Although the federal economic stimulus package allocates billions of dollars to support health IT implementation, it remains to be seen whether the funding will improve health care quality or simply boost sales for health IT vendors, the Dallas Morning News reports.

Under the stimulus law, hospitals and physicians who demonstrate “meaningful use” of electronic health records can qualify for federal incentive payments.

The Obama administration contends that EHRs will allow physicians to better coordinate patient care, reduce medical errors and avoid duplicate testing. Medical errors alone cost the U.S. about $37.6 billion annually, according to the Institute of Medicine.

However, some advocates are concerned that health care providers will be unable to achieve the administration’s goals if meaningful use criteria tie stimulus funding to simply purchasing software.

They caution that such action could benefit health IT software companies at the expense of achieving interoperability and improved patient outcomes.

Conflict of Interest?

The federal stimulus package requires health care providers to purchase certified EHR systems to qualify for incentive payments.

In the past, certification responsibilities fell to the Certification Commission for Healthcare IT, which was founded by the trade group Healthcare Information and Management Systems Society.

Some critics argue that CCHIT is too closely linked with the health IT industry to be designated as the sole certifying body for EHRs.

However, leaders of the commission say CCHIT maintains its independence from health IT firms.

Although commission officials acknowledged that certification thus far has failed to promote EHR interoperability, they said the group is working to support system compatibility. In addition, CCHIT leaders say the commission is beginning to focus on alternative health IT systems and not just those developed by large software vendors (Michaels/Roberson, Dallas Morning News, 7/14).

Above article published on

http://www.ihealthbeat.org/Articles/2009/7/15/
Questions-Raised-About-Stimulus-Law-Benefits-for-Health-IT-Vendors.aspx

By Tod Newcombe, Editor

I live in Massachusetts, where 97 percent of citizens have health-care coverage thanks to a 2006 law that mandates every resident have insurance through a unique public-private initiative. The first part of the law was to get as many people covered as fast as possible, and everybody agrees the results have been wildly successful.

That was the easy part. Now Massachusetts is working to rein in health-care costs. A key part of the state’s plan calls for increased use of electronic health records (EHRs). In fact, the state passed a law last year requiring hospitals and health-care clinics to use EHRs and created a fund to help physicians put IT into their practices.

Massachusetts also began building an interoperable statewide EHR network that will let doctors, hospitals and insurance providers share information electronically. The investment will save money and lives by reducing medical errors.

States are sometimes called “laboratories of democracy,” and in this case, Massachusetts is the test tube everybody is watching because no state has gone this far to insure so much of its population and require such a massive shift to EHRs.

Fortunately the rest of the public sector isn’t waiting to see what happens in New England. Several key federal agencies that provide insurance to their workers and clients are adopting EHRs, as have some publicly financed health-care facilities. The economic stimulus package is about to pour $20 billion into programs similar to Massachusetts’. The infusion of funds will thrust the public sector into a much more active health-IT role.

Not surprisingly, public CIOs have a role to play even if health IT isn’t part of their existing responsibilities. Public policies on IT interoperability, standards and infrastructure will expand as billions of technology funds start flowing through our country’s public and private health-care system. CIOs must have a seat at the table as this happens.

To help readers get a sense of what some CIOs are already doing, writer David Raths investigated. His findings are an intriguing, first-draft look at what happens when health IT intersects with the public CIO’s role.

While some public CIOs may think they have enough on their plate without the addition of health IT, one former CIO wishes he still had a plate to hold. Former Missouri CIO Dan Ross was the unfortunate victim of state politics when his boss, then-Gov. Matt Blunt, didn’t seek re-election, forcing Ross to vacate his office and state government.

As Missouri CIO, he managed the state’s IT programs, which he streamlined and consolidated with the help of some brilliant deputies, such as Bill Bott, while also keeping up with emerging IT trends. Ross worked with a legislature that thought cell phones were a frivolous luxury in state government, yet he recruited and hired IT workers through the virtual world Second Life.

Ross’ ability to balance the somewhat conservative views of state politicians with the trendiness of technology made him unique among public CIOs. Though he wishes he could remain a public servant, Ross has launched a consulting company that advises governments and IT firms on how to work together. He’s written an essay on his being a public-IT servant, with advice for current and future public CIOs. It’s well worth the read.

These are just two of the many articles in an issue rich in knowledge and advice. I hope you agree. Let me know what you think.

Above article published on

http://www.govtech.com/gt/articles/698261

Delegates call for eliminating Medicare penalties for failing to show “meaningful use” of electronic records by 2015. But some fear incentives could also go.

By Emily Berry, AMNews staff.

