CMS unveils plan for how doctors, hospitals can get EMR incentives

Some organizations worry about the speed at which health professionals are expected to move in adopting EMR capabilities.

By Chris Silva — Posted Jan. 18, 2010

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The federal government has issued two sets of regulations that are designed to lay the groundwork for physicians and hospitals to receive payments for implementing and utilizing electronic medical records.

A proposed rule issued by the Centers for Medicare & Medicaid Services outlines provisions governing EMR incentives and details what constitutes meaningful use of the technology -- a prerequisite for receiving any bonus dollars. A separate, interim final regulation issued by the Office of the National Coordinator for Health Information Technology sets initial standards and certification criteria for the use of approved EMRs.

Both rules were posted in the Federal Register on Jan. 13 and will be open for public comment for 60 days. Numerous organizations, including the American Medical Association, said they were reviewing the rules and plan to offer comments.

At stake is an estimated $14.1 billion to $27.3 billion in net Medicare and Medicaid incentive payments that the government expects to pay over 10 years. The money was made available through the economic stimulus package signed into law in early 2009.

For stage 1, which begins in 2011, CMS proposes 25 objectives for physicians and 23 objectives for hospitals to meet to be deemed meaningful EMR users. Stages 2 and 3 will expand the list in 2013 and 2015, and the added requirements will be proposed through future rulemaking. Hospitals and physicians failing to adopt EMRs and meet the objectives by 2015 will face Medicare penalties.

Each stage 1 objective has a corresponding measure attached to it. For example, an objective for physicians to generate and transmit prescriptions electronically requires doctors to submit at least 75% of all prescriptions electronically using certified EMR technology. Other 2011 objectives include using computerized physician order entry, maintaining patient medication allergy lists and recording patient demographics.

The interim final regulation issued by the national coordinator's office describes the standards that must be met for EMRs to be considered certified. The regulation describes standard formats for clinical summaries and prescriptions, standard clinical terminology, and standards for the secure transmission of information over the Internet.

David Blumenthal, MD, the national health information technology coordinator, said the combination of certification and federal dollars would help drive EMR adoption.

Concerns with time

In response to the new rules, some health care organizations cheered the government for taking a long-overdue step toward EMR system interoperability. "We're encouraged by the rules, because it's saying to our industry we're going to have a defined set of data points so that we can achieve interoperability," said American Academy of Family Physicians President Lori Heim, MD, who noted that the majority of her academy's members already have adopted EMRs. "We generally think the meaningful use rules are going to be acceptable and positive for primary care."

The Healthcare Information and Management Systems Society said the proposed regulations present an opportunity to develop a multiyear road map of future expectations.

"There is a lot of work for our membership to do, but at the same time, this is what they have been expecting," said Tom Leary, senior director of federal affairs at HIMSS. "There will be some challenges, though, with getting to an EHR adoption level that is consistent with the stage 1 level of meaningful use."

While the AMA is still reviewing the new rules, it previously had said that some EMR objectives recommended by a federal advisory board for inclusion in the CMS proposed rule appeared too aggressive and inflexible. The Association said it was unreasonable, for instance, to expect physicians to meet EMR objectives on using computerized physician order entry and reporting ambulatory quality measures by the 2011 deadline -- two recommendations that were incorporated into the proposed rule.

"The AMA is committed to EHR adoption that streamlines physician practices and helps them continue providing high-quality care to patients," said AMA Board of Trustees member Steven J. Stack, MD. "We have provided ongoing input this year on standards for the use of EHRs and have stressed the importance of realistic time frames for adoption, the removal of extraneous requirements that would delay successful adoption and reasonable reporting requirements."

Rick Pollack, executive vice president of the American Hospital Assn., cited similar themes. "America's hospitals have serious concerns that the new health information technology rules severely limit hospitals' ability to access federal financing for health information technology that is used to improve patient care."

Pollack said hospitals could be unfairly penalized by the rules. In addition, payment incentives might unfairly exclude physicians who practice at outpatient centers and clinics owned by a hospital, he said.

Marc Probst, a member of the Health Information Technology Policy Committee, the advisory board that made the rule recommendations, said the version released largely followed the intent of the committee's working groups. However, he echoed some of the worries about timing.

"At the pace defined, I think there are many hospitals, clinics and physician practices that may not be capable of achieving meaningful use, and it may negatively incent some from even trying," said Probst, who is also chief information officer with Intermountain Healthcare, a nonprofit system of hospitals and clinics based in Salt Lake City. "Essentially, if they are not well on their way to implementing an EHR solution, many may struggle with the technical and operational requirements."

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Meaningful use guideposts from Congress

The Centers for Medicare & Medicaid Services has proposed rules for how physicians and hospitals can qualify for federal electronic medical records incentive money. Leaving CMS to fill in the blanks, Congress had stipulated that Medicare reward "meaningful users," defined by lawmakers as any eligible professional who:

  • Demonstrates use of certified EMR technology in a meaningful manner.
  • Demonstrates to the satisfaction of the HHS secretary that certified EMR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination, in accordance with all laws and standards applicable to the exchange of information.
  • Using certified EMR technology, submits information on clinical quality measures and other measures as specified by the secretary.

Source: Centers for Medicare & Medicaid Services, December 2009

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The first stage

Under a proposed federal rule, physicians with EMRs would need to meet 25 objectives starting in 2011 to qualify for Medicare and Medicaid incentives. Additional responsibilities would be added for future years via additional rules. Requirements in 2011 for doctors include:

Physician objectives Physician measures
Use computerized physician order entry CPOE is used for at least 80% of all orders
Maintain diagnosis list (ICD-9 or SNOMED) At least 80% of patients have at least one entry or an indication of "none"
Maintain active medication list At least 80% of patients have at least one entry or an indication of "none"
Incorporate clinical lab results At least 50% of all ordered tests are incorporated as structured EMR data
Send reminders to patients for preventive/follow-up care At least 50% of patients age 50 or older receive reminders through the EMR
Check public and private insurance eligibility electronically At least 80% of patients undergo eligibility checks
Submit public and private claims electronically At least 80% of all claims are paperless
Provide patients an electronic copy of health information At least 80% patients who request a copy receive it within 48 hours
Provide clinical summaries for patients At least 80% of all office visits result in a summary
Check capability to provide electronic surveillance data to public health agencies At least one test of the EMR is performed

Source: Centers for Medicare & Medicaid Services, December 2009

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