FAQ on HITECH, Meaningful Use, Eligible Providers, and the Stimulus Money

NOTE: Read my latest post on how to register and attest for the EHR Incentive Programs here.

Where Did the Idea of Meaningful Use of Electronic Medical Records Come From?

The American Recovery and Reinvestment Act of 2009 was signed by President Obama on February 17, 2009.  The Law includes the Health Information Technology for Economic and Clinical Health Act or the HITECH Act.  The HITECH Act establishes programs under Medicare and Medicaid to provide incentive payments for the Meaningful Use of Certified Electronic Health Records technology.

The goal of the HITECH legislation is to improve healthcare outcomes, to facilitate access to care and to simplify care.  It is believed that the installation of electronic health records in medical practices is only the beginning.  The goals of HITECH will be met when the EHR is used in a meaningful way.

What is Meaningful Use (MU)?

There are three  identified components of Stage I Meaningful Use.  They are:

  1. Use of a certified EHR in a meaningful manner such as e-prescribing.
  2. Use of Certified EHR Technology for the exchange of health information (exchange data with other providers of care or business partners such labs or pharmacies)
  3. Use of Certified EHR Technology to submit clinical quality and other measures.

The first stage of Meaningful Use is capturing and sharing the data.  Meaningful Use Stage II is advanced clinical processes and Stage III is starting to look Meaningful Use of an EHR in the context of improved healthcare outcomes.

There are 25 specific criteria for MU Stage I listed in this article in Healthcare IT News:

[1] Objective: Use CPOE (Computerized Physician Order Entry)
Measure: CPOE is used for at least 80 percent of all orders

[2] Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP (Eligible Provider) has enabled this functionality

[3] Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.

[4] Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

[5] Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.

[6] Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.

[7] Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

[8] Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

[9] Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded

[10] Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

[11] Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.

[12] Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

[13] Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over

[14] Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.

[15] Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP

[16] Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP.

[17] Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

[18] Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information

[19] Objective: Provide clinical summaries to patients for each office visit.
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits.

[20]  Objective: 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.
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

[21] Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

[22] Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.

[23] Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries.

[24] Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).

[25] Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: 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.

Have the Details of MU been finalized?

The comment period for the NPRM (Notice of Proposed Rule Making) for Meaningful Use is currently open but will close on March 15, 2010. You can read the NPRM here.  Many individuals and organizations have expressed concern that the timeline for implementing EHR and meeting MU criteria is too short for the majority of providers. The American Academy of Family Physicians (AAFP) recently sent a 7-page letter to acting CMS Administrator Charlene Frizzerathat included the following concerns:

  1. The administrative burden of reporting computerized physician order entry measures “is excessive to the point of being unachievable for most eligible providers.”
  2. The rule could require manually entering results from laboratories that don’t have an interoperable interface with the physician’s electronic health record.
  3. The term “health information” is used throughout the proposed rule, but is never defined.
  4. A requirement that a patient’s health information be shared with that patient within 48 hours doesn’t take in account that physicians or their staff may not be able to process the information if that 48-hour period includes weekend days.
  5. There is no incentive for physicians who meet less than 100% of the proposed requirements, so it is an all-or-nothing approach.

The Medical Group Management Association recently surveyed (see Modern Healthcare story here) 445 physician practice administrators in February 2010 with the following feedback:

  1. Nearly all are aware of the upcoming incentive programs for meaningful use of electronic health records, but fear the programs will reduce physician productivity.
  2. 68% of respondents expect physician productivity will decrease if all 25 proposed meaningful use criteria are implemented.
  3. Nearly one-third believe the decrease in productivity will be greater than 10 percent.
  4. Almost 25% of practices without an EHR doubt some of their providers will ever attempt to qualify for incentives.
  5. Among practices with an EHR, nearly 84 percent believe some of their physicians will attempt to qualify for Medicare or Medicaid incentives by the end of 2011.

How Do I Comment on the MU Standard?

You can submit your comments on the NPRM on MU here.

You can read comments already submitted here.