Chicago – Physician-delegates at the AMA Annual Meeting in June formally came out against planned penalties included in this year’s federal stimulus bill that would dock Medicare pay for physicians who do not have a qualifying electronic health record.

The “adjustments” start at 1% of the physician’s Medicare fee schedule and are set to begin in 2015, after four years of available incentives for adoption. The penalties are set to increase each subsequent year to a maximum of 5%.

Delegates passed a resolution calling for the Association to ask the federal government to eliminate the penalties and advocate for federal assistance with up-front and maintenance costs of EHR use.

The stimulus package, officially titled the American Recovery and Reinvestment Act of 2009, sets out incentives for both physicians and hospitals who can demonstrate “meaningful use” of an EHR, including the use of an e-prescribing component. Qualifying physicians will be eligible for additional Medicare payments of as much as $44,000 over the course of five years, beginning in 2011.

The national Health IT Policy Committee, an advisory group charged with defining principles for “meaningful use,” released its first draft recommendations June 16, but the Centers for Medicare & Medicaid Services has indicated proposed rules won’t be released until late 2009.

There is a case-by-case exemption written into the law for physicians who can demonstrate “significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access.”

Delegates at the Annual Meeting argued that the penalties violate the AMA’s pay-for-performance policies and unfairly punish physicians who can’t afford the up-front cost of adopting an electronic record system.

“My financial calculations say it’s cheaper for me to take the penalty than to put the system in, and that’s what I’m going to do,” said David McKalip, MD, a neurosurgeon and alternate delegate for the Florida Medical Assn.

No coverage for up-front costs

There are no provisions in the stimulus package that cover the up-front cost of adopting an EHR for a physician in private practice, and some physicians are concerned about buying an EHR now without knowing exactly what type of system will qualify them for incentives.

“Whatever you’re buying now is going to be obsolete in the near future,” said Stephen Sebert, MD, a family physician and president of the West Virginia State Medical Assn.

Other physicians speaking to the issue in reference committee urged delegates to “not throw the baby out with the bathwater” and pointed out the incentives represent the first assistance the government has offered for health IT adoption.

“I think if we ask for this to be rescinded, what we’ll wind up with, possibly, is nothing,” said Steven Kanig, MD, a nephrologist and delegate for the New Mexico Medical Society.

Above article published on

http://www.ama-assn.org/amednews/2009/06/29/prsd0629.htm

More than 50% of healthcare providers surveyed by IVANS do not believe the federal stimulus package will successfully encourage health IT adoption.

By Marianne Kolbasuk McGee InformationWeek

Although a majority of healthcare providers remain skeptical about how they’ll benefit by the federal government’s $20 billion stimulus program, many plan to forge ahead anyway, according to a report released this week.

About seven in 10 healthcare providers believe electronic medical records will have a positive impact on their businesses and patient care, but 80% say the lack of money is their biggest obstacle to deploying health IT systems, said the new report by IVANS, a supplier of EDI and network services to the insurance industry.

The nationwide, e-mailed survey of 508 healthcare providers — including hospitals, clinics, private medical practices, nursing homes, home healthcare organizations and medical billing companies — found that while nearly 40% plan to forge ahead with e-medical record deployments within the next 12 months, more than 50% of healthcare providers do not believe the federal stimulus package will successfully encourage health IT adoption.

Healthcare providers’ doubt appears to be rooted to several factor, most notably uncertainty about the specifics of the government’s eligibility requirements for receiving HIT-related rewards. Starting in 2011, the federal government is expected to begin awarding approximately $20 billion over the next five years, rewarding higher Medicare and Medicaid reimbursements to doctors and hospitals that demonstrate “meaningful use” of health IT.

However, the details of what will constitute “meaningful use” haven’t been worked out yet. The federal government is in the process of investigating and defining the scope of what “meaningful use” of health IT will qualify for the American Recovery and Reinvestment Act of 2009’s HITECH (Health Information Technology for Economic and Clinical Health) stimulus funding incentives. Just this week, a federal advisory panel — the HIT Policy Committee — unveiled some of its recommendations for the “meaningful use” definition.

“They’re on the right track,” said Clare DeNicola, IVANS CEO, of the HIT Policy Committee’s recommendation so far to the U.S. Dept. of Health and Human Services about the “meaningful use” definition. “It’s not about technology, it’s about the care — we can’t lose sight of that,” she said about the committee’s suggestions for how IT can be used for improving quality of patient care and public health.

Also fueling uncertainty among healthcare providers participating in the survey was this: Home healthcare providers and nursing homes were among the 508, healthcare providers polled. However, so far the HITECH federal stimulus legislations is vague on how those healthcare providers will participate in the new programs, despite the growing population of aging baby boomers who’ll likely increasingly require their services in coming years.

