The Good, the Bad, and the Ugly of the
EHR Meaningful Use and Certification
Final Rules:
What Hospital Leaders Should Know about
the Medicare EHR Incentive Program
September 9 and 10, 2010
1
Background and Overview
2
HITECH Act
HITECH Act created the Medicare and Medicaid EHR Incentive Programs
•HITECH Act was a section of the 2009 Federal Stimulus Bill – the American
Reinvestment and Recovery Act (ARRA).
•HITECH Act directs the Centers for Medicare and Medicaid (CMS) and the Office
of the National Coordinator for Health Information Technology (ONC) to
promulgate regulations implementing the EHR Incentive Programs.
Meaningful use and EHR certification rules
•Health care providers must be “meaningful users” of “certified” electronic
health records in order to receive Medicare HIT incentive payments/not receive
penalties.
3
Rulemaking
Proposed Meaningful Use and EHR Certification rules
•Released in December 2009.
•WHA and a number of Wisconsin hospitals submitted comments.
Final Meaningful use and EHR certification rules
•Published in July 2010.
•No comment period.
4
Major Changes to Final Rule
Proposed Rule - December 2009
Final Rule - July 2010
All-or-nothing approach.
Some flexibility for meeting MU
requirements.
Physicians in hospital OPDs and clinics
excluded.
Physicians in hospital OPDs and clinics, now
included, per legislation fix.
CAHs ineligible for Medicaid incentives.
CAHs now eligible for both Medicaid AND
Medicaid incentives.
High number of quality measures,
required, not all of which had electronic
specifications.
Fewer quality measures to report; all with
electronic specifications.
Inequitable treatment of multi-campus
hospital systems.
Multi-campus hospital system inequity not
addressed.
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The Good…
Modified “all or nothing”
•Proposed Rule – 23 requirements
•Final Rule – 14 requirements PLUS choose 5 of 10 additional functionality
requirements (1 public health related). Measures generally easier to meet.
CAHs now eligible for Medicaid EHR incentives
Exclusion for “hospital-based physician” narrowed
•Congress passed legislation correcting language that excluded many physicians
who work in hospital-owned clinics from receiving EHR incentives
Reduction in reporting burden
•Certification rule now requires certified EHRs to automatically calculate the
meaningful use measures.
6
The Bad…
Multi-campus hospital definition remains unchanged
•Hospitals are defined by their provider number.
Introduction of non-EHR related policy
•Measure - 10% of admitted patients are “provided patient-specific education
resources.”
No long term plan
•CMS declined to follow recommendations to set requirements through 2017.
•Stage 2 begins as early as October 1, 2012. Stage 2 criteria “expected” by “end
of 2011.”
•Unclear if new criteria for FY2015 (penalty year) and beyond.
7
The Ugly.
Regulatory uncertainty will hinder hospitals’ ability to meet timelines
•No certified EHRs currently exist; certifying bodies just announced.
•Ambiguity in regulations; CMS to provide additional guidance and explanation.
•Unknown future stages.
Widespread adoption of EHRs?
•CMS estimate: As few as 32.1% of hospitals will get the maximum incentive.
•CMS estimate: As many as 33.7% of hospitals will receive penalties.
CMS agrees that rural hospitals will have a more difficult time achieving MU
•CMS believes additional $12K to CAHs (contingent on achieving MU) will lessen
disparities.
Hidden functionality requirements in quality measure requirements
•Significant changes to existing EHRs needed to calculate quality measures.
8
WHA’s Early Advocacy Strategy
House Ways and Means Subcommittee
•Letters to Reps. Kind and Ryan
•Contacts with their offices
D.C. visits
Multi-campus issue
9
Key Provisions
10
Medicare Incentive Timelines
First
Qualifying
Year
FFY 2011
FFY 2012
FFY 2013
FFY 2014
FFY 2015
Stage criteria EHs and EPs must meet in each payment year:
FFY
2011
FFY
2012
FFY
2013
FFY
2014
FFY 2015
and Beyond
Stage 1
Stage 1
Stage 2
Stage 2
TBD
Stage 1
Stage 1
Stage 2
TBD
Stage 1
Stage 1
TBD
Stage 1
TBD
TBD
•Only 90 days of compliance must be shown in first payment year.
•FFY begins October 1.
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Medicare Incentive Timelines
Incentive Payment Transition Factor for PPS Hospitals
Year hospital first qualifies
FFY
2011
Year
hospital
meets MU
and
receives
incentive
payment
FFY
2012
FFY
2013
FFY
2014
FFY
2015
FFY 2011
100%
FFY 2012
75%
100%
FFY 2013
50%
75%
100%
FFY 2014
25%
50%
75%
75%
25%
50%
50%
50%
25%
25%
25%
FFY 2015
FFY 2016
•Only 90 days of compliance must be shown in first payment year.
•FFY begins October 1.
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Medicare Incentive Timelines
Penalties if not adopting by FY 2015
FFY
2015
FFY
2016
FFY
2017
PPS Hospitals - Three-quarters of the applicable
market basket update is reduced by:
33.33%
66.66%
100%
CAHs – Allowable Medicare cost reimbursement
percentage reduced to:
100.66%
100.33%
100.00%
•FFY begins October 1.
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PPS Hospital Medicare Incentive Payment Formula
Step 1: Calculate base dollar
amount
($2 million + (your discharges from 1150 through and
including 23,000)*200))
Example assuming 3,149 discharges (2,000 within
eligible range):
$2 million + $400,000 = $2,400,000
Step 2: Calculate “Medicare
Share”
Medicare inpatient days / (total inpatient
days*((gross revenue – charity) / gross revenue))
Step 3: Multiply base by
Medicare share
Using an example Medicare Share of .50: $2,400,000
X .50 = $1,200,000
Step 4: Determine payment
for each year (Assuming 4
years of payments)
Payment Year 1:
Payment Year 2:
Payment Year 3:
Payment Year 4:
$1,200,000 (100%)
$900,000 (75%)
$600,000 (50%)
$300,000 (25%)
14
CAH Medicare Incentive Payment Formula
•Basis for CAH Medicare EHR incentive payments is the reasonable cost
reimbursement structure.
