The Medicare EHR Incentive Program

The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009 (ARRA), authorizes the U.S. Department of Health and Human Services to provide financial incentives to eligible health professionals (EPs) and hospitals that “meaningfully use” EHR technology. In 2010, CMS published the final rule that physicians must follow to obtain the criteria for Stage 1 of the incentive payments. Subsequently, in late August, CMS released the final rule for Stage 2 of the program that also contains modifications to Stage 1.

The penalties take effect in 2015. Why should I get on board now?

Incentive payments began in calendar year 2011 and are scheduled for implementation as follows:

  • EPs that began meeting the Stage 1 meaningful use requirement in 2011 or 2012 are eligible to receive the maximum incentive payment amount of $44,000 over a period of five years
  • If they begin in 2013, EPs will be able to earn a total incentive payment of $39,000 over a period of four years
  • EPs will receive a total incentive payment of $24,000, if they begin in 2014, over a period of three years
  • No incentives are scheduled to be available to EPs who become meaningful users beginning in 2015 and beyond

It is important to note that although the Medicare EHR Incentive Program penalties will not be applied to Medicare Part B payments until calendar year 2015, the assessment of the penalty will depend on an EP’s performance in 2013 or 2014. In other words, EPs must be able to achieve Stage 1 of meaningful use before 2015 to avoid the payment penalty in 2015. Table 1 describes accumulations of incentives and percentages of penalties from 2011 to 2015 and beyond.

Table 1: Maximum total amount of EHR incentive payments for a Medicare EP

Calendar year* First calendar year in which the EP receives an incentive payment
2011 2012 2013 2014 2015 and on
2011 $18,000
2012 12,000 $18,000
2013 8,000 12,000 $15,000
2014 4,000 8,000 12,000 $12,000
2015 2,000 4,000 8,000 8,000 $0; -1 percent of Medicare fee schedule (penalty)
2016 2,000 4,000 4,000 $0; -2 percent of Medicare fee schedule (penalty)
TOTAL $44,000 $44,000 $39,000 $24,000 $0

*Note: A calendar year equals a payment year.

What are the requirements to begin Stage 1?

It is important to note that the following Stage 1 requirements are only applicable through calendar year 2012. Beginning in 2013, CMS has modified the Stage 1 requirements. The ACS will publish more information on the new Stage 1 requirements for use in 2013.

To begin Stage 1 of the Medicare Incentive Program, EPs must first register with the CMS Registration and Attestation System. The purchase of certified EHR technology is not required to register with the CMS system. However, to meet the  meaningful use objectives, EPs must use certified EHR technology approved by the Office of the National Coordinator (ONC). A list of the ONC-certified EHR systems can be found at http://oncchpl.force.com/ehrcert.

Core set objectives and measures for EPs are summarized in Table 2. Once an EP is ready to begin reporting cases, he or she must meet the 15 core set measures and select and meet five of the 10 menu set measures. EPs must choose at least one of the population and public health measures from the menu set. The menu measure set of objectives and measures for EPs are summarized in Table 3.

In addition to meeting the set measure requirements, EPs must report on three core clinical quality measures in order to demonstrate meaningful use: blood pressure level, tobacco status, and adult weight screening and follow-up (or three alternate core measures if these are inapplicable). EPs who are unable to report on the core clinical quality measures may instead report the alternate core measures, which include influenza immunization for patients older than age 50, weight assessment and counseling for children and adolescents, and childhood immunizations. If all six core and alternate core measures are inapplicable, EPs may report zeros for all six denominators.

Moreover, EPs must select and report on three additional measures from a subset of clinical measures most appropriate to their scope of practice. If these three additional selected measures have a value of zero in the denominator, then EPs must attest that all other clinical quality measures, if calculated by the certified EHR technology, would also have a value of zero in order to be exempt from reporting on additional measures.

Keep in mind that some of the Stage 1 core, alternate core, and clinical quality core, alternate, and additional measures will change beginning in 2013. The ACS will provide additional information regarding the modifications to the Stage 1 program for use in 2013.

In the first year of participation, EPs will need to report for a consecutive 90-day reporting period during any point in a calendar year until October 1 of a respective year. EPs must report for a full calendar year in subsequent years of participation.