In fact, despite their skepticism and uncertainly about the government incentive programs, about four in 10 healthcare providers are planning to implement e-medical record systems over the next 12 months.

Many are already making investments in IT, including those that can help support e-medical record deployments, including wireless networks, business continuity technologies and connectivity to remote locations.

“Healthcare providers are wary but they are moving forward with technology innovations,” said DeNicola. “They’re not driven so much by the stimulus funds as they are in their belief that these technologies can help improve their businesses and patient care,” she said.

Finally, when survey participants were asked who should take the lead on driving adoption of healthcare IT to ensure its success, 47% of healthcare providers named themselves; 21% suggested the government should lead; 14% said healthcare insurers/payers should have that responsibility; and 18% were divided between industry associations and consumers leading the charge, according to the report.

Above article published on

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By Joseph Conn / HITS staff writer

Part two of a two-part series (Access part one):

The Certification Commission for Healthcare Information Technology has put on hold the rollout of its new sets of completed testing criteria for multiple health IT systems while it waits for HHS to release its plans for certifying IT under the American Recovery and Reinvestment Act of 2009, also called the stimulus law.

Earlier this month, CCHIT announced it had completed work on updated versions of test scripts and criteria for use in the 2009-10 round of testing and certification.

The commission also announced it will publish in either June or July an updated certification handbook explaining the testing and certification process. But CCHIT Chairman Mark Leavitt said that it won’t be taking applications from IT vendors for testing and certifying their electronic health record and other systems until HHS acts

Leavitt said that CCHIT will defer launch of its 2009-10 testing programs until its people have had a chance to look at the initial batch of HHS-approved criteria under the stimulus act. The law mandates the creation of an HIT Policy Committee and an HIT Standards Committee to develop and review IT certification criteria as well as health information transmission standards and implementation specifications.

“The policy and standards committees have some very tight deadlines,” Leavitt said.

“HHS has to take it through a public rulemaking and then it goes to OMB,” Leavitt said, referring to the White House’s Office of Management and Budget.

To keep the whole process on schedule, the policy and standards committees have to be done with their work by Aug 21, Leavitt said. “Since we want to conform our process to what those committees’ recommendations are, we want to hold our process,” until the committees’ work is completed. “They may want to add or subtract something. This will give us a chance to adapt the 2009-2010 process” to the stimulus act.

Initially, CCHIT certification lasted for three years, but testing was updated annually. Going forward, Leavitt said, he’s guessing certification will be on a two-year cycle.

CCHIT has been criticized in some quarters for certifying systems only on functionality, but not ease of use. Leavitt said that CCHIT is “beginning to investigate how to test usability.”

“There are a number of ways to do it, but we have to look for ways that are objective, that we can repeat,” Leavitt said.

One way, Leavitt said, would be to “look for the most common tasks and then count the number of clicks to do those tasks.” Those would include what Leavitt, himself a physician, calls “the speed-dial tasks in a physician’s office,” including refilling a prescription or taking a history on a new patient.

“You test that part of the product and you literally time it,” Leavitt said. Vendors could be asked to bring in their systems and their best user and test them on these common tasks. “If it takes 150 clicks and 10 minutes, you have a big problem.

“The other end of the spectrum is you survey users,” Leavitt said. “We ask the vendors for 10 sites. We want to see at least one that’s measuring quality, or using (the system) to manage chronic disease. Or even do a survey as part of the reimbursement payment process.”

The survey results could provide data on how many customers of a given system have applied for reimbursement under the “meaningful use” standard in the stimulus act vs. how many have qualified under that standard.

Leavitt said that the new certification criteria for 2009-10 have “a big focus on interoperability, including a requirement that EHRs be able to input and store data using the Continuity of Care Document format developed by standards development organizations Health Level 7 in collaboration with ASTM International.

Another test area—an option, not a requirement this year—will be whether the systems incorporate the interoperability specification approved by the federally supported Healthcare Information Technology Standards Panel that deals with querying another data source, such as a health information exchange, for the existence of patient records.

“If they do it, we give them a gold star and everyone will know it, but if they don’t, they’ll still get certified,” Leavitt said.

Another testing requirement that was on the CCHIT road map for inclusion in future certification criteria was that all EHRs be able to link the diagnosis code with an electronic prescription and be able to communicate the diagnosis code and prescription information together in a single electronic prescription sent to a drugstore or pharmacy benefit manager outside the physician’s practice.

The American Medical Association has a long-standing and oft-reaffirmed policy against any requirement to include diagnosis codes on prescriptions “to protect patient confidentiality and to minimize administrative burdens.”

