The Hitech Act provided for incentives to eligible professionals (EP) and hospitals that have adopted Certified EHR Technology and can demonstrate that they are meaningful users of the technology.
HHS has published the proposed rule governing the criteria for me aningful use . The criteria for meaningful use will be finalized in 2010, following a 60 day comment period.
Extracts of key elements of the proposed rule follow.
Meaningful Use Criteria
In Stage 1 beginning in 2011, meaningful use criteria focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured), implementing clinical decision support tools to facilitate disease and medication management and reporting clinical quality measures and public health information. The rule specifies criteria for Stage 1 only and will be the criteria used for all payment years until updated by future rulemaking. It is intended as new criteria are established in 2013 and 2015, that the Stage 1 criteria is applied to the first payment year.
Stage 2, beginning in 2013, encourages the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pulmonary function tests and other data needed to diagnose and treat disease).
Stage 3, beginning in 2015 focuses on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.
Separately issued rules for HIPAA transactions and code sets and e-Prescribing are incorporated into the meaningful use criteria
Under HITECH, an EP or eligible hospital is considered a meaningful EHR user if they (1) demonstrate use of certified EHR technology in a meaningful manner, (2) demonstrate that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care such as promoting care coordination and (3) using its certified EHR technology submits information on specified clinical quality measures and other measures.
For Medicaid incentives in the initial payment year, the EP or eligible hospital may demonstrate that they have engaged in efforts to adopt, implement or upgrade certified EHR technology. For Medicaid incentives in subsequent payment years, they must demonstrate that they are meaningful users of the certified EHR technology, in a similar manner to the criteria under Medicare, but with states having the option to add additional objectives or to modify how the existing objectives are measured.
Each meaningful use objective must be satisfied by an individual EP as determined by unique National Provider Identifiers (NPIs) and an individual hospital as determined by unique CMS certification numbers (CCN).
1. Health outcomes policy priority: Improve quality, safety, efficiency and reduce health disparities
Starting in 2011, to be a meaningful user, EPs and eligible hospitals will be required to use certified EHR technology to capture the data elements and calculate the results for the applicable clinical quality measures. EPs and eligible hospitals must demonstrate that they have satisfied this requirement during the EHR reporting period for 2011 through attestation.
Medicare EPs and eligible hospital attest to the accuracy and completeness of the numerators and denominators for each of the applicable measure. EPs and eligible hospitals must demonstrate their use of certified EHR technology to capture the data elements and calculate the results for the applicable clinical quality measures by reporting the results to CMS for all applicable patients.
For the Medicaid incentive program, States may accept provider attestations in the same manner to demonstrate meaningful use in 2011. However, we expect that Medicaid providers will qualify for the incentive payment by adopting, implementing, or upgrading to certified EHR technology, and therefore; will not need to attest to meaningful use of EHRs in 2011, for their first payment year.
Final detailed specification documents for all 2011 Medicare incentive-related clinical quality measures will be posted on the CMS website April 1, 2010
For 2011 and 2012 EHR reporting periods, most quality measures are already documented through PQRI or NQF. The following quality measures are proposed with each measure associated with core/specialty measure group(s)
measures and the subset of clinical measures most appropriate given the EPs specialty.
Core measures include 1) preventive care and screening: inquiry regarding tobacco use, 2) blood pressure measurement, and 3) Drugs to be avoided in the elderly.
The second required measure set for each EP is to submit information on at least one of the sets of measures for specialty groups. The specialty groups are Cardiology, Pulmonology, Endocrinology, Oncology, Proceduralist/Surgery, Primary Care Physicians, Pediatrics, Obstetrics and Gynecology, Neurology, Psychiatry, Ophthalmology, Podiatry, Radiology, Gastroenterology, and Nephrology.
The denominator of clinical quality measures and the applicability of a measure is determined by the patient population to whom the measure applies and the services rendered by the particular EP.
