When President Barack Obama put his signature to the American Recovery and Reinvestment Act—also known as ARRA, or “Stimulus #1”—on February 17, 2009, he also enacted legislation to accelerate the adoption of electronic health records across the United States: the Health Information Technology for Economic and Clinical Health, or HITECH, Act.

HITECH authorizes substantial payments to physicians, and to hospitals, if they 1) utilize a government-certified electronic health record (EHR) and 2) demonstrate that they are using that EHR in a manner that advances the quality of health care—the so-called meaningful use.

On July 13, 2010, the federal government issued final rules about requirements for eligible EHR systems and reporting criteria for clinicians to demonstrate their meaningful use of the EHR. The program officially began on January 1, 2011.

TABLE 1

The 3 stages of meaningful use of an EHR

Stage of use	What is the main goal of this stage?	By what will attainment of that goal be measured?
Stage 1	To capture and share data	By use of information in the EHR to track key clinical problems By communication, broadly and seamlessly, of key information to all care providers involved with the patient By reporting of practice-level quality measures
Stage 2	To exchange clinical data To advance electronically enhanced clinical processes	By use of the EHR for disease management and clinical decision support By management of drug interactions and allergies using the EHR By an increase in patients’ direct access to their EHR By demonstration of bidirectional electronic data sharing with public health agencies
Stage 3	To improve clinical outcomes	By demonstration of improvements in quality, safety, and efficiency By utilization of advance decision support within the EHR By development of patient self-management tools within the EHR By improvement in population and public health outcomes

TABLE 1 provides an overview of the three proposed stages of the HITECH Act. TABLE 2, page 10, is a timeline of the payment schedule for each year and stage of the HITECH program.

TABLE 2

Schedule of maximum government payments to a qualifying* physician

Year in which you begin meaningful use	What is the highest annual payment you can receive?
Year in which you begin meaningful use	2011	2012	2013	2014	2015	2016	Total payments
2011	Stage 1 $18,000	Stage 1 $12,000	Stage 2 $8,000	Stage 2 $4,000	Stage 3 $2,000	Stage 3 0	$44,000
2012		Stage 1 $18,000	Stage 1 $12,000	Stage 2 $8,000	Stage 3 $4,000	Stage 3 $2,000	$44,000
2013			Stage 1 $15,000	Stage 2 $12,000	Stage 3 $8,000	Stage 2 $4,000	$39,000
2014				Stage 1 $12,000	Stage 3 $8,000	Stage 3 $4,000	$24,000
2015					0	0	0
The schedule is “front-loaded”: The largest payments are made in the first 2 years of the program. Physicians receive payments based on when they start the program. The maximum payment that a physician can receive under the Medicare rules is 75% of the professional part B allowable charges you have submitted to Medicare in the calendar year. Example: To collect the full payment of $18,000 in 2011, you must submit $24,000 in allowable professional charges to Medicare. Physicians who practice in a health-care provider shortage area receive an additional 10% of their qualifying amount.
*“Qualifying” refers to those who 1) utilize a certified EHR, in 2) a meaningful manner, under 3) Medicare rules for the program

You must show “meaningful use” of your certified EHR

In the first year of the program, you must be using a certified EHR and must demonstrate meaningful use of that record over any 90-day period within the payment year (2011 or 2012).

In the second year, and beyond, the reporting period will be the entire calendar year.

Here are some of the initial rules for demonstrating meaningful use:

You can qualify for the program through either of two mechanisms: 1) participation in Medicare and 2) through Medicaid, if 30% or more of patient encounters are with Medicaid patients. Maximum reimbursements are $44,000 and $64,000 under the Medicare and Medicaid programs, respectively. Under Medicare rules (the more common way to achieve meaningful use), all physicians qualify (midlevel providers do not qualify). Under Medicaid rules, physicians, physician assistants, nurse midwives, and nurse practitioners qualify.
Through an Internet portal (yet to be established), you must register your EHR to determine if it is certified by the government
50% or more of your patient record documentation must be in a certified EHR
You need to report on 1) functional metrics related to your EHR and 2) clinical quality metrics
For functional metrics, there are 15 required core reporting measures and five optional measures that you select from a list of 10 items. Some of those measures include demonstrating that:

– at least 40% of your prescriptions are written electronically
– 80% or more of your patients have an active medication list
– 80% or more of them have a medication allergy list
– you perform medication reconciliation during at least 50% of your office visits
– you use clinical decision support and electronic alerts
– you record vital signs at 50% or more of encounters
– 10% or more of your patients have access to their EHR through an Internet portal
– you can exchange electronic data with a physician who is not in your organization
– you submit immunization reports to a public health department through your EHR.

Fortunately, if you attest that any core reporting measure is not clinically relevant to your practice, you can delete it from your list.