According to a grid of CCHIT testing criteria posted on the organization’s Web site, the specific listing of this testing requirement “will be removed in 2009 when the corresponding Foundation criterion is tested.” The requirement itself isn’t being eliminated, however.

Leavitt said that by requiring EHRs be able to combine prescription data with a patient’s diagnosis doesn’t mean physicians will be forced to do so.

“The AMA doesn’t want you to provide it. Fine. Don’t provide it,” Leavitt said. “That’s a policy decision, so go ahead and fight that one out.”

But there are safety benefits, Leavitt said, allowing a second set of eyes to review the applicability of the prescription for the specified diagnosis. “It’s a potential way to reduce errors.” And there are financial considerations. “For some medications, in some prescribing situations, you’re required to do it. I believe it has to do with health plans qualifying patients to be on a medication.”

Another controversial requirement that was originally proposed as a separate line item in the 2009 criteria would require building into EHRs a back door to allow access by insurance companies for fraud control. The requirement would make EHRs conform to a recommendations in the 2007, HHS-funded report by RTI International “Recommended Requirements for Enhancing Data Quality in Electronic Health Records Systems,” which, despite the title, primarily dealt with the issue of medical billing and payment fraud control.

According to CCHIT spokeswoman Sue Reber, that specific testing criterion also was de-listed—but not eliminated—sometime before the first draft of the 2009 criteria was published “because it is redundant with existing security criteria in the area of ‘access control.’ ”

Above article published on

http://www.modernhealthcare.com/article/20090529/REG/305299991

By Steven Kraus, DC, DIBCN, CCSP, FASA

This spring, I traveled extensively to Washington, D.C., for a variety of reasons, mainly to advocate on behalf of chiropractic physicians as our government initiates massive health care reform efforts.

I attended the HL-7 Conference, which is an invitation-only gathering of health care officials dedicated to setting the programming standards for health information exchanges (HIEs) and standards for required data for electronic health records (EHRs).

The conference, sponsored by the Agency for Healthcare Research and Quality, has historically been limited to hospital and allopathic audiences. This year’s group was expanded for the first time to include other health care experts, and I was the designee from the chiropractic profession. My goal and commitment to the profession remains clear: I want to ensure that the interests of chiropractic physicians are considered in any and all discussions related to policy-making for health care information technology. And in the case of HL-7, chiropractic participation is critical so the concerns of our profession with regard to the development of HIEs will be heard.

The catalyst for broadening this conference audience was presumably the economic stimulus package, formally known as the American Recovery and Reinvestment Act (ARRA) of 2009, which includes more than $19 billion to fund the introduction of electronic health records in every physician office in America. The section of the ARRA that deals specifically with this appropriation is the HITECH Act, which outlines the requirements for funding eligibility. To be qualified for incentive payments offered through the legislation, doctors must adopt qualified EHRs that have the functionality to communicate with HIEs, making the standards by which HIEs are governed extremely important and elevating the prominence of interfacing capabilities with other systems.

I’ll discuss more about the requirements for incentive payments later in this article, but the main reason I share my involvement with the creation of health care information technology standards is to demonstrate how the general health care industry is finally opening its arms to the chiropractic profession. We’ve been dancing on the periphery for years, but finally, we are gaining recognition as an essential component of health care delivery and actively participating in these important discussions regarding policy, standards and reform.

Reform = Collaboration + Technology

Speaking of reform, during that same visit to D.C., I also met with Sen. Tom Harkin’s staffers as well as government relations personnel from the American Chiropractic Association to discuss the evolving model of reform for our health care system. As I shared in a previous column, elements of several models are under consideration including the Medical Home Model, which relies heavily on collaboration among health care professionals in order to improve the quality of patient care. Harkin and several of his colleagues are outlining a comprehensive national health care reform plan we can expect to be introduced later this year.

The cornerstone of that plan will be collaboration, and the framework to support collaboration will be driven by technology. While many uncertainties still remain, these two elements are certain. And with collaboration at the forefront, Harkin and others understand that chiropractic physicians and other nonmedical providers are an integral element of national reform. The reform movement is committed to supporting true wellness, something doctors of chiropractic have been preaching for years.

Now it’s time for us to rise to the occasion and continue walking our talk, while we have people watching us and listening. The first step in walking the talk is adopting EHRs. Why? Because technology will create the path to collaboration by assisting case management through registries, database queries, instant access to information, alerts and reminders, and all the related tools the digital age provides us. We need technology to form the health care teams that will improve patient care for every American.