Clinical Quality Measures for Electronic Submission by Eligible Hospitals will be required to report summary data to CMS on the set of clinical quality measures including
Medicare EPs and eligible hospitals would be required to report the required clinical quality measures information electronically using certified EHR technology via one of three methods.
For CY 2011 and FY 2011, EPs and eligible hospitals demonstrate that they satisfy each of the proposed meaningful use objectives through attestation. For payment years beginning in CY and FY 2012 and subsequent years, EPs and eligible hospitals demonstrate that they satisfy each of the proposed quality measures through electronic reporting and the remainder through attestation.
Incentive payments for EPs
Incentives will be made at the EP level, not at the group practice level. EPs that change practices may continue their incentive payments at their new practice. EP's that no longer qualify for Medicaid incentives due to such a change, may elect a one-time change to the Medicare program.
Administrative data to be collected
Hospital-based Professionals are not eligible for the Medicare incentive payments. Most are also not eligible for Medicaid, unless they practice predominantly in an FQHC or RHC. A Professional is considered hospital-based if substantially all (90%) of the professional services are in the inpatient or outpatient hospital settings, based on the place of service (POS) codes on physician claims.
Stage 1 meaningful use criteria for eligible hospitals apply to the hospital's inpatient setting only.
If a Medicare FFS or MA EP receives an incentive payment from the Medicare EHR incentive program, the EP (or group practice) is not eligible to also receive the incentive payment under the E-prescribing Incentive Program created by MIPPA. EPs receiving a Medicaid EHR incentive payment would remain eligible for the Medicare MIPAA E-Prescribing Incentive Program payment.
An Eligible Professional is one of five types of professionals, each of which must be legally authorized to practice their profession under state law: 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.
Medicare Compensation for EP's
For EPs working with more than one practice, the EP selects one tax identification number to receive the applicable EHR incentive payment.
EP Services in Geographic Health Professional Shortage Area (HPSA)
EPs that provide service in designated HPSA's are entitled to an increased incentive payment limit of 10 percent per year. EP's that provider more than 50% of their service in an HPSA (for claims submitted within 60 days of calendar year-end) and otherwise meet the meaningful use requirements are entitled to the increased incentive payment.
EP Payment Adjustments
These adjustments (penalties) start in 2015 for EPs who are not Meaningful Users of Certified EHR Technology. Beginning in 2015, if an EP is not a meaningful EHR user for any EHR reporting period for the year, then the Medicare physician fee schedule is adjusted by the applicable percent': “(I) for 2015, 99 percent (or, in the case of an EP who was subject to the application of the payment adjustment if the EP is not a successful electronic prescriber under section 1848(a)(5) for 2014, 98 percent);” “(II) for 2016, 98 percent; and (III) for 2017 and each subsequent year, 97 percent.” In addition, if for 2018 and subsequent years the Secretary finds that the proportion of EPs who are meaningful EHR users is less than 75 percent, the applicable percent shall be decreased by 1 percentage point from the applicable percent in the preceding year, but in no case shall the applicable percent be less than 95 percent. There is a significant hardship exception which cannot exceed 5 additional years.
The hospital payment methodology starts with an initial amount calculated as a base amount ($2 million) and adds a discharge related amount based on the number of discharges for the period ($200 for discharges from 1,150 up to 23,000 discharges). The initial amount is then multiplied by the Medicare Share and an applicable transition factor to determine the incentive payment for an incentive payment year.
Adjustments to the market basket update to the IPPS payment rate will be made for hospitals that are not meaningful users by 2015.
Qualifying Medicare Advantage Eligible Professional
A qualifying MA organization may receive an incentive payment for EP's that are employed by the qualifying MA organization; or are employed by, or be a partner of, an entity that through contract with the qualifying MA organization furnishes at least 80 percent of the entity's Medicare patient care services to enrollees of the qualifying MA organization. Further, the EP must furnish at least 80 percent of his or her professional services covered under Medicare to enrollees of the qualifying MA organization and must furnish, on average, at least 20 hours per week of patient care services during the EHR reporting period.