For clinical quality metrics, you must select six of 44 dimensions of care for reporting purposes, including three core measures and three alternate measures
Physicians who work only with hospitalized patients and do not have an outpatient practice—for example, internal medicine hospitalists and ObGyn laborists—are, currently, ineligible
If you bill Medicare with point-of-service codes 21 and 23 for more than 90% of your patients, you are ineligible for this program
You will be paid within 46 days of attesting to meaningful use of the EHR. Payments will be made to your billing entity’s taxpayer identification number.

Then, there are the penalties

What government program doesn’t have hidden penalties? Physicians who do not demonstrate meaningful use of a certified EHR by 2014 will be hit with a 1% reduction in their Medicare fees every following year from 2015 to 2017—and, potentially, after that. The penalty reduction may increase to 2%, annually, if less than 75% of US physicians adopt an EHR.

A transforming event in health care. Maybe.

EHRs generally improve the coordination of health care. At times, however, they can be burden-some—to clinicians and to patients. Furthermore, development of a national grid of interoperable medical records, with oversight by government agencies, subtly changes the relationship between the patient and her physician and increases the power and authority of large health systems, insurers, and government agencies to shape the future of health care.

The prediction among health care experts who are optimists is that HITECH will stimulate rapid adoption and interoperability of EHRs in the United States. In turn, such development of a nationwide system of health records will improve the quality and efficiency of care. They view the HITECH Act, and its consequences, as truly revolutionary.

The pessimists among us have quipped that, if you and your life partner decided to have children because your main goal was to be eligible for the IRS child tax credit, then you will really like HITECH.

The reality? It’s likely found midway between those two extremes of anticipation.

Regardless: Whether you’re optimistic or pessimistic about HITECH, you must decide whether you will participate; optimally, you need to make that decision this year. The accompanying sidebar, “A ‘meaningful use’ how-to-guide”, walks you through the steps of the program in detail.

A “meaningful use” how-to guide for medical practices

#1 START THE LEARNING PROCESS

To see all the information that will be used for the EHR incentive program, start here: http://www.cms.gov/EHRIncentivePrograms/01_Overview.asp

#2 CHOOSE

Because the incentive is offered through two programs, choose the one that’s right for you

Medicare
Pros Meaningful use criteria are set and will not change over time.

Cons If you already receive e-prescribing incentives, you cannot also receive
Medicare EHR program incentives.

Medicaid
Pros There is no penalty if you choose not to participate. For this program, you must
demonstrate that you have adopted, implemented, or upgraded to certified
EHR technology in the first year, and become a meaningful user for at least
90 days in the second year. If you already qualify as a meaningful user of a
certified EHR, you will have to show meaningful use for 90 days in the first year,
and for the whole year in succeeding years. If you are receiving e-prescribing
incentives for Medicare you can also receive EHR incentives for Medicaid.

Cons Not all states are participating. As of February 1, 2011, this program is an option
if you practice in Alaska, California, Iowa, Kentucky, Louisiana, Oklahoma,
Michigan, Mississippi, Missouri, North Carolina, North Dakota, South Carolina,
Tennessee, and Texas. Other states may decide to participate at a later date.
In addition, each state will be allowed to develop more meaningful use criteria than
are applied through the Medicare program, if they choose to.

#3 REGISTER

It all starts at: https://ehrincentives.cms.gov. Click “Continue” until you reach the login screen, where you enter your National Plan and Provider Enumeration System (NPPES) Web server account user ID and password (you must have an active National Provider Identifier [NPI] number to do this).

(If you do not have an account, click on the link to the NPPES Web site to establish one.)

After logging in, click on the “Registration” tab to begin the online registration process, which includes selecting the Medicare or Medicaid incentive program. (Online registration allows you to complete the process at one session or to come back at a later time to finish registration or to modify your information.)

You do not have to be using a certified EHR to begin the registration process. You must be using one to receive the incentive payment, however.

#4 ATTEST

To receive the incentive payment for a given year, you must “attest” that you meet the criteria. All the criteria are listed on the Center for Medicare and Medicaid Services (CMS) Web site at: http://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp.

To attest for the Medicare incentive payment, you must again log in to the registration site (listed above) and click on the “Attestation” tab. This tab will not be available until April 4, 2011, at the end of the first 90-day period. You will be asked to confirm each of the listed criteria by entering “Yes,” “No,” or “Exclusion (when allowed),” as applicable to each.

To attest for the Medicaid program, you must contact each participating state. The best way to do this is to search the Web, using the search parameter: “[state name] EHR incentive program”. For example, searching this way for the Alaska program brings up the Web site: http://ak.arraincentive.com. Some states have set up online attestation questionnaires; others have indicated that they will contact providers who have registered nationally.

#5 REPORT QUALITY MEASURES

Your work isn’t done when you’ve completed the attestation step. For the Medicare program, you must also report six clinical quality measures abstracted from the EHR. These measures are submitted by the certified vendor, but you must make certain you have reported them in your EHR record.—Melanie Witt, RN, CPC, COBGC, MA

Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.

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