Final rules for EHR incentive program allows some exceptions

September 1, 2010

Dermatologists may be able to breathe a sigh of relief over the final rules for the government's electronic health record (EHR) incentive program released July 13 - but only a small sigh. Although the rules are hardly light reading, understanding them and putting them into operation is essential to successful participation in the government's bonus payment program for EHRs.

Key Points

The final rules issued by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) explain how eligible professionals, which include physicians, can access a bonus of $44,000 from Medicare or $63,750 from Medicaid.

Implementing an EHR isn't enough to qualify for the bonus payments; the government requires eligible professionals to be meaningful users of a certified system. The recently released rule presented by CMS features the final criteria for meaningful use; ONC's announcement complements the criteria by establishing the framework for the process of credentialing EHR systems.

Most notable was the reduction in criteria from the 25 measures CMS proposed earlier. Steering away from its initial and unpopular "all-or-nothing" approach, CMS restructured the criteria into two buckets: 15 "core" - required - measurements and objectives, and five other criteria to choose from a menu of 10. Not only did CMS lower many - though not all - of the thresholds, the agency outlined exclusions to most of the criteria.

For the 13 of the 25 criteria that have exclusions, CMS designates narrow windows for physicians to report that the objective or measure does not apply to them because "They have no patients, or no or insufficient number of actions that would allow calculation of the meaningful use measure." For example, a physician who has no patients age 65 or older or age 5 or younger would not have to meet the requirement to send an appropriate reminder to 20 percent or more of all patients in those age groups during the EHR reporting period.

Also of some comfort to dermatologists is that CMS lowered thresholds for many of the meaningful use measures. For example, the measurement for electronic prescribing will be for more than 40 percent of all permissible prescriptions written by the physician to be transmitted electronically using certified EHR technology. CMS backed off from its initial proposal setting the minimum e-prescribing threshold at 75 percent of all permissible prescriptions.

The 15 core criteria, presented in an abbreviated format, are:

1. Use computerized physician order entry (CPOE);

2. Implement drug-drug and drug-allergy interaction checks;

3. Generate and transmit permissible prescriptions electronically;

4. Record demographics;

5. Maintain an up-to-date problem list of current and active diagnoses;

6. Maintain active medication list;

7. Maintain active medication allergy list;

8. Record, chart changes in vital signs;

9. Record smoking status for patients age 13 or older;

10. Implement one clinical decision support rule;

11. Report ambulatory clinical quality measures;

12. Provide patients with an electronic copy of their health information, upon request;

13. Provide clinical summaries for patients for each office visit;

14. Demonstrate capability to exchange key clinical information;

15. Protect electronic health information.

Five additional criteria, of the provider's choosing, must be selected from a menu of 10 that include entering test results into an EHR as structured data, maintaining lists of patients with specific conditions, and submitting information to immunization registries electronically.

Eligible professionals will be required to report the numerator - for example, how many patients were provided with an electronic copy of their health information - and the denominator - how many patients made the request, and, if applicable, the basis for which they are seeking an exclusion.

CMS plans to issue additional guidance on how physicians will attest to these measures. It also plans to offer a secure, Web-based portal to register for the program and accept the attestation of meaningful use of a certified system.

Clinical quality measures

Eligible professionals seeking the incentive bonuses must report on six clinical quality measures: three required core measures and three additional quality measures selected from a menu of 38. The physician would be required to report up to three additional measures selected from the menu if he/she does not have an adequate population of patients suitable to the required measurements.

The three core measures are: Blood Pressure Management; Tobacco Use Assessment and Cessation Intervention; and Adult Weight Screening and Follow-up. More information about the quality measures is posted on the CMS website:http://www.cms.gov/QualityMeasures/03_ElectronicSpecifications.asp#TopOfPage.

Medicare vs. Medicaid

CMS sought to keep the requirements as similar as possible between Medicare and Medicaid, even though the bonus totals differ markedly.

Although the meaningful use criteria was confirmed to be the same for the two programs, professionals participating in the Medicaid program do not have to comply with meaningful use in the program's first year. Instead of attesting to meaningful use of certified EHR technology for a period of 90 days during the initial year of participation, the Medicaid incentive payment can be obtained by the eligible professionals demonstrating that they are "engaged in efforts to adopt, implement, or upgrade certified EHR technology." Although eligible professionals are exempt from the first year of the Medicaid incentive program, meaningful use may be more challenging. CMS granted the states the ability to add up to four additional criteria to the core.

While CMS clarified that the Medicare program will have five payment years, it also made clear that participation is on a consecutive basis. In other words, skip a year or fail to qualify that year, and that portion of the incentive payment is lost. A different rule, however, applies to the Medicaid EHR incentive program. Participants may skip a year and still garner the entire bonus payment. Eligible professionals participating in the Medicaid program also have longer to participate than Medicare participants: The last year a dermatologist may begin receiving payments is 2016, and the program continues through 2021.

CMS took other steps to encourage participation in the Medicaid incentive program. For example, eligibility determination for Medicaid requires that 30 percent or more of patient encounters - 20 percent or more for pediatricians - are Medicaid patients. Even having a Medicaid enrollee on the panel assigned to you (such as a managed care plan) will count. Plus, Medicaid can be a primary or secondary payer. Medicaid-eligible professionals must still annually reattest to meeting the patient volume thresholds.

By contrast, Medicare incentive participation is tied to 75 percent of Medicare-allowed charges. For example, a dermatologist who wants to capture the $18,000 bonus offered in the program's first year (2011) must bill $25,000 in Medicare-allowed charges that year.

CMS even allows some alternatives in how a Medicaid incentive participant calculates patient volume. It sets out criteria that will allow clinics and group practices to apply the practice or clinic Medicaid patient volume to all physicians in the practice.

All of this hinges on using an EHR that meets the implementation specifications and certification criteria established by the ONC, which also issued its final rule in July. ONC anticipates certifying the first EHR in the program by fall 2010.

For those eyeing the Medicare incentives, it pays to get prepared. Only 90 consecutive days of meaningful use is required in 2011. It is possible to begin the meaningful use process in 2012, but those doing so must meet the use and quality reporting criteria for the full year.

In other words, time is running short.

INCENTIVE ELIGIBILITY

Eligible professionals for the Medicare EHR incentive program:

Eligible professionals for the Medicaid EHR incentive program:

Elizabeth Woodcock is the principal of Woodcock & Associates and a speaker and writer specializing in practice management. Visit her website at http://www.elizabethwoodcock.com/.