The payment rules for MA organizations are beyond the scope of this article.
Medicaid Program Participation A “Medicaid EP” is a Medicaid professionals including : physicians, dentists, certified nurse-midwives, nurse practitioners, and physician assistants practicing in an FQHC or RHC that is so led by a physician assistant. Additionally, to qualify for incentives, most Medicaid EPs cannot be hospital-based, unless practicing in an FQHC or RHC. Medicaid EPs must also meet the patient volume thresholds or practice predominantly in an FQHC or RHC. Medicaid EPs must have at least 30 percent patient volume attributable to those who are receiving Medicaid (20 percent for pediatricians).
Acute care hospitals and separately certified children's hospitals are eligible under the Medicaid program if they have at least 10% of Medicaid patient volume, but not long-term care facilities (where the average length of patient stay is greater than 25 days).
Calculation of the 30 percent of all patient encounters is attributable to needy individuals over any continuous 90-day period within the most recent calendar year prior to reporting. Needy individuals include: (1) they are receiving medical assistance from Medicaid or the Children's Health Insurance Program (CHIP); (2) they are furnished uncompensated care by the provider; or (3) they are furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay.
Medicaid EPs may voluntarily assign payments to entities promoting EHR technology so long as the assignee does not retain more than 5 percent of the Medicaid incentive payments for costs unrelated to certified EHR technology. Health information exchanges are one example of such entities and have the potential to transform the healthcare system by facilitating timely, accurate, and portable health information on each patient at the point of service. HIEs provide the capability to move clinical information electronically between disparate health care information systems while maintaining the meaning of the information being exchanged. HIEs also provide the infrastructure for secondary use of clinical data for purposes such as public health, clinical, biomedical, and consumer health informatics research as well as institution and provider quality assessment and improvement, where permissible under HIPAA and other requirements included in the HITECH Act. In addition, use of health information exchange models can reduce the need for costly point-to-point interfaces between different EHR tools, as used in laboratories and pharmacies, thus providing a more scalable model of interoperable health information exchange. HIEs promote adoption of certified EHR technology by providing the infrastructure for providers' EHRs to reach outside of their clinical practice sites and connect with other points of care. Providers report that having a more complete picture of their patients' healthcare data from other providers and care settings is one of the primary appeals to using EHRs. Without health information exchange, electronic health records are simply digitized filing cabinets and will not achieve their quality of care or cost containment potential. Furthermore, given the proposed definition of meaningful use, HIEs can significantly help Medicaid providers adopt and use EHR in such a way that the goals of the incentive program are met. The inclusion in HITECH of HIE grants to be awarded to States or State-designated Entities by ONC are an additional indication of the symbiotic relationship between health information exchanges and optimal use of EHRs.
Unlike the Medicare incentive programs, the Medicaid program allows eligible providers to receive an incentive payment even before they have begun to meaningfully use certified EHR technology. These providers may receive a first year of payment if they are engaged in efforts to “adopt, implement, or upgrade” to certified EHR technology.
“Implement” means that the provider has installed certified EHR technology and has started using the certified EHR technology in his or her clinical practice. Implementation activities would include staff training in the certified EHR technology, the data entry of their patients' demographic and administrative data into the EHR, or establishing data exchange agreements and relationships between the provider's certified EHR technology and other providers, such as laboratories, pharmacies, or HIEs.
“Upgrade” means the expansion of the functionality of the certified EHR technology, such as the addition of clinical decision support, eprescribing functionality, CPOE or other enhancements that facilitate the meaningful use of certified EHR technology.
A Medicaid EP would not need to demonstrate that it has adopted, implemented, or upgraded certified EHR technology in year one of the program, if they can already demonstrate meaningful use of such technology.
Estimates of Meaningful Use Adoption by EPs - Medicare
Estimates of Meaningful Use Adoption by EPs - Medicaid