Meaningful Use: Electronic Health Record (EHR) incentive programs

The Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program—also known as Meaningful Use or MU—initially provided incentives to accelerate the adoption of electronic health records (EHRs) to meet program requirements.

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Now, physicians who fail to participate in MU will receive a penalty in the form of reduced Medicare reimbursements. Physicians must use certified electronic health records technology (CEHRT) and demonstrate meaningful use through an attestation process at the end of each MU reporting period to avoid the penalty.

Avoiding the 2017 Meaningful Use penalty

The AMA is encouraging all physicians subject to the 2015 Medicare MU program to apply for a hardship exception. CMS has stated that it will broadly accept hardship exemptions because of the delayed publication of the program regulations. Applying for the hardship will not prevent a physician from earning an incentive. Applications for physicians are due July 1, 2016.

How to avoid the 2017 Meaningful Use penalty (PDF) (members only)

Meaningful Use: Overview

CMS developed a program that requires physicians using CEHRT to capture, exchange and report specific clinical data and quality measures. The program, which began in 2011, evolved over the course of 3 stages:

Stage 1 established the base requirements for electronic capturing of clinical data.
Stage 2 encouraged the use of EHRs for increased exchange of information and continuous quality improvement at the point of care.
Modified Stage 2, released in October 2015, consolidated Stages 1 and 2 into a new program. These are the current requirements all physicians should follow. While some changes were made to reduce the complexity of the measures, many of the objectives were carried over from Stage 2.

Summary of 2015–2017 Meaningful Use (MU) Final Rule (PDF) (members only)

The requirements for Stage 3 have been published by CMS. Starting in 2018, all eligible physicians will be required to participate in Stage 3.

Summary of the Meaningful Use Stage 3 and 2015 certification rules requirements (PDF) (members only)

MU will eventually become part of the Medicare Merit-based Incentive Program.

Understanding Medicare’s Merit-based Incentive Payment System (MIPS)

Demonstrating Meaningful Use

Physicians participating in MU for the first time in 2016 will not qualify for any MU incentive payments but will be subject to a penalty if they do not participate.

All physicians participating in MU in 2016 must demonstrate the 10 new Modified Stage 2 requirements.

Modified Stage 2 requirements (PDF)

CMS has developed a webpage on 2016 Program Requirements with detailed and downloadable lists of each requirement.

CMS 2016 program requirements

CMS has also posted their presentations on Modified Stage 2 and Stage 3 requirements from the HIMSS 2016 Annual Conference.

CMS presentations on Modified Stