The EHR Incentive Program

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The EHR Incentive Program

Summary of the Centers for Medicare and Medicaid Services (CMS) Final Rule on

Meaningful Use

On July 13th, the Centers for Medicare and Medicaid Services’ (CMS) released its final rule outlining how eligible physicians and hospitals can qualify for specific Medicare and Medicaid incentives for the adoption and use of certified EHR technology. The final rule establishes the program requirements for participating in the EHR incentive program beginning in 2011, and provides both challenges and opportunities for dermatologist interested in adopting EHRs. Authorized under the American Recovery and Reinvestment Act (ARRA) of 2009, the EHR incentive program is expected to stimulate interest in the adoption of EHRs by eligible

physicians and hospitals through payments of up to $44,000 over five years under Medicare, or up to $63,750 over six years under Medicaid. Providers will need to meet several requirements to be eligible for the incentive funds including using a certified EHR system (systems are listed at http://onc-chpl.force.com/ehrcert) and become a meaningful user, which is outlined in the final rule. Starting in 2015, dermatologists and other physicians who do not participate in adopting certified EHR systems and becoming meaningful users of this technology will risk reduced Medicare payments. With this final rule, CMS is moving ahead to stimulate participation in achieving significant improvements in health care coordination processes and quality outcomes through EHRs.

Table 1: Payment Schedule for Participation in the Medicare EHR Incentive Program* YEAR OF ADOPTION PAYMENT IN 2011 PAYMENT IN 2012 PAYMENT IN 2013 PAYMENT IN 2014 PAYMENT IN 2015 PAYMENT IN 2016 TOTAL INCENTIVE PENALTY 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000 0% 2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 0% 2013 $15,000 $12,000 $8,000 $4,000 $39,000 0% 2014 $12,000 $8,000 $4,000 $24,000 0% 2015 1% 2016 2% 2017 and beyond 3%

*Note: Payment is based on 75 percent of the physician’s Medicare allowed charges or a maximum which is listed in the table above. Providers must also have at least $24,000 in Medicare Part B allowed

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Important guidelines to remember:  Providers must use an ONC‐ATCB certified system  Providers will only need to attest in 2011 and 2012 that they completed the objectives for Stage 1.  Providers must complete 15 core objectives and 5 objectives from a menu set.  A total of $44,000 over a five year period is available to providers who successfully report the stated objectives for the Medicare EHR Incentive Program.  A total of $63,750 over a six year period is available to providers who successfully report the stated objectives for the Medicaid EHR Incentive program. Eligibility

CMS defines eligible providers (EP) for the Medicare EHR Incentive Program as providers who are a doctor of medicine or osteopathy, doctor of dental surgery or dental medicine, doctor of podiatry, doctor of optometry or a chiropractor who is not hospital-based. A Medicaid eligible provider is defined as a physician, nurse

practitioner, certified nurse-midwife, dentist, or physician assistant who furnish services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant. To qualify for an EHR incentive payment, a Medicaid EP must not be hospital-based and must have a minimum of 30% of their patient volume composed of Medicaid patients, be a pediatrician and have at least 20% of their patient volume composed of Medicaid patients or practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals. Providers may only select one program to participate in.

Final Rule Guidelines

Thanks to its advocacy efforts, the American Academy of Dermatology Association (AADA), along with other national medical associations and specialty societies, voiced their concerns about the pace and scope of the original implementation requirements. As a result, we

were able to convince CMS to reduce the number of meaningful use requirements and lower the reporting thresholds it had previously proposed for Stage 1 of the program. Though the

program requirements remain challenging, complex and comprehensive—with some 15 core criteria set that all participants must meet, dermatology practices will now have greater flexibility in determining which additional five from the menu criteria set to report. CMS has also made changes to the timeline and set all of the criteria for 2011 and 2012 as “Stage 1”. Upcoming years will involve “Stage 2” and “Stage 3” criteria which are expected to be more difficult to achieve.

Table 2: Stage of Meaningful Use Criteria by Year

First Payment Year Payment Year

2011 2012 2013 2014 2015

2011 Stage 1 Stage 1 Stage 2 Stage 2 TBD

2012 Stage 1 Stage 1 Stage 2 TBD

2013 Stage 1 Stage 1 TBD

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Example of Incentive Payment Schedule: Question: A dermatologist applies for the Medicare EHR incentive funds in 2011, however fails to apply in 2012. She continues applying in 2013, 2014 and 2015. How much is she eligible to collect in incentive funds? Answer: She would be eligible to collect up to $32,000. She would not be able to collect any funds from 2012 as she skipped the registration process for that year. The Medicare Incentive Program only allows physicians to collect the money on a continuous basis. They may not go back and collect any funds from previous years. The final rule retains many of the same criteria

originally outlined in the earlier proposed rule; 2011 will still be the first year eligible providers can apply for the funds and providers

participating in the Medicare incentive program may only be allowed to apply for five successive payment years. Thus, if you apply for the funds in 2011 and do not apply in 2012, you will only be eligible to collect your incentive in 2013, 2014 and 2015 and cannot apply for an additional year. The reporting period is still minimized to 90 days in the first year and a full reporting year in any successive year. Providers who

participate in the e-prescribing incentive

program the same year they apply for the EHR incentive program will still be ineligible to collect money from both programs, and providers who successfully report and receive incentive dollars

will have their names and addresses published on the CMS website. Providers should still continue to report in the e-prescribing incentive program to avoid any e-prescribing penalties. The major changes, however, between the proposed and final versions of the meaningful use rule are in the reporting of measures. The proposed meaningful use rule would have required providers to report on 25 core criteria. The final rule reduces these core criteria to 15 measures and requires providers to report on an additional 5 measures from a menu set. Providers will need to attest in 2011 and 2012 on the CMS website that they performed these measures in order to be eligible for the stimulus dollars. After 2012, CMS will require providers to

electronically submit this data to CMS. Please note, CMS has up to ten years to audit your documentation for meaningful use, so you should keep this information safely secured. Providers must begin their participation in this program by October 1, 2012, at the latest, to quality for the full $44,000. Dermatologists may not need to report on all core and menu sets of measures. Providers may attest that their denominator is zero for a particular quality measure if it does not apply to their specialty. Additionally, one of the core measures required is the

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Table 3: Core Measures for Meaningful Use - Eligible Providers (EPs) Must Report All Measures

Measure Numerator Denominator Frequency

(Numerator/ Denominator) Exceptions 1. Use CPOE (Computer Physician Order Entry) The number of patients in the denominator that have at least one medication order entered using CPOE

Number of unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period

The resulting percentage must be more than 30 percent in order for an EP to meet this measure

Does not apply to EPs that write fewer than 100

prescriptions during the reporting period

2. Implement drug to drug and drug allergy

interaction check

N/A N/A N/A None

3. E-Prescribing The number of prescriptions in the denominator generated and transmitted electronically Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the EHR reporting period

Does not apply to EPs that write fewer than 100

4. Maintain an up-to-date problem list of current and active diagnoses The number of patients in the denominator who have at least one entry or an indication that no problems are known for the patient recorded as structured data in their problem list

Number of unique patients seen by the EP during the EHR reporting period

The resulting percentage must be more than 80 percent in order for an EP to meet this measure None 5. Maintain active medication list The number of patients in the denominator who have a medication (or an indication that the patient is not currently prescribed any medication) recorded as structured data

The resulting percentage must be more than 80 percent in order for an EP to meet this measure None 6. Maintain active medication allergy list The number of unique patients in the denominator who have at least one

entry (or an indication that the patient has no known medication

The percentage must be more than 80 percent in order for an EP to meet this measure

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allergies) recorded as structured data in their medication allergy list 7. Record the following demographics: preferred language, gender, race and ethnicity, and date of birth

The number of patients in the denominator who have all the elements of

demographics (or a specific exclusion if the patient declined to provide one or more elements or if recording an element is contrary to state law) recorded as structured data Number of unique patients seen by the EP during the EHR reporting period

The resulting percentage must be more than 50 percent in order for an EP to meet this measure None 8. Record the following vital signs: height, weight and blood pressure as structured data The number of patients in the denominator who have at least one entry of their height, weight and blood pressure are recorded as structure data.

