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Medicare/Medicaid EHR Incentive Program

The American Recovery and Reinvestment Act (ARRA) of 2009 authorizes the Centers for Medicare & Medicaid Services (CMS) to provide financial incentives to eligible professionals and hospitals that demonstrate "meaningful use" of certified electronic health record (EHR) technology.

In general, you will be considered a meaningful EHR user during an EHR reporting period in a payment year if you use certified EHR technology to capture, exchange and report specific information/quality measures.

New AMA White Paper on ICD-10, EHRs, and Administrative Simplification
The AMA has published a new white paper that discusses the promised benefits of ICD-10, EHRs, and administrative simplification. The paper describes the initial regulations and anticipated gains from them. Recommendations on what practices can do to achieve these benefits are also provided.

Use of certified EHR technology

Part of qualifying for EHR incentives involves the use of technology that is certified by the U.S. Department of Health and Human Services (HHS). HHS included both complete EHR systems and EHR modules in its definition of certified technology, meaning you can: (1) purchase a comprehensive certified package from a single vendor or (2) purchase certified components from different vendors. If you are already using an EHR or a module(s) and are unclear whether it is or will be certified for use under the Medicare / Medicaid EHR Incentive Program (often referred to as the "Meaningful Use Program"), ask your vendor what their plans are. Also, if your vendor indicates they are certified, verify this by visiting the website for the Office of the National Coordinator for Health IT, the federal agency within HHS that is charged with certifying EHRs.

Visit the Office of the National Coordinator for Health Information Technology (ONC) website for more on certification specifics. Also see the final rule on standards, specifications, and certification criteria for EHR technology, issued October 4, 2012, by HHS/ONC for Stage 2 of the EHR Meaningful Use Incentive Program. More information about the various “Stages” of the program can be found below.

Demonstrating meaningful use

The Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs are staged in three steps with increasing requirements for participation. Eligible professionals begin participating by meeting the Stage 1 requirements for a 90-day period in their first year of meaningful use and a full year in their second year. To receive the full incentive amount – $43,720 – eligible professionals participating in the Medicare EHR Incentive Program must have attested for meaningful use in 2011 or 2012. Eligible professionals who start the Meaningful Use Program in 2013 or later can receive reduced incentives up to $38,220. After meeting the Stage 1 requirements, eligible providers will then have to meet Stage 2 requirements for two full years or face a financial penalty.. However, because all eligible providers must upgrade or adopt newly certified EHRs in 2014, all eligible providers regardless of their stage of meaningful use are only required to demonstrate meaningful use for a three-month (or 90-day) EHR reporting period in 2014. Eligible professionals participate in the program on the calendar years, while eligible hospitals and CAHs participate according to the federal fiscal year. For more information please visit the CMS Stage 2 website.

NOTE: The CMS expects physicians to meet meaningful use measures for all patients seen during the reporting period—including both Medicare and non-Medicare patients and private payer non-Medicare/Medicaid patients—in order to qualify for Medicare/Medicaid EHR incentives. The AMA believes that the law only requires accomplishing measures for Medicare (or Medicaid) patients seen/provided services for during the reporting period and does NOT include private payer non-Medicare/Medicaid patients. While the AMA continues to pursue this point with CMS, it is important for physicians to know that CMS expects physicians to meet the meaningful use measures for all patients seen during the reporting period in order to qualify for Medicare/Medicaid EHR incentives.

NOTE: Physicians who are not participating in Medicare but are interested in receiving incentives for using certified EHR technology are eligible as long as they submit claims to Medicare for Part B physician fee schedule services on behalf of Medicare patients to whom they furnish services. Physicians must also successfully register and demonstrate meaningful use of certified EHR technology. The calculation of a physician’s incentive payment will reflect claims for all services reimbursed under the Part B physician fee schedule regardless of whether the physician accepted assignment on those claims or not.

To learn more please visit the CMS FAQ Web page.

Stage 1

Following substantial input from the AMA and other stakeholders, CMS published the final requirements physicians and hospitals will need to meet to receive these incentives. The final rule for Stage 1 was published in the Federal Register. Learn more about what requirements must be met for Stage 1.

The AMA has developed a series of short fact sheets and frequently asked questions which provide a brief overview of the requirements for Stage 1, found below.

CMS Specification Sheets for Stage 1 for each requirement.

