greater experience with CPOE, though CMS will expect greater use of the function in later stages. The rule indicates for stage 2, the threshold for CPOE use will rise to 60 percent: We are finalizing a Stage 2 measure for CPOE at 495.6(h) for EPs and 495.6(i) for eligible hospitals and CAHs as More than 60 percent of all unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) during the EHR reporting period have at least medication one order entered using CPOE. Though the language in the final rule limits the discussion of a Stage 2 CPOE measure to medication orders, Farzad Montashari, deputy national coordinator for programs and policy within HHS' Office of the National Coordinator for Health Information Technology, has indicated that "Everything that was in the proposed rule (NPRM), we intended it to be part of Stage 2," which would indicate that Stage 2 CPOE requirements will be expanded to all orders. 2 2 Conn, J. ONC's Mostashari defends meaningful-use regs, Modern Healthcare, July 16, 2010, available at: (accessed August 2, 2010).

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