How Do I Know if My EHR is Certified?

No EHRs have been certified for the CMS Incentive Program and the certifying bodies have not yet been announced.  It seems reasonable that CCHIT will be one certifying body, but there are expected to be others.  If your vendor tells you that his EHR is certified before the rule has been finalized and the certifying bodies have been announced, ask him “For what?”

What Does it Mean to Be Eligible? (description courtesy of Everything HITECH)

This term encompasses three general types of payers to establish eligibility: 1) Medicare Fee For Services (FFS), 2) Medicare Advantage (MA) and 3) Medicaid.

For hospitals to be eligible, they can be acute care (excluding long term care facilities), critical access hospitals, children’s hospitals.

For providers, these include non-hospital-based physicians who receive reimbursement through Medicare FFS program or a contractual relationship with a qualifying MA organization. The Act defines the term “hospital based” eligible professional to mean an EP such as a pathologist, anesthesiologist,or emergency physician, who furnishes substantially all of his or her Medicare covered professional services during the relevant EHR reporting period in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospital’s qualified EHR’s (Fed Reg p. 1905). The determining factor is the site of service as to whether the service is hospital based or not. If the EP provides at least 90 % of their services in a hospital inpatient, hospital outpatient or hospital emergency room setting (Point of Service codes 21, 22, 23), then they are considered a hospital based EP and not eligible for EHR incentive payments (i.e. providing substantially all of his or her Medicare covered professional services).

There is a difference between Medicare and Medicaid when it comes to defining an eligible professional for EHR incentive payment purposes. Medicare defines an eligible professional as (Fed Reg p. 1996):

 

  1. doctor of medicine or doctor of osteopathy
  2. doctor of dental surgery or dental medicine
  3. doctor of podiatric medicine
  4. doctor of optometry
  5. chiropractor

Medicaid, on on the other hand, defines an eligible professional as (Fed Reg p. 2001):

  1. physician
  2. dentist
  3. certified nurse-midwife
  4. nurse practitioner
  5. physician assistant practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic, led  by a physician assistant.

What are the Guidelines for Providing Patients With Their Medical Records Electronically?

Under HIPAA, patients currently have the ability to access their medical records.  Meaningful Use does not change HIPAA in that regard.  You may charge patients for the expense related to providing paper or electronic medical records.  Each state has its own schedule for charging for medical records (state-by-state schedule here.)

Do Eligible Providers Have to be Participating With Medicare to Receive the Incentive Money?

No, the eligibility requirements only relate to the benchmarks for the percentage of Medicaid patients you have, or amount of allowed Medicare charges you have.

Can Eligible Providers Work at Locations Other Than Hospitals and Private Practices and Receive the Incentive Money?

The location where the provider works is not the issue.  The issue is whether or not the provider meets the requirements, either for Medicare or Medicaid, to be considered eligible for the program.

It doesn’t matter where the provider accesses the certified EHR.  If they meet the eligibility criteria, and they are using a certified EHR, they can collect on the stimulus money.

What Are Health Provider Shortage Areas?

Physicians practicing in determined “health provider shortage” (detailed info here) areas will be eligible for a 10% bonus payment.

How Does This Incentive Relate to ePrescribing or PQRI?

If the PQRI Program is extended in its current form, practices can participate in both PQRI and an EHR Incentive Plan.

If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously.  If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously.

Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR!

How Do EPs Get Paid For Meaningful Use of a Certified EHR?

For the first payment year only, all an EP or hospital has to do is to be a “meaningful user” for a continuous 90-day period during the payment year. Hospitals’ payment year is October 1 to September 30 and EPs’ payment year is the calendar year.  You must start and complete the 90-day period within the payment year with no overlapping.

 

Also, if  you can qualify as a Medicaid Eligible Provider (or Hospital), are in the process of adopting, implementing or upgrading your EHR  and your Medicaid patient volume is at least 30% (Pediatricians only need 20% minimum and Hospitals need 10% minimum), you can collect your incentive money without meeting Meaningful Use criteria.

