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Are you in line to receive your EHR stimulus?

CMS has proposed 25 “meaningful use” criteria for eligible providers to meet if they hope to receive an incentive payment

May 2010 · Vol. 22, No. 05

The Center for Medicare and Medicaid Services (CMS) has finally come around to defining “meaningful use” of electronic health records (EHR) under the American Recovery and Reinvestment Act of 2009, better known as the federal stimulus plan. Only providers who meet meaningful use criteria will be eligible to receive the incentive payment for implementing EHR. That incentive is significant, totaling as much as $44,000 per physician from Medicare or $64,000 from Medicaid—provided you derive at least 30% of revenue from the Medicaid program.

What do you have to do to get your incentive?

It’s no small feat. CMS has proposed 25 criteria for “meaningful use” (TABLE), with five overarching priorities. You must:

  • improve quality, safety, and efficiency and reduce health disparities
  • engage patients and their families in their health care
  • improve the coordination of care
  • improve population and public health
  • ensure adequate privacy and security protections for personal health information.

The individual criteria for Stage 1 of EHR implementation include using computerized provider order entry (CPOE) on at least 80% of orders, transmitting at least 75% of all permissible prescriptions electronically, and meeting five specialty-specific measures of quality.

TABLE

CMS proposes 25 criteria for “meaningful use” of EHRs

Priority

Stage 1 criterion

Proposed measure

Improve quality, safety, and efficiency and reduce health disparities

Use computerized provider order entry (CPOE)

Use on at least 80% of orders

Implement drug-drug, drug-allergy, and drug-formulary checks

Enable the function

Maintain an up-to-date list of current and active diagnoses based on ICD-9-CM or SNOMED CT

Record an entry for at least 80% of unique patients or indicate its absence

Generate and transmit permissible prescriptions electronically (eRx)

Transmit at least 75% of all permissible prescriptions electronically using certified EHR technology

Maintain an active medication list

Record at least one entry for at least 80% of unique patients or indicate “None”

Maintain an active medication allergy list

Record at least one entry for at least 80% of unique patients or indicate “None”

Record the following demographics:

  • preferred language
  • insurance type
  • gender
  • race and ethnicity
  • date of birth

Enter demographics as structured data for at least 80% of unique patients

Record and chart changes in the following vital signs: height, weight, and blood pressure. Calculate and display body mass index (BMI) for ages 2 and over. Plot and display growth charts for children 2–20 years, including BMI

Record blood pressure and BMI for at least 80% of unique patients age 2 and older. Plot a growth chart for at least 80% of unique patients 2-20 years old

Record smoking status for patients 13 years and older

Record smoking status for at least 80% of unique patients 13 years and older

Incorporate clinical lab-test results into EHR as structured data

Incorporate at least 50% of all clinical lab test results whose results are in positive/negative or numerical format

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach

Generate at least one report listing patients with a specific condition

Report ambulatory quality measures to CMS (or, for eligible professionals seeking the Medicaid incentive payment, to the States)

For 2011, provide the aggregate numerator and denominator through attestation as described in the proposed rule. For 2012, electronically submit these measures

Send reminders to patients, according to their preference, for preventive/follow-up care

Send reminder to at least 50% of unique patients 50 years and older

Implement five clinical decision support rules relevant to the specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules

Implement five clinical decision support rules as described in the proposed rule

Check insurance eligibility from public and private payers

Check insurance eligibility electronically for at least 80% of unique patients

Submit claims electronically to public and private payers

Submit at least 80% of claims electronically

Engage patients and families in their health care

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies) upon request

Provide electronic record to at least 80% of patients who request it within 48 hours

Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the eligible professional

Provide electronic access to health information to at least 10% of patients

Provide clinical summaries for patients for each office visit

Provide clinical summaries to patients for at least 80% of office visits

Improve coordination of care

Ensure the capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results) among providers of care and patient-authorized entities electronically

Perform at least one test of the certified EHR’s capacity to electronically exchange key health information

Perform medication reconciliation at relevant encounters and each transition of care

Provide medication reconciliation for at least 80% of relevant encounters and transitions of care

Provide a summary of care record for each transition of care or referral

Provide a summary for at least 80% of transitions of care and referrals

Improve population and public health

Ensure the capability to submit electronic data to immunization registries, and submit such data where possible and accepted

Perform at least one test of the certified EHR’s capacity to submit electronic data to immunization registries