With the anticipated health care reform model so heavily reliant on technology, those who do not adopt an EHR will be left out of the health care framework. In fact, the government is emphasizing the critical role an EHR will play in successful reform so heavily that it is funding the digital transition in its entirety. In order to adapt to the new model of health care, we must adopt an EHR. Since the government will pay for our EHR (up to $44,000 for each physician), we’re simply being asked to fund the energy and effort to implement it. Seems like more than a fair deal to me.

How to Access Your $44,000 Incentive

As I mentioned earlier, the process to fund your EHR is structured through incentive payments to physicians who adopt such systems. Not all health care professionals will be eligible for incentive payments, but doctors of chiropractic are an approved group, as they are covered by the Social Security code defining physicians, which the ARRA is using as its definition.

Two major areas will be evaluated by our government when determining payment approvals. First, the EHR system must be qualified, and second, the system must be used meaningfully by the chiropractic physician. A qualified EHR system must have the capacity to handle patient demographics and clinical health information, and also must have clinic management capabilities, as outlined by the entity that certifies qualified EHR. Only a certified EHR system will be eligible. The certifying body has not yet been announced, but the industry anticipates that the Certification Commission for Healthcare Information Technology (CCHIT) will be the likely choice since it was approved in 2006 by the government’s Office of the National Coordinator of Health Care Information Technology and Medicare to manage such efforts.

The second requirement, “meaningful use,” is determined by three important measures: (1) connectivity to health information exchanges and other EHR systems so they can share information when authorized by the patient; (2) regular reporting of quality measures to the Centers for Medicare & Medicaid Services (CMS), including capturing outcome assessments and performance of pain assessments; and (3) e-prescribing capability. Because we don’t have prescribing privileges, it is unknown at this time whether this will remain a requirement for doctors of chiropractic. With regard to reporting requirements, the general structure of the plan suggests that reporting of quality measures will likely be managed by the PQRI (Physicians’ Quality Reporting Initiative), a standardized mechanism that already exists.

As much as $44,000 can be paid as an incentive to a doctor for investing in a qualified EHR system. And in clinics with multiple physicians, each physician can qualify for the incentives, as long as the aforementioned terms are met. And while we know that CMS will be involved, its specific role is still being evaluated with regard to reporting and eligibility requirements for doctors participating in the incentive program. For example, minimum billing thresholds such as an annual $25,000 in covered services to CMS are being considered in order to be eligible for the incentive payments. However, there is some discussion on consideration for proportionate payments if the threshold is not met. So, if you average 16 Medicare patient visits a week, you would likely qualify. I will follow-up on this issue in a future article once the policies and standards relating to the Department of Health and Human Services and Medicare have been formally released.

To access the full $44,000, which is paid through Medicare in stages (four annual installments starting in 2011), the EHR system has to be qualified and used in a meaningful way starting in 2010. To clarify the timing, it is necessary to explain PQRI’s influence on the process. PQRI, which is expected to oversee reporting requirements, currently requires reporting on at least 80 percent of patients. To accommodate this requirement, the EHR system would need to be in use for the majority of the year prior to the first incentive payment, assuming adherence to PQRI standards will be required. Hence, EHR implementation in 2010 is necessary in order to receive an $18,000 first payment in 2011 and maximize the incentives available.

For new users, implementation of an EHR system typically requires 90 days to six months. Given the expectation that meaningful use will be necessary for the better part of 2010 in order to get a 2011 incentive payment, the implementation process for chiropractic physicians should begin promptly in 2009. Those who had the vision to implement a qualified EHR and can demonstrate meaningful use are already eligible for the full incentive payments.

Penalties for Not Transitioning to EHR

The Evolving Health Care Landscape: Technology Front and Center Those who choose not to transition to an EHR system will be penalized beginning 2015 and continuing through 2018. These penalties will be assessed through a reduction in your Medicare claims reimbursement on services billed. To further motivate adoption, some states have already passed laws that mandate EHR use after 2014 in order to attain a license to practice or to renew a license, concurrent with the stimulus plan. With financial and legal ramifications in play, the incentives to adopt an EHR now are enormous.

The Reform Cube

Given the benefits the government is providing chiropractic physicians, it is a wonder that any of us are still waiting to implement EHR. If the financial incentives are not enough motivation, doctors of chiropractic must consider what role they will play in the health care reform cube. Our health care landscape will soon shift to a different model; consider a cube in which quality, cost, and delivery of care through collaboration and access exist at each point, while technology sits squarely in the middle. Technology improves quality by offering reminders, alerts and other assistive techniques; technology lowers costs by reducing duplication of services; and technology improves collaboration and access by providing a mechanism to share patient health information across all providers. All of this allows for a robust clinic management system.