Attestation forms and forms of other types are most likely the way that EPs will provide information to apply for the incentive funds, although the details have not yet been released.

What Does it Mean to Transition From One Program (Medicaid or Medicare) to Another?

EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs will be able to participate in only one program, and will have to designate which one they would like to participate in.  After their initial designation, EPs are allowed to change their program selection only once during payment years 2012 through 2014.


To Recap:

How Do I Get My EHR Stimulus Money?

  1. Decide whether you are an eligible provider for any of the programs.
  2. If you are, buy a certified EMR (once certification has been defined.)
  3. Use your EMR in a way that demonstrates your meaningful use of the product.
  4. Pass “GO” and collect your money.

ARRA (Stimulus Bill) Acronyms

”¢ A/I/U ”“Adopt, implement or upgrade
”¢ CAH ”“Critical Access Hospital
”¢ CCN ”“CMS Certification Number
”¢ CDS ”“Clinical Decision Support
”¢ CMS ”“Centers for Medicare & Medicaid Services
”¢ CY ”“Calendar Year
”¢ EHR ”“Electronic Health Record
”¢ EP ”“Eligible Professional
”¢ eRx ”“E-Prescribing
”¢ FFS ”“Fee-for-service
”¢ FY ”“Federal Fiscal Year
”¢ HHS ”“U.S. Department of Health and Human Services
”¢ HIT ”“Health Information Technology
”¢ HITECH Act ”“Health Information Technology for Electronic and Clinical Health Act
”¢ HITPC ”“Health Information Technology Policy Committee
”¢ HIPAA ”“Health Insurance Portability and Accountability Act of 1996
”¢ HPSA ”“Health Professional Shortage Area
”¢ IFR ”“Interim Final Rule
”¢ MA ”“Medicare Advantage
”¢ MCMP ”“Medicare Care Management Performance Demonstration
Ӣ MITA-Medicaid Information Technology Architecture
”¢ MU ”“Meaningful Use
”¢ NPI ”“National Provider Identifier
”¢ NPRM ”“Notice of Proposed Rulemaking
”¢ OMB ”“Office of Management and Budget
”¢ ONC ”“Office of the National Coordinator of Health Information Technology
”¢ PQRI ”“Medicare Physician Quality Reporting Initiative
”¢ Recovery Act ”“American Reinvestment & Recovery Act of 2009
”¢ TIN ”“Taxpayer Identification Number

For more information who is eligible and for how much, read my post ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?”

Posted in: Electronic Medical Records, Headlines, Medicare & Reimbursement

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19 Comments

  1. James July 13, 2010

    What if I already have an EHR in place. What happens if it is not “certified” and I have already spend $$$$.

  2. Mary Pat Whaley July 13, 2010

    Hi James,

    Agencies are just now applying to become eligible to test EHRs and rate them certified through a temporary program. Therefore, you don’t really know if your EHR is certified or not. You might be surprised that your EHR will either become certified or your vendor will make the necessary changes to make it qualify for certification.

    Best wishes,

    Mary Pat

  3. Gina LeBlanc November 5, 2010

    Mary,
    If a medical practice does not have a Medicare or Medicaid patient volume of 30%, can we still qualify for the incentive program by only showing meaningful use of our EHR?

  4. Mary Pat Whaley November 6, 2010

    Hi Gina,

    To be eligible for the Medicaid incentive, 30% of the provider’s patient panel must be Medicaid patients. There is no percentage of patients necessary for Medicare; the incentive is directly related to the a percentage of allowed charges you billed Medicare in the previous period. So the answer is that for Medicaid, you will have to enough patients to qualify. For Medicare, you do not and the incentive you receive will be based on allowed charges submitted.

    Best wishes,

    Mary Pat

  5. David January 4, 2011

    Hi Mary,

    I have a private practice, but over 90% of the patients I see are hospital inpatients with very few follow up patients seen in the office.