•Design of Medicare EHR incentives allows CAHs to accelerate and increase the
inpatient payment for depreciation of reasonable costs for purchase of
depreciable assets such as computers and associated hardware and software,
to support meaningful use of certified EHR technology
•Reasonable costs can be depreciated in a single year, rather than over the
life of the assets.
•The costs of assets incurred in previous years that have not been fully
depreciated may also be included.
•Medicare’s share of CAH EHR incentives is calculated the same as the PPS
hospital EHR incentives plus 20 percentage points (not to exceed 100%).
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CAH Medicare Incentive Payment Formula
Step 1: Calculate Cost of HIT
Hypothetical:
FY 2011: $5 million
FY 2012: $5 million
FY 2013: $5 million
FY 2014: $5 million
Step 2: Calculate Medicare
Share
(Medicare inpatient days / (total inpatient
days*((gross revenue –charity) / gross revenue))) +
20%
Step 3: Multiply Cost by
Medicare Share
Using an example Medicare Share of 50%, plus 20%
bonus = 70%
$20,000,000 X .70 = $14,000,000
Step 4: Calculate 101% of
Medicare Share of Costs
Total Payment: 101% * $14,000,000 = $14,140,000
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Medicaid EHR Incentive Program
Significant differences between the Medicare and Medicaid EHR Incentive
Programs
•Only eligible for Medicaid Incentive Program if:
• The hospital is a children’s hospital or
• 10% or more of the hospital’s volume is attributable to Title XIX Medicaid.
•Hospitals can receive both Medicaid and Medicare EHR incentive payments;
eligible professionals must choose either Medicaid or Medicare EHR incentive
payments.
Focus of WHA’s September 21 webinar
•Additional information on the Medicaid EHR Incentive Program can be found at:
http://www.wha.org/education/default.aspx
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Meaningful Use Measure Highlights
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Meaningful Use Measure Highlights
CPOE retained, but substantially revised
•Objective: Use CPOE for medication orders directly entered by any licensed
healthcare professional who can enter orders into the medical record per state,
local and professional guidelines.
•Measure: More than 30% of unique patients with at least one medication in
their medication list admitted to the eligible hospital’s or CAH’s inpatient or
emergency department (POS 21 or 23) have at least one medication order
entered using CPOE.
•CPOE only required for medication orders in Stage 1.
•Others may enter the order.
•Measure limited to “patients whose records are maintained using certified EHR”
•Emergency department included in measure.
•Stage 2 increases percentage to 60%.
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Meaningful Use Measure Highlights
Quality measures and submission revised…
•Hospitals must report 15 measures (3 sets)
•Endorsed by National Quality Forum
•Not in current quality reporting program (RHQDAPU)
•“e-specified” but not field tested
•Calculation through the EHR, but submission is through attestation in 2011
•Numerators
•Denominators
•Patient exclusions
•Anticipate electronic submission in 2012
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Meaningful Use Measure Highlights
Quality measures and submission revised
Condition
Emergency Department Throughput
Measure Name
Median time from ED arrival to ED departure for
admitted patients
Admission decision time to ED departure time for
admitted patients
Stroke
Venous Thrombo-embolism (VTE)
Discharge on anti-thrombotics
Anticoagulation for A-fib/flutter
Thrombolytic therapy for patients arriving within 2
hours of symptom onset
Anti-thrombotic therapy by day 2
Discharge on statins
Stroke education
Rehabilitation assessment
VTE prophylaxis within 24 hours of arrival
Intensive care unit VTE prophylaxis
Anticoagulation overlap therapy
Platelet monitoring on unfractionated heparin
VTE discharge instructions
Incidence of potentially preventable VTE
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Meaningful Use Measure Highlights
…but the new quality measures contain hidden functionality requirements
•The 15 quality measures require data capture functionality beyond the initial
EHR functional requirements explicitly required in certification and MU rule.
•Examples:
•Data sources for the quality measures include physician documentation,
medication administration, computerized provider order entry and
discharge instructions.
•Data elements for quality reporting must be in structured formats that are
not widely used.
•Computer Sciences Corporation study:
•Hospitals meeting the explicit data capture requirements under meaningful
use will have only 35% of the data needed for the hospital quality measures.
•The remaining 65% are hidden requirements of meaningful use.
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Certification Rule Highlights
Hospitals must “attest” that they have certified EHR technology
•Complete EHR, or
•Combination of EHR modules.
Certification requirements linked to each meaningful use criteria
No grandfathering of CCHIT certification
•All providers with existing CCHIT certified EHRs will need to re-certify
No EHRs will be certified until ONC establishes certification entities
•ONC will approve “ONC testing and certification bodies” (ONC-ACTBs)
•First ONC-ACTBs announced last week: CCHIT and the Drummond Group.
•ONC anticipates first certifications by the end of the year.
Certification will be for 2011-2012
•NEW certification will be required in 2013.
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Resources
WHA Toolkit
•http://www.wha.org/toolKit/default.aspx
WHA Education
•http://www.wha.org/education/default.aspx
•Sept 21 - Medicaid and Meaningful Use - The "Other" EHR Incentive
Program: What Hospital Leaders Should Know About the Medicaid EHR
Incentive Program (Webinar)
•Third Party Webinars
EHR Consulting Database (coming soon)
ONC Resources
•http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3006&PageID=20401
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Questions?
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