Number of unique patients age 2 or over seen by the EP during the EHR reporting period.

The resulting percentage must be more than 50 percent in order for an EP to meet this measure.

EPs who do not collect vital signs may report this measure does not apply

9. Record smoking status of

patients 13 years and older

The number of patients in the denominator with smoking status recorded as structured data Number of unique patients age 13 or older seen by the EP during the EHR reporting period

EPs who do not see patients 13 years and older 10. Implement one clinical decision support rule relevant to specialty along with the ability to track compliance with that rule

N/A N/A Once per reporting

period. None 11. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request The number of patients in the denominator who receive an electronic copy of their electronic health information within three business days The number of patients of the EP who request an electronic copy of their electronic health information four business days prior to the end of the EHR reporting period

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12. Provide clinical summaries for patients for each office visit

Number of patients in the denominator who are provided a clinical summary of their visit within three business days

Number of unique patients seen by the EP for an office during the EHR reporting period

EPs who have no office visits are exempt from reporting this measure 13. Electronically exchange key clinical information

N/A N/A Perform at least one

test whereby data is submitted to a separate legal entity with an EHR system that can accept the data None 14. Protect electronic health information created or maintained by certified EHR

N/A N/A Conduct or review a

security risk analysis per 45 CFR 164.308(a)(1) of the certified EHR technology, and implement security updates and correct identified security deficiencies as part of its risk management process None 15. Report clinical quality measures Please visit http://www.cms.gov/QualityMeasures/03_ElectronicSpecifications. asp#TopOfPage for more information.

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Table 4: Menu Set of Measures for Meaningful Use – Eligible Providers (EPs) Must Report Five Measures

Measure Numerator Denominator Frequency

(Numerator/ Denominator)

Exceptions

1. Implement drug-formulary

checks and have access to at least one internal or external drug formulary

N/A N/A N/A Does not apply to

EPs who write fewer than 100

2. Incorporate clinical lab-tests results into certified EHR technology as structured data

The number of lab test results whose results are

expressed in a positive or negative affirmation or as a number which are incorporated as structured data

Number of lab tests ordered during the EHR reporting period by the EP whose results are expressed in a positive or negative affirmation or as a number The resulting percentage must be more than 40 percent in order for an EP to meet this measure

EPs who order no lab tests and don’t have results in either a positive /negative or numeric format during the EHR reporting period

3. Generate at least one report listing the patients of the EP with a specific condition

N/A N/A Once per reporting

period None 4. Send reminders to patients per patient preference for preventive/follow up care The number of patients in the denominator who were sent the appropriate reminder Number of unique patients 65 years old or older or 5 years older or younger The resulting percentage must be more than 20 percent in order for an EP to meet this measure

EPs who do not see patients 65 years and older or 5 years and younger are excluded from reporting this measure 5. Provide patients with timely electronic access to their health information The number of patients in the denominator who have timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information online Number of unique patients seen by the EP during the EHR reporting period

The resulting percentage must be at least 10 percent in order for an EP to meet this measure

EPs who neither order nor create lab tests or information that would be contained in the problem list, medication list, or medication allergy list during the EHR reporting period 6. Use certified EHR to identify patient-specific Number of patients in the denominator who are provided patient education

The resulting percentage must be more than 10 percent in order for

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education resources and provide those resources to the patient if appropriate

specific resources an EP to meet this measure 7. Perform medication reconciliation for patients The number of transitions of care in the denominator where medication reconciliation was performed Number of transitions of care during the EHR reporting period for which the EP was the receiving party of the transition