Table 2: Stage 1 Core Measure Set*

Core measure set
Objective Measures
Computerized Physician Order Entry (CPOE) for medication orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local, and professional guidelines More than 30% of unique patients with at least one medication in their medication list have at least one order entered using CPOEExclusion: EPs who write fewer than 100 prescriptions during the EHR reporting period
Implement drug-drug and drug-allergy interaction checks More than 40% of all permissible prescriptions are transmitted electronically using certified EHR technology
Generate and transmit permissible prescriptions electronically (eRx) More than 50% of all unique patients have demographics recorded as structured data
Record patient demographics, including: Preferred language, gender, race, ethnicity, date of birth More than 80% of all unique patients have at least one entry or an indication that no problems are known for the patient recorded as structured data
Maintain up-to-date problem list of current and active diagnoses More than 80% of all unique patients have at least one entry (or an indication that the patient is not currently prescribing any medication) recorded as structured data
Maintain active medication list More than 80% of all unique patients have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data
Maintain active medication allergy list For more than 50% of all unique patients age two and older, height, weight, and blood pressure are recorded as structured dataExclusion: EPs who see only patients younger than two years old, or who believe that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice
Vital signs: Record and chart changes in height, weight, blood pressure; calculate and display body mass index (BMI); plot and display growth charts for children from 2 to 20 years, including BMI More than 50% of all unique patients age 13 or older have smoking status recorded as structured dataExclusion: EPs who see no patients 13 years or older
Smoking status: Recorded for patients 13 years of age or older Implement one clinical decision support rule
Implement one clinical decision support rule relevant to specialty or high clinical priority, along with ability to track compliance with that rule For 2011, provide aggregate numerator, denominator, and exclusions through attestation; for 2012, submit clinical quality measures electronically
Report ambulatory clinical quality measures to CMS or in the case of Medicaid EPs, the states More than 50% of all patients who request an electronic copy of their health information receive it within three business daysExclusion: EPs who have no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period
Provide patients with an electronic copy of their health information (including test results, problem list, medication lists, medication allergies) upon request Clinical summaries provided to patients for more than 50% of all office visits within three business daysExclusion: EPs who have no office visits during the EHR reporting period
Provide clinical summaries for patients for each office visit
Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results) among providers of care and patient authorized entities electronically Perform at least one test of certified EHR technology’s capacity to electronically exchange key clinical information
Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriatetechnical capabilities Conduct or review a security risk analysis and implement security updates as necessary and correct identified security deficiencies as part of its risk management process

*These core measures are only applicable until the end of calendar year 2012. Some additional mandatory and optional changes will begin in 2013.

When will Stage 2 begin?

Stage 2 of the Medicare EHR Incentive Program is scheduled to begin in calendar year 2014. This means that EPs who decide to wait until 2014 to begin participation must first complete Stage 1 and take the following steps:

  • Report Stage 1 90-day reporting in 2014
  • Provide Stage 1 full calendar year reporting in 2015
  • Begin compliance with Stage 2 requirements in 2016

The ACS will provide more information on Stage 2 of the program for use in 2014.

Table 3: Stage 1 Menu Measure Set*

Menu measure set
Objective Measures
Implement drug-formulary checks This functionality is enabled and the EP has access to at least one internal or external drug formulary for the entire EHR reporting period
Incorporate clinical lab-test results into certified EHR structured data More than 40% of all clinical lab test results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured dataExclusion: EPs who order no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Generate at least one reporting listing patients with a specific condition
Send reminders to patients per patient preference for preventive/follow-up care More than 20% of all unique patients ages 65 or older or five years old or younger were sent an appropriate reminder during the EHR reporting periodExclusion: EPs with no patients 65 years or older or five years or younger with records maintained using certified EHR technology
Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the EP More than 10 percent of all unique patients are provided timely (available to the patient within four business days of being updated in the EHR) electronic access to their health information, subject to the EP’s discretion to withhold certain informationExclusion: EPs who neither order nor create any lab results, problem lists, medication lists, or medication allergies during the EHR reporting period
Use certified EHR technology to identify patient-specific education resources and provide those resources to patient if appropriate More than 10% of all unique patients are provided patient-specific education resources
EPs who receive a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation EPs perform medication reconciliation for more than 50% of transitions of care in which patients are transitioned into their carelusion: EPs who were not the recipients of any transitions of care during the EHR reporting period
Transition/referral of patient to another setting or provider of care: EP should provide summary of care record for each transition of care or referral Summary of care record provided for more than 50% of transitions of care and referralsExclusion: EPs who neither transfer a patient to another setting nor refer a patient to another provider during the EHR reporting period
Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow-up submission if the test is successful (unless none of the immunization registries to which EPs submit such information have the capacity to receive the information electronically)Exclusion: EPs who administer no immunizations during the EHR reporting period, or where no immunization registry has the capacity to receive the information electronically
Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which EPs submit such information have the capacity to receive the information electronically)Exclusion: EPs who do not collect any reportable syndromic information

*These menu set measures are only applicable until the end of calendar year 2012. Some additional mandatory and optional changes will begin in 2013.

What resources are available to assist a user in enrolling and participating in the program?

The American College of Surgeons (ACS) has created several resources to help surgeons learn more about the program. Visit the ACS EHR website or the CMS EHR website  for more information. The ACS also partnered with AmericanEHR Partners, which provides more information on various EHR vendor ratings, podcasts offering an overview of various components of the program, and proposals from various vendors, and also disseminates e-newsletters, and more. To register, visit www.americanehr.com/Home.aspx.

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Contact

Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611