    According to the eligibility rules, I would not be able to seek any incentives. So, does this also mean that I will not be penalized with a Medicare payment reduction in 2015 and beyond?

    Will I have the option to not participate in EHR technology since I see less then 10% of my patients in an office setting?

    Thank you,
    David

  6. Mary Pat Whaley January 5, 2011

    Hi David,

    CMS states that hospital-based EPs do not qualify for incentives, but I am not able to find anything from CMS that states that if you don’t qualify for the incentive you won’t be penalized for not using an EHR. The whole point of the program is to encourage physicians who can use EHRs to use EHRs and if your practice doesn’t use an EHR because you’re working in the hospital, I’m not sure that a penalty can be justified. Having said that, we are talking about CMS!

    Considering that you see most of your patients in the hospital, I think you’ll be able to opt out of using an EHR without any problem.

    If I see anything on this topic from CMS, I’ll publish it on Manage My Practice.

    Best wishes,

    Mary Pat

  7. Kindra February 3, 2011

    Mary,
    I can’t find anything regarding how to be excluded from being an Eligible Provider. For example, I am a physician who sees patients in my private practice. I don’t see patients in a hospital at all, so under my private practice, I would qualify as an EP. But, I don’t want to have to purchase a Certified EHR or participate in any of the reporting required as an EP to get the incentives. Do you have any information on options for exclusion from this?
    Thank you for your time.
    Kindra

  8. Mary Pat Whaley February 4, 2011

    Hi Kindra,

    To the best of my knowledge, you do not have to apply for exclusion. You will not receive the bonus, however, you may receive a reduced payment from Medicare if and when they require meaningful use of an EHR to receive full Medicare reimbursement.

    Best wishes,

    mary Pat

  9. Ricki Holm March 2, 2011

    Hi There,

    I Noticed some doctors wanted to opt out of meaningful use so they dont have to purchase certified EHR’s. Remember in certain states like MA, physicians who have not adopted a certified EHR in in their practices will NOT be abe to RENEW MEDICAL LICENSES after 2015.

    There is a much bigger picture here than just MEANINGFUL USE/ PQRI

    Thanks
    Ricki

  10. Daniel April 1, 2011

    When you speak about meaningful use/incentives for Medicare and medicaid. How to we categorize Patients billed under the Managed Medicare and medicaid programs. 99% of my patients are “Managed”.
    Thanks

  11. Mary Pat Whaley April 20, 2011

    Hi Daniel,

    I apologize for the delay in answering, but I’ve been looking for something absolutely definitive in writing to point you to and I haven’t found it – maybe another reader can point you to it. My understanding is that Medicare and Medicaid managed care patients count just the same as Medicare and Medicaid traditional-program patients, but I don’t have a reference for you.

    Best wishes,

    Mary Pat

  12. Wendy June 16, 2011

    My office is new to this EHR Meaningful Use Incentives program. How and when do we submit for this program?

    Thanks

  13. Mary Pat Whaley June 19, 2011

    Hi Wendy,

    Check out HITECHAnswers (http://www.hitechanswers.net/) for comprehensive information – membership in their resource center is free for eligible providers.

    Best wishes,

    Mary Pat

  14. Tricia December 20, 2011

    Our office participated in MU, PQRI and submitted the eRx code for Medicare this year. Our providers are now wondering if they WILL NEED TO do all three for 2012 as well? I’ve been researching for them but it is so confusing and mainly stating monies and penalties instead of what we’re looking for. Is there a definitive place that states we can participate in only one instead of reporting in two or all three?

  15. Mary Pat Whaley December 23, 2011

    Hi Tricia,

    For 2012, there is no eRx bonus, and if you e-prescribed last year, you are avoiding the eRx penalty this year.

    You can attest again for the EHR Stimulus money under Stage 1 in 2012.

    PQRS (what PQRI is now called) is still available for 2012.

    For 2012, you can do two of the three – great job!