Ensure the capability to provide electronic syndromic surveillance data to public health agencies, and transmit such data according to applicable law and practice

Perform at least one test of the certified EHR’s capacity to provide electronic data to public health agencies (unless none of the relevant agencies have the capacity to accept such data)

Ensure adequate privacy and security protections for personal health information

Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities (and in compliance with the HIPAA Privacy and Security Rules and with fair sharing data practices outlined in the Nationwide Privacy and Security Framework)

Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary

ACOG and AMA object to criteria, timeline

After CMS defined meaningful use on December 30, 2009, the proposed criteria were opened to formal comments. The American Medical Association (AMA) submitted comments on March 15; ACOG and 94 other state and specialty medical societies signed on.

“The AMA is supportive of the widespread adoption and meaningful use of EHRs by physicians, but the Stage 1 criteria proposed by CMS are too aggressive,” said AMA Board Member Steven J. Stack, MD. “It could unreasonably punish physicians who undertake great efforts to achieve meaningful use of EHRs—only to be denied incentive payments due to overly complex and unattainable criteria.”

Albert L. Strunk, JD, MD, agreed. Dr. Strunk is Deputy Executive Vice President and Vice President of Fellowship Activities for ACOG.

“The intent of the American Recovery and Reinvestment Act of 2009 is to provide financial incentives through the Medicare and Medicaid programs to encourage doctors and hospitals to adopt and effectively use certified electronic health records,” Strunk noted in formal comments. “We are concerned that the Stage 1 criteria of the proposed rule are too numerous and the timeline too aggressive. We are further concerned that few obstetrician-gynecologists, especially those in small to mid-sized practices, will implement EHRs in their practice if these criteria are not modified. The costs associated with implementing an EHR in terms of dollars, productivity, and patient care are not outweighed by the benefits of incentive money.”

ACOG outlines 6 concerns

ACOG expressed specific concern in six areas.

Measurement of functionality thresholds. “CMS considered two methods for measuring the functionality thresholds—a count of the number of times an act was performed vs. a percentage showing the number of times an act was performed and not performed. CMS chose the percentage method and in doing so, administratively burdened the provider with excessive manual work. While an [EHR] can count the number of times a service was provided in the electronic system, it cannot count the number of times the service was done on paper. Reasonable providers should not be required to take time to manually calculate these process measurement percentages. Process measurements are not indicators of outcomes and not relevant to meaningful use.”

Electronic prescriptions. “The proposed rule does not take into account patient preference for paper scripts in order to shop for the lowest price. The rule also does not take into account the many times patients are given a prescription to have filled ‘just in case.’ Also, many areas of the country do not have the resources to support the electronic exchange needed for electronic prescribing… Eligible providers should not be required to report based on percentages.”

Patients’ access to their records. “ACOG supports providing patient health information electronically to the patient when requested. However, we are concerned that the 48-hour and 96-hour requirements to provide that information are more stringent than the 30-day requirement under HIPAA.”

Immunization registry. “With the advent of the HPV vaccine, some obstetricians are providing immunizations in their offices. However, most obstetrician-gynecologists do not provide immunizations to patients in their practices.… An interface to an immunization registry costs approximately $6,000. It is unreasonable to expect a practice that does not provide the service to have and test such an expensive capability.”

Need for a testing tool. “Many practices have had discouraging experiences with PQRI that have left them wondering if they should participate with another reporting initiative. Many practices thought they were reporting PQRI measures correctly to CMS but did not find out until long after the reporting period ended that they were reporting incorrectly. As a result, practices did not receive the money they were expecting, although they consistently reported measures. Providers need feedback in time to fix reporting errors. Therefore, it is recommended that CMS develop and make available to eligible providers and hospitals, a pretesting tool to ensure that providers are reporting effectively from the onset.”

Measurement of clinical quality. “Providers should not be required to meet all of the clinical measures currently identified in the meaningful use matrix, but rather only those measures which are applicable to their specialty and patient population. While the measures identified for obstetrics and gynecology may be appropriate for general obstetrician-gynecologists, they are not appropriate for maternal fetal medicine specialists, reproductive endocrinology and infertility specialists, and urogynecologists. In fact, these specialists will not report on any measures identified for ObGyn.”

What happens next?

CMS is reviewing comments and will issue a final rule in coming weeks. It remains unclear whether proposed criteria will be modified at that time.

Once Stage 1 criteria are finalized, they will take effect in 2011.

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