As chiropractic physicians, we strive to improve quality, we seek to reduce costs, and we crave the opportunity to collaborate on the health care team, so the cube is the ideal home for us. When we adopt the proper technology, we gain not only substantial financial support, but also membership in the cube. And isn’t membership what we’ve been asking for from the health care community all these years? This membership is not for the sake of privilege, but for the sake of having other providers refer patients to receive the benefit of chiropractic care, achieve wellness, and experience cost-effective and efficacious care naturally. Accept the invitation now - it won’t be offered again.

Above article published on

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53922

Like many physicians, you may have put off purchasing an EHR system because of the cost. Now you’ve heard the government is offering a chunk of money to physicians who have EHRs. What should you do?

The first step is to understand what the government is and isn’t offering. Under the health IT provisions of the American Recovery and Reinvestment Act of 2009, you won’t get any cash if you simply buy an EHR; you have to show that you’re using it in a “meaningful” way. And, except for a small loan program, the feds aren’t providing any money upfront. You still have to go out and purchase or lease a system yourself. But, starting in 2011, Medicare or Medicaid will reimburse you for part of the cost if you can demonstrate “meaningful” use of a qualified EHR.

Here’s how the program works: Non-hospital-based physicians who participate in Medicare or derive 30 percent or more of their business from Medicaid (20 percent for pediatricians) are eligible to receive subsidies. The maximum amounts for which you may be eligible range from Medicare payments of $44,000 to nearly $64,000 from Medicaid over a five-year period. You can apply for either of these programs, but not both, and physicians practicing in underserved areas are eligible for an extra 10 percent from Medicare.

Under the Medicare provisions, if you apply in 2011 or 2012, you can receive $18,000 in reimbursements that year, followed by annual payments of $12,000, $8,000, $4,000, and $2,000. Those who apply in 2013 receive $15,000 in the initial year, followed by three years of diminishing payments. The first-year payment in 2014 is $12,000, with lower incentives the following two years. No incentives are available to anyone who applies after that, and no payouts will occur after 2016.

Physicians who are not using qualified EHRs meaningfully by 2015 will lose 1 percent of their Medicare reimbursement; in 2016, they will forfeit 2 percent, and in 2017 and each year thereafter, 3 percent. If less than 75 percent of physicians have met the EHR requirements by 2018, the Secretary of Health and Human Services is empowered to cut Medicare payments to the laggards by up to 5 percent.

Of the $19.2 billion allocated for the health IT program (including subsidies to hospitals), $2 billion has been placed in a discretionary pool that’s controlled by the Office of the National Coordinator for Health Information Technology (ONC). About $300 million of that must be spent on health-information exchanges, and another $25 million is earmarked for standards development. Amounts for meeting ONC’s other legislated goals have not been specified yet, but a significant percentage will be invested in regional extension centers that will, among other things, help small practices implement EHRs.

Some observers have interpreted “meaningful use” as including the use of electronic prescribing, the exchange of clinical information with other providers, and the reporting of quality data to CMS. But a Senate aide who asked not to be identified said the only thing written in stone is that you have to show you’re exchanging data. The HHS Secretary will have to flesh out the details, he says.

What “qualified” means

The Secretary also must define what constitutes a “qualified EHR” that practices must use to qualify for subsidies. Because of the short timeline and other factors, observers believe that certification by the Certification Commission on Health Information Technology (CCHIT), an existing private-sector body, may be required. Dr. Mark Leavitt, chairman of CCHIT, said in a recent webinar that he’s “confident” that CCHIT will be recognized as a certifying body for purposes of the financial incentives. He added that it’s a “good bet” that either 2008 or 2009 certification (perhaps with some additions to or deletions of CCHIT criteria) will be required. That would mean products that were certified only in 2006 or 2007 wouldn’t pass muster.

At press time, only 30 EHRs had been certified under 2008 CCHIT criteria, and of those, 12 are well-established ambulatory-care products. In contrast, about 150 EHRs were certified in 2006 and 2007. The increased requirements for certification are largely responsible for the drop in the number of certified products. Leavitt said that, since the stimulus law’s enactment, there had been a “surge” of applications for 2008 certification. The 2009 certification period begins in July.

The government health IT initiative will put a lot of pressure on software vendors to upgrade their programs to meet federal requirements, predicts Robert Doherty, vice president of governmental affairs and public policy for the American College of Physicians. Justin Barnes, chairman of the EHR Vendors Association and vice president of marketing and government affairs for Greenway Medical Technologies, agrees that more vendors will seek certification, but he doubts that many will be able to clear CCHIT’s rising bar, which includes the interoperability functions that the government wants. “I think a handful of companies — perhaps 15 or 16 — can come close to satisfying that requirement today,” he says.

