Published 8/1/2010
Michele M. Zembo, MD, MBA

Final EHR meaningful use rules released

Temporary rules on EHR certification also released

The electronic health record (EHR) train continues to roll. The Health Information Technology for Economical and Clinical Health (HITECH) Act provisions of the American Recovery and Reinvestment Act (ARRA) of 2009 got the train on the track; the recently released temporary rules for EHR certification and final ‘meaningful use’ criteria are keeping the momentum going.

The HITECH provisions of ARRA allow the Centers for Medicare & Medicaid Services (CMS) to offer financial motivation to providers who become meaningful users of EHRs. After the Department of Health and Human Services (HHS) released proposed regulations for meaningful use requirements (what providers have to do as a minimum to quality for any financial reimbursement), it received more than 2,000 comments from individuals, physician groups such as the AAOS, and other organizations.

The concept behind meaningful use is to improve health and transform health care through the use of health information technology (HIT) in a measurable way. HHS identified the following three stages in the process: data capture and sharing, advanced clinical processes, and improved outcomes. It also focused on five domains: quality, safety, and efficiency; patient engagement; care coordination; public health; and privacy and safety of personal health information.

According to David Blumenthal, MD, the nation’s HIT coordinator, another long-term goal of meaningful use is to have information follow a patient wherever that patient goes in the healthcare system. He also sees EHR adoption as a competitive advantage for practices, both in recruiting new physicians and in selling the practice. Dr. Blumenthal believes connectivity among physicians, hospitals, laboratories, and pharmacies will help medical practices maintain their independency.

Temporary certification program in place
On June 18, 2010, HHS released a final regulation for a temporary certification process for EHR vendors. This regulation establishes the steps required for an organization to be authorized as a certifying body and the steps required for an EHR vendor to have products certified against meaningful use criteria. To qualify for Medicare or Medicaid EHR incentive payments (
Table 1), physicians must use an EHR that has been certified by the Office of the National Coordinator for Health Information Technology–Authorized Testing and Certification Body (ONC-ATCB).

Until now, the Certification Commission for Health Information Technology (CCHIT) has been the only organization recognized by the federal government as offering certification for EHRs. Under the new guidelines, CCHIT will have to apply to be an EHR-certifier. HHS specifically has stated that “any certifications issued by an organization that is not an ONC-ATCB at the time of issuance will be invalid for the purpose of meeting the definition of certified EHR technology and cannot be used to qualify for incentive payments.”

While physicians wait to find out which EHRs will become certified, CMS took a step toward integrating the Physician Quality Reporting Initiative (PQRI) and meaningful use, as required under the Patient Protection and Affordable Care Act of 2010. In its proposed rule setting payment policies for Medicare Part B for calendar year 2011, CMS starts the steps toward integration. CMS plans to roll PQRI into meaningful use; in the future, physicians and hospitals will not be able to receive PQRI bonuses unless they are using an HHS-certified EHR.

Meaningful use rules
On July 13, HHS released the final meaningful use rules for 2011 and 2012. Responding to concerns about the pace and scope of implementation, HHS believes that it has added flexibility and options so that providers are more likely to achieve the goals to be eligible for the incentive payments.

A two-track approach has been established for the first 2 years, replacing the previously proposed “all-or-nothing” approach. The final rule establishes a set of core objectives that constitute meaningful use; physicians can choose to implement additional activities from a set list.

HHS has also lowered the threshold necessary to meet the criteria for computerized physi-cian order entry (CPOE) from 80 percent of all orders (including lab tests, referrals, and drugs) to at least one drug order through CPOE for 30 percent of patients.

Core objectives comprise tasks essential to creating a patient’s medical record, including basic data, vital signs and demographics, active medications, allergies, up-to-date problem lists, current and active diagnoses, and smoking status.

Other core objectives include features that help physicians and others make better clinical decisions and avoid preventable errors. For example, physicians will need to use EHRs to enter clinical orders (prescriptions) and to provide patients with electronic versions of their health information.

The rules allow physicians to choose an additional five tasks to implement in 2011 and 2012. The list of additional tasks includes performing drug-drug interaction and drug formulary checks, incorporating clinical laboratory results, providing reminders to patients regarding needed care, identifying and providing patient-specific health education resources, and supporting patient transitions between care settings and physicians.

The ambulatory setting has 25 meaningful use criteria for EHRs in the final rules; physicians will have to meet all of the core criteria and five from a menu of options. Initially, incentive dollars are at stake in meeting the criteria (up to $44,000 for Medicare or $63,750 for Medicaid for each eligible physician). Eventually, there will be payment penalties for not meeting the rules.

The final rule for standards and certification criteria has also been released. This rule establishes the required capabilities EHR technology will need for certification. These defined capabilities and related standards will enable physicians to achieve meaningful use in Stage 1. A certified EHR for the ambulatory setting must include at least nine clinical quality measures specified by CMS.

The push for adoption
States and private payors are joining the push for EHR adoption. Massachusetts has already passed healthcare reform legislation requiring EHR adoption by 2015. A Maryland law that takes effect in 2011 requires private insurers to provide financial incentives to physicians to advance EHR adoption, leaving the choice of incentive to the insurer. CareFirst Blue Cross Blue Shield currently offers increased reimbursements to doctors who use EHRs under the Maryland/DC Physician EHR Demonstration Collaborative.

Medicare Advantage Plans will also require practices to adopt meaningful use of EHRs. Beginning in 2012, these plans will be eligible for bonus payments based on meeting quality performance improvement goals; adopting EHRs and meeting meaningful use criteria are anticipated to play a strong role in these bonus plans.

Orthopaedic surgeons will have to pay close attention to all the information from Washington, DC, with regard to EHR implementation because the programs for bonus payments begin in 2011. CMS has recently launched a new Web site to help physicians stay up-to-date. The Web site includes details about the incentive programs, eligibility, and certification information.

More information is also available in the AAOS online Practice Management Center.

Michele M. Zembo, MD, MBA, is codirector of the AAOS course, Practice Forward: Managing Your Practice Ahead of the Curve, which takes place Sept. 24–26, in Chicago. She can be reached at mzembo@tulane.edu