Stage 2

CMS Extends Stage 2 through 2016
The Centers for Medicare and Medicaid Services (CMS) announced they are extending Stage 2 of the Meaningful Use (MU) program -- which starts January 1, 2014 -- through 2016. Originally CMS planned Stage to end after 2015. The Stage 2 extension follows a recommendation by the AMA made to CMS to ensure physicians have adequate time to participate in Stage 2 before being thrust into Stage 3. This mimics CMS' actions with Stage 1 which was also extended a year at the AMA's urging. Also announced is that physicians will have to upgrade to Version 2017 software to meet Stage 3, though vendors will be permitted to conduct voluntary 2015 and 2016 software upgrades to their products should they choose.

The requirements for Stage 2 are final. The AMA has summarized CMS' final requirements for Stage 2, and prepared a table tracking the final requirements.

CMS has created a toolkit to help understand how to meet the Stage 2 requirements.

CMS Specification Sheets for Stage 2 for each requirement.

Septemeber 24, 2013 letter sent by 17 U.S. Senators to HHS requesting more time for eligible professionals to meet Stage 1 if they need it before moving to Stage 2.

Stage 3

Stage 3 Meaningful Use Recommendations Move Forward
On March 11, 2014 the Health IT Policy Committee (HITPC) -- a group of private sector volunteers commissioned by the Office of the National Coordinator (ONC) to provide HIT recommendations to the federal government -- voted in favor of 18 proposed Meaningful Use (MU) objectives that will be considered for Stage 3 of the EHR Incentive Program. These objectives focus on four areas of emphasis: clinical decision support, patient engagement, care coordination, and population management.

The MU timeline calls for a notice of proposed rule-making to be published in the fall of 2014 with the final rule for Stage 3 to be issued in the first half of 2015. Physician participation in Stage 3 is not scheduled to start until 2017.

At the March 11th meeting, the AMA made public comments reflecting concern for the current trajectory of the MU program. The AMA, along with other members of the medical community, believe that advancing Stage 3 objectives without taking time to reevaluate lessons learned from both Stages 1 & 2 will only increase the burden on physicians and hospitals. In addition, our comments cited the need for a less prescriptive MU program. The AMA will continue to advocate for MU objectives that do not impede physicians' workflow and to increase attention on the needs of physician specialists.

Support for becoming a meaningful user

There are numerous online resources available to physicians interested in becoming a "meaningful user" of an EHR, many of which are listed below under "Additional Resources." The Agency for Health Research and Quality (AHRQ) has developed a webpage on Meaningful Use with detailed and downloadable lists of each requirement. In addition, the federal government is funding entities known as "Regional extension centers" (RECs) which are aimed at helping primary care physicians select and adopt a certified EHR. Locate your REC using ONC’s interactive map or by visiting ONC’s REC Web page. Also, see this facts-at-a-glance document on the RECs.

EHR Usability

Usability is the capacity for an individual to learn and easily use an object. Both utility (how well a system handles the work a user must do) and ease-of-use are factors in usability. For, electronic health records (EHRs) and other health information technology, usability is a key component in promoting adoption and continued use.

The AMA strongly believes that EHRs should facilitate a physician’s practice and improve patient care. EHRs should enhance care coordination, practice efficiencies, and processes that improve health outcomes. The usability of EHR products should also support decision-making and not circumvent the need for critical thinking.

To improve care EHRs and other health technology must work well for the people who use them. Unfortunately, the swift implementation of EHRs has compelled physicians to purchase tools not yet optimized for patients or doctors. As a result, EHRs can often impede, rather than enable, efficient clinical care. Information clinicians and others are unable to find what they need, cannot easily understand what they find, and are unable to use the technology effectively, efficiently, safely, and with satisfaction.

The AMA believes that the addition of user-centered design (UCD) in the development of EHR products can improve usability and increase physician satisfaction with EHRs. UCD is a design process that focuses on the needs, wants, and limitations of end users. Although there are many variations of the UCD process, analyzing and incorporating user requirements from the beginning of the development cycle is a fundamental attribute of UCD. In addition, there is a need to better understand the relationship between clinical workflows, EHR usability, and patient safety to ensure that EHRs enhance established clinical processes without negatively impacting patient outcomes.