The mad rush?

Despite the limited number of choices, Barnes believes that the subsidy program will have a huge impact on EHR sales to physicians. In the next six to nine months, he predicts, between 50,000 and 100,000 physicians will acquire EHRs. In addition, he expects many physicians who now have low-end systems to upgrade to certified products in order to get government cash.

Bruce Merlin Fried, a Washington, DC, healthcare attorney who specializes in health IT, agrees that the stimulus will greatly accelerate EHR adoption. For doctors who are reluctant to invest upfront, he believes that the back-end penalties will be a strong incentive. As for the current lack of interoperability standards, he says that’s why the incentives don’t start until 2011. “The plan is that in the ensuing period, the necessary standards will be met, and the vendors will be required to certify that those standards are employed.”

But Mark Anderson, a health IT consultant in Montgomery, Texas, notes that few EHRs today have even a basic ability to exchange information. And he views the requirement that practices buy systems before they can qualify for government subsidies as “a deal breaker” for many physicians.

Even if physicians are willing to pay upfront — and they’d have to buy soon to qualify for maximum Medicare subsidies — some observers point out that the government incentives will cover only a third to a half of the five-year cost of an EHR system. A recent study by Avalere Health concluded that many physicians in small practices may decide they’d be better off taking the hit on Medicare payments after 2014 than investing in an EHR now.

Where physicians stand

Some physicians agree. For example, Will Sawyer, a solo family physician in Cincinnati, hasn’t bought an EHR system “because none of them has been effective enough to integrate into a busy family practice. Also, they cost a fortune.” Although the government incentives would lower the cost barrier, Sawyer doubts that an EHR would help him significantly improve the quality of his care, especially in the absence of interoperability among systems.

Family physician Mitchell Cohen, who belongs to a three-doctor practice in rural Elma, Wash., would like to acquire an EHR. His group might even qualify for the $64,000 Medicaid subsidy in the stimulus package. But he and his colleagues are now putting up a new office building to accommodate their growing practice. “We just couldn’t swing the extra cost” of investing in an EHR right now, he notes, adding that that might change in another year.

But other physicians are ready to take advantage of the government subsidy now. Internist Jeff Kagan of Newington, Conn., says, “If someone is going to pay for us to get an EHR, we’re certainly going to be much more interested in doing it.”

Kagan and his partner rejected an offer by a local hospital to pay for 65 percent of the cost of EHR software, because the EHR it offered was unsuitable for ambulatory practices. He says the government offer is more appealing, especially since they can choose among certified EHRs.

Some physicians who already have certified EHRs are happy that the government is finally going to reward them. For example, Ed Bujold, an internist in Granite Falls, N.C., figures he’s spent $150,000 on EHR software and computer equipment since 2000. While his EHR has made his practice more efficient and improved his ability to code appropriately, he’s delighted about the government incentive. “This is a novel concept that you might be rewarded for doing the right thing, and that you might get paid more for practicing quality medicine,” he crows.

Gearing up for the future

Despite everything, many physicians remain skeptical about the value of EHRs and are fearful about what the work flow changes might mean to their practices. Although the regional extension centers are designed to help small practices get over the hump, EHRs represent a formidable technical challenge. And it’s unclear that there are enough qualified technicians available to help physicians implement EHRs and train them and their staffs, notes MGMA consultant Rosemarie Nelson.

Nelson believes that physicians should start shopping for EHRs now. If a product is not yet CCHIT-certified, she recommends getting the vendor to commit to that as a condition of purchase. Anderson says that even if an EHR was certified in the past, the vendor should promise to obtain CCHIT’s 2009 seal of approval. Also, you should make sure the EHR and its associated PM system can be upgraded for compliance to the ICD-10 coding system that must be in place by 2013, he says.

Family physician Steven Waldren, director of the American Academy of Family Physicians’ Health Information Technology Center, notes that physicians who already have a non-certified EHR will be reluctant to switch to another system, especially if they can show the meaningful use that the government demands. But other experts say it’s unlikely that such EHRs will be grandfathered in so that physicians can receive subsidies for them.

Doherty regards the HHS incentive program as “kind of a now-or-never decision for physicians.” If doctors don’t take advantage of it, he points out, they risk not receiving government subsidies and being penalized later on. On the other hand, he says, physicians have found some systems don’t work well, and many don’t offer robust quality improvement features.

At some point, if not enough physicians acquire EHRs, Congress may mandate them as a condition of participation in Medicare and Medicaid, Doherty says. Jim Morrow, a family physician in Alpharetta, Ga. who is an experienced EHR user, believes that that could happen within as little as five years. But he suggests that the government might not require the kind of EHR it’s talking about now.