    Best wishes,

    Mary Pat

  16. Tammy February 15, 2013

    Good day,

    One of the docs is interested to participate in the Medicaid Incentive Program. We already completed 2011 Medicare EHR Incentive Program. We have 9 docs and 2 NPs in the practice of Nephrology.

    Here’s the question: They also see Medicaid primary and Medicaid secondary hemodialysis patients at 4 dialysis units. These units do not have an EMR system. after the docs/NPs see the patients they note the visit on capitations sheets. We then enter the charges into our EMR system in our practice and charges are sent to Medicaid. Can the still docs still participate in the Medicaid Incentive Program?

    I have been on the CMS website and googled. I don’t see anything that pertains to what our docs do.

    I would appreciate any information you can share.

    Thank you for time.

    Tammy

  17. Mary Pat Whaley February 17, 2013

    Hi Tammy,

    Do the nephrologists document the visit in the EMR?

    I found a May 2012 letter from Ruben L. Velez, MD, the President of the Renal Physicians Association to Marilyn Tavenner at CMS saying:
    “Most importantly, we urge CMS to address the significant obstacle uniquely facing nephrologists in their efforts to participate in meaningful use. In short, due to the structure of the end-stage renal disease (ESRD) monthly service codes and the meaningful use program’s “50% rule”, nephrologists are required to duplicate virtually all of their documentation to demonstrate meaningful use. As such, RPA urges CMS to address this issue so that providers of care to the approximately 400,000 Medicare beneficiaries with ESRD can participate in the meaningful use program.”

    It sounds that as long as the nephrologists document in their EMR, regardless of the fact that the service was provided elsewhere, those services are eligible to be a part of meaningful use.

    Best wishes,

    Mary Pat

  18. Joanna February 12, 2014

    Our Endocrinology practice (5 doctors) completed attestation for full (2013)year stage 1 this January. We are adding additional doctor this year, his first day will be July 21, according to CGM I have to complete his attestation for 90 days before October 1 , I am not sure if he will be ready (it give us only 99 days total) , is he eligible for exclusion? And what do I do when the rest of the doctors attest for stage 2 before October 1?
    Any advice? Thank you

  19. Mary Pat Whaley February 21, 2014

    Hello Joanna,

    Mary Pat forwards these questions on to us.

    Any provider attesting in their first year only attests for 90 days. Given that Stage 2 starts in 2014, ALL providers attest for a 90 day period again.
    Per your questions above. I am not sure what was exactly communicated to you, but October 1 is NOT the date you have to complete attestation by. October 3, 2014 is the LAST Day an Eligible Professional (EP) can begin a 90 day report period. 2014 is also the last year an EP can begin the program.

    Your new physician will only be required to meet Stage 1 of Meaningful Use, whereas, your other physicians will meet Stage 2 requirements given they have already completed two years of Stage 1 requirements.

    Participation Timeline Link: http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Participation-Timeline.html#.UwfBh4XIvWE

    You may want to refer to this link as well: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/HIT-Programs-Timeline-2012-.pdf

    There is no eligibility for exclusion. If a provider is participating with Medicare, they will have to comply otherwise they will receive an adjustment in their Medicare reimbursement in 2015.

    As far as your other physicians, they will all attest for a 90-day period again to coincide with calendar quarters, although they will have to comply with new Stage 2 requirements, as will ALL providers that attest in 2014.

    You may also want to reference this Stage 2 link: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html

    In order for your new physician not to have a payment adjustment in 2015, he would have to attest by October 1, 2014, but that does not mean he cannot attest the last quarter of 2014. If he was unable to attest until October 3, 2014, he would receive a 1% payment adjustment in 2015. If he continued with attestation in 2015, the adjustment would go away in 2016.

    If you have further questions, please do not hesitate to contact me, or check-in on our Blog on our website which provides updated information along with our Twitter account and you can also sign up for our newsletter on our website at http://www.zetter.com.

    Good luck to you.

    Best regards,

    David
    djzetter@zetter.com
    __________________________________________________________________________________________________

    David J. Zetter, PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC
    161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
    Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855

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