EPs who do not receive any transitions of care would be exempt from reporting this measure

8. Provide

summary of care record for each transition of care or referral

The number of transitions of care and referrals in the denominator where a summary of care record was provided

Number of

transitions of care and referrals during the EHR reporting period for which the EP was the

transferring or referring provider

The percentage must be more than 50 percent in order for an EP to meet this measure

EPs who do not transfer a patient to another setting or refer a patient to another provider during the EHR reporting period would be exempt from reporting this measure 9. Capability to submit electronic data to immunization registries*

N/A N/A Perform one test

during the reporting period

EPs who do not administer immunizations during the reporting period would be exempt from reporting this measure 10. Capability to submit electronic syndromic surveillance data to public health agencies*

N/A N/A 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 an EP, eligible hospital, or CAH submits such

information have the capacity to receive the information

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electronically)

*At least one public health objective must be selected.

Timeline

The first step for any provider wishing to participate in the EHR Incentive Program is to insure they select an EHR software program that is certified for meaningful use and the dermatology specific CCHIT certification (for more information on CCHIT, please visit www.cchit.org). You should conduct a practice wide readiness assessment, workflow analysis, and identify a shortlist of preferred certified vendors. Consider what certified vendors are able to deliver with regard to the best value in terms of technical capabilities, workflow impact, and financial commitment. A vendor’s value should be determined by their certification status. It may also be helpful to test drive your various EHR options to see how the meaningful use criteria is formatted, presented, and recorded so to assess the end-user’s degree of comfort with system usability and workflow impact. Remember vendors that become certified may have different ways of charting and documenting data. Review, test, and verify your satisfaction before investing in a system. Providers can begin registering on the CMS website for the EHR Incentive program at

http://ehrincentives.cms.gov/hitech/login.action. You must be enrolled in PECOS and have an NPPES username and password. If you choose to begin reporting in 2011, you will only need to perform the stated objectives for 90 days. Thus, a provider would need to begin using their certified EHR technology in a meaningful way by October 1, 2011.

Table 5: Timeline Explaining Implementation of Medicare EHR Incentive Program

Reporting Year Must Begin By First Year Payment Reporting Method 2011 October 1, 2011 $18,000 Attest all measures 2012 October 1, 2012 $18,000 Attest all measures

2013 October 1, 2013 $15,000 Electronically submit data directly to CMS 2014 October 1, 2014 $12,000 Electronically submit data

directly to CMS

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Table 6: Overall CMS Incentives Available to Providers YEAR EHR INCENTIVE* E‐PRESCRIBING

INCENTIVE* PQRS INCENTIVE MOC INCENTIVE TOTAL INCENTIVES AVAILABLE 2011 $44,000 (dispersed over a 5 year period) 1% 1% 0.5% 2.5% OR $44,000 + 1.5% 2012 $44,000 (dispersed over a 5 year period) 1% 0.5% 0.5% 2% OR $44,000 + 1% 2013 $39,000 (dispersed over a 4 year period) 0.5% 0.5% 0.5% 1.5% OR $39,000 + 1% 2014 $24,000 (dispersed over a 3 year period) 0% 0.5% 0.5% 1% + $24,000

Note: Percentages based on Medicare Part B allowed charges.

*EHR and e-prescribing incentive cannot be combined. Providers must select one program to participate in.

Table 7: Overall CMS Penalties Applicable to Providers

YEAR EHR PENALTY E‐PRESCRIBING PENALTY PQRS PENALTY TOTAL PENALTIES 2012 0% 1% 0% 1% 2013 0% 1.5% 0% 1.5% 2014 0% 2% 0% 2% 2015 1% 0% 1.5% 2.5% 2016 2% 0% 2% 4% 2017 and beyond 3% 0% 2% 5%

Note: Percentages based on Medicare Part B allowed charges.

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