“It might be a requirement to share data electronically,” he says. “The aim of an EHR is not to create better progress notes, but to be able to access and analyze your patient data. It’s the data that’s important, not the notes.”

Ken Terry is a New Jersey-based freelance writer and the author of the book “Rx for Health Care Reform.” He can be reached at physicianspractice@cmpmedica.com.

This article originally appeared in the July/August 2009 issue of Physicians Practice.

Above article published on

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articles.details/articleID/1343/page/1.htm

By now you’ve heard about the $850 billion American Recovery and Reinvestment act of 2009 - the stimulus bill recently passed by Congress. The bill is aimed at spurring economic growth across multiple industries by way of government spending.

What’s in it for you?

Well if you are a healthcare provider, you can take advantage of the $51 billion that has been allocated to the health care industry, $19 billion of which will be used to incentivize medical practices to adopt and implement Electronic Health Records (EHRs), also known as Electronic Medical Records (EMRs).

How does the subsidy work?
Starting in 2011, providers deemed to be “meaningful users” of EHR systems will be eligible to receive $40,000 - $60,000 in incentive payments paid out over five years in the form of increased Medicare and Medicaid premiums.

For the first year a physician is deemed to be a meaningful user, he or she will be eligible for payments of 75% of that year’s Medicare and Medicaid charges, up to a maximum of $15,000. The maximum payment is increased to $18,000 if the first year is 2011 or 2012. The incentive payments decline for each subsequent year within the five year period; $12,000 will be paid in year two, $8,000 in year three, $4,000 in year four, and $2,000 in year five.

No incentive payments will be available after 2015, and no payments will be offered to physicians who first become eligible after 2014. This creates a decreasing incentive for late adopters.

What is a “meaningful user”?
To qualify as a “meaningful user,” eligible providers must demonstrate use of a “qualified EHR” in a “meaningful manner.” The bill defers to the secretary of Health and Human Services (HSS) to set specific guidelines for determining what constitutes a “qualified EHR”; however, it does specify that e-prescribing, electronic exchange of medical records, and interoperability of systems will be determining criteria.

HSS will be working throughout 2009 to set the necessary criteria for certifying systems, and is expected to have a final report by January of 2010. Many expect CCHIT certification to play a major role in setting standards of interoperability. (See “Should CCHIT Influence Your EHR Selection” for more information). After all, HHS funded the creation of CCHIT to start certifying EHRs a few years ago.

How do I qualify for the maximum payment?
In order to receive the maximum payment, physicians must qualify as a meaningful user in 2011. Eligible physicians will receive a first year bonus of $18,000 (up from $15,000) and will max out the payment schedule over the next five years.

The table below illustrates the amount of a subsidy paid each year (columns) based on the year the provider first becomes eligible (rows):

No payments will be offered to physicians who first become eligible after 2014.

Practices with multiple physicians will be eligible to receive incentive payments for each provider. Remember that payments will be based on 75% of the correlating year’s Medicare and Medicaid charges. Therefore, in order to qualify for the maximum payment of $18,000 in the first year, each provider must bill Medicare or Medicaid a minimum of $24,000.

Should I purchase an EHR now or wait until 2010?
An obvious concern is whether an EHR implemented in 2009 will meet the standards set by HHS in 2010. Although a legitimate concern, waiting until 2010 to implement a system may be a mistake. Researching and selecting the right EMR can be a lengthy process, and many providers who wait may find it difficult to have a system in place in time.

Practices would be well-served to begin the research process now, allowing ample time to create a short-list of systems, perform demos with several vendors, check references, meet with vendors in person, negotiate terms, and complete the implementation and training process. To alleviate buyers’ concerns, vendors may provide binding agreements, guaranteeing their system will comply with all emerging standards.

Furthermore, buyers’ should consider CCHIT an important Certification relative to the requirement for “qualified EHRs.” While we have discussed the many opinions for and against CCHIT, we expect it to play a critical role in the EHR subsidy qualification.

What if I choose not to purchase an EHR?
Unfortunately, for physicians who choose not to implement an EHR, the stimulus bill is a double-edged sword. Not only will they forego thousands in incentive payments, but starting in 2015, they will be penalized by way of decreased Medicare and Medicaid payments. Physicians who fail to qualify as meaningful users will face decreases of 1% in 2015, 2% in 2016, and 3% in 2017, with a maximum reduction of 5% by 2020.

Above article published on

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the-stimulus-bill-and-meaningful-use-of-qualified-emrs-1031209/