The AMA continues to interface with key stakeholders in the EHR industry and advocate that ONC include robust UCD when certifying EHR technology. Below are links to the AMA’s letters and testimony from 2013 regarding EHR usability:

May 8, 2014 comment letter to CMS and ONC providing input on ways to improve the EHR Meaningful Use program

July 23, 2013 AMA testimony before ONC's Health IT Implementation and Certification/Adoption Workgroups

June 14, 2013 letter to HHS on Penalty Programs and ICD-10

AMA response to Senators Thune, Alexander, Roberts, Burr, Coburn and Enzi on the "Reboot White Paper"

May 3, 2013 AMA Chair Steven J. Stack, MD testifies before CMS on EHR Meaningful Use, May 3, 2013

January 14, 2013 comment letter to ONC on HIT Policy Committee's Proposed Stage 3 Meaningful Use criteria

Additional resources:
RAND/AMA report on physician professional satisfaction

AmericanEHR vendor and product review community site

Selecting an EHR

Online Forum
AmericanEHR Partners, in partnership with the AMA, is an online community of physicians and other health care providers who use information technology to deliver care to Americans. Through education, social media, and the collection of peer-contributed data, it organizes information to facilitate optimal decision making.

AmericanEHR Partners provides the ability for a physician to rate his or her EHR system or comment on other ratings from verified physicians who participate within the AmericanEHR community. Much like Internet message boards, AmericanEHR facilitates group discussion and allows users the opportunity to refine their search for product information by criteria that are most relevant to them, for instance, practice size and specialty. However, unlike Internet message boards, all ratings and discussion topics are originated by verified members who must register with AmericanEHR Partners and are compared against a physician master file, ensuring real users are discussing and rating real products.

The AMA encourages physicians to take advantage of AmericanEHR Partners. Registration is fast, easy, and provides a structured community for the discussion and discovery of EHRs and their vendors. Physicians can register today and see what others are saying about their EHR.

EHR Contracts
The Office of the National Coordinator for Health IT (ONC) through a contract with Westat, published a guide, EHR Contracts: Key Contract Terms for Users to Understand, aimed at helping break down the types of terms physicians can find in contracts with EHR vendors.

Avoiding meaningful use penalties

File for a hardship by July 1, 2014 if eligible.

A tip sheet from AMA describes the hardships available and how to file.

Eligible professionals (EPs) participating in the Medicare EHR Incentive Program may be subject to penalties beginning on January 1, 2015. CMS will determine the penalties based on meaningful use data submitted prior to the 2015 calendar year. EPs must demonstrate meaningful use prior to 2015 to avoid penalties.

Determine how your EHR Incentive Program participation start year will affect the 2015 penalties:

  • If you began in 2011 or 2012...
    If you first demonstrated meaningful use in 2011 or 2012, you must demonstrate meaningful use for a full year in 2013 to avoid the penalties in 2015.
  • If you began in 2013...
    If you first demonstrate meaningful use in 2013, you must demonstrate meaningful use for a 90-day reporting period in 2013 to avoid the penalties in 2015.
  • If you plan to begin in 2014...*
    If you first demonstrate meaningful use in 2014, you must demonstrate meaningful use for a 90-day reporting period in 2014 to avoid the penalties in 2015. This reporting period must occur in the first 9 months of calendar year 2014, and EPs must attest to meaningful use no later than October 1, 2014, to avoid the penalties.

* Because all physicians – no matter when you started the meaningful use program – must upgrade or adopt newly certified EHRs in 2014, all physicians regardless of their stage of meaningful use are only required to demonstrate meaningful use for a three-month (or 90-day) EHR reporting period in 2014.

Avoiding penalties in the Future
You must continue to demonstrate meaningful use every year to avoid penalties in subsequent years. If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you MUST demonstrate meaningful use to avoid the penalties. You may demonstrate meaningful use under either Medicare or Medicaid.

If you are only eligible to participate in the Medicaid EHR Incentive Program, you are not subject to these penalties.

Helpful Resources
For more information on EP penalties, view the Payment Adjustments and Hardship Exceptions Tipsheet for EPs.

AMA Advocacy on EHR Incentive Programs

The AMA continues to advocate strongly for making the EHR Meaningful Use Incentive Program more workable for physicians by asking CMS to establish more reasonable reporting requirements, measurement thresholds, and overall flexibility so that all physicians who want to participate are able to do so. Below are links to all of the AMA’s letters and testimony. As a result of significant AMA advocacy, CMS made several changes to the Stage 1 requirements reducing the number of overall requirements and including exceptions to certain measures.

September 15, 2014 sign-on letter to HHS on Meaningful Use

July 21, 2014 AMA comment letter to CMS on proposed modifications to certified EHR technology and Meaningful Use reporting periods.

July 7, 2014 comment letter to FDA on Food and Drug Administration Safety and Innovation Act (FDASIA) Health IT Report

June 5, 2014 AMA letter to CMS, ONC, and OIG on EHR Program Integrity Guidance

May 16, 2014 AMA letter to CMS on Meaningful Use and PQRS audits

May 8, 2014 comment letter to CMS and ONC providing input on Meaningful Use

April 28, 2014 letter to ONC on Version 2015 voluntary certification of EHRs

February 21, 2014 sign-on letter to the Secretary on Meaningful Use

December 18, 2013 AMA Wire article on Selecting an EHR

December 9, 2013 AMA Wire article on meaningful use Stage 2 extension

July 23, 2013 joint letter with AHA on Meaningful Use

July 23, 2013 AMA testimony before ONC's Health IT Implementation and Certification/Adoption Workgroups

June 14, 2013 letter to HHS on Penalty Programs and ICD-10

June 10, 2013 letter to CMS on EHR Safe Harbor under the Anti-Kickback Statute

AMA response to Senators Thune, Alexander, Roberts, Burr, Coburn and Enzi on the "Reboot White Paper"

May 3, 2013 AMA Chair Steven J. Stack, MD testifies before CMS on EHR Meaningful Use, May 3, 2013

April 22, 2013 AMA response to CMS and ONC on HIE RFI

February 1, 2013 comment letter to ONC on HIT Policy Committee's Patient Safety Action and Surveillance Plan

January 14, 2013 comment letter to ONC on HIT Policy Committee's Proposed Stage 3 Meaningful Use criteria

May 7, 2012 sign-on letter to CMS on Proposed Stage 2 Meaningful Use Rule

May 7, 2012 comment letter to ONC on Proposed Stage 2 Certification Rule

March 1, 2012 health IT and patient safety letter to ONC.

June 29, 2011 Sign-on letter to HHS on Stage 1 and Stage 2 MU measures, accompanied by a matrix illustrating applicability to different specialties of Stage 1 and proposed Stage 2 Meaningful Use requirements, and a color-coded dashboard depicting overall ability of several specialties to meet EHR Incentive Program requirements.

April 21, 2011 statement to ONC HIT Policy Committee on usability of EHRs

February 25, 2011 sign-on letter on proposed requirements for Stage 2 meaningful use of EHRs

January 27, 2011 letter to CMS opposing application of Meaningful Use requirements to private pay patients and March 10, 2011 response from CMS

June 16, 2011 cross-industry letter to HHS on EHR Incentive Program

July 2010 press release on Stage 1

March 15, 2010 letter to CMS on Stage 1 proposed rule signed by several state and specialty medical societies

August 2009 letter and attached matrix to CMS and ONC in reaction to the Health IT Policy Committee’s proposal on meaningful use

September 17, 2009 letter to HHS on meaningful use

September 29, 2009 letter AMA signed onto concerning lack of sufficient quality measures for specialists

Meaningful use audits

The AMA has received a number of complaints and concerns associated with physicians undergoing an audit for receipt of the Meaningful Use (MU) of Electronic Health Records (EHRs) Incentive program including requests for information to support attestation which difficult to produce (i.e. screen shots showing a requirement was met since some products cannot do this), requests for information that physicians were never informed they needed to retain, extremely short response times to furnish information to the MU audit contractor, and physician who have received both pre-payment and post-payment audits. Presently between 5% to 10% of "eligible professionals" (which includes physicians) are being targeted for a Meaningful Use audit. The AMA has communicated these concerns to CMS and they are exploring our concerns in greater depth. Should a physician come across any of these problems they are urged to communicate this to the MU audit contractor (i.e. ask for more time to comply, indicate any documents they are unable to furnish). CMS has also said it was not their intention to target the same physician for both a post-pay and pre-pay audit. Physicians who have encountered this problem are encouraged to contact the contractor as well. The contact information for the MU audit contractor can be found below:

Peter Figliozzi
Figliozzi & Company, CPAs P.C.
585 Stewart Avenue
Suite 416
Garden City, NY 11530
(516) 745-6400 ext. 302

The AMA has advocated since the inception of the MU program for greater flexibility in meeting the program’s requirements. We have also advocated for certified EHRs to have better capabilities for helping physicians demonstrate to the Centers for Medicare and Medicaid Services (CMS) that in the event of an audit that they have met the requirements. We continue to engage CMS and the Office of the National Coordinator on these concerns. It is our understanding that physicians who have undergone these audits have been most challenged in demonstrating they met the “yes/no” requirements that call for attestation as well as proving they successfully met the security risk analysis. CMS has shared the following two documents on the audit process which may be of interest to your members: 1) EHR Incentive Programs Supporting Documentation for Audits; and 2) EHR Incentive Programs Audits Overview. CMS has also posted information to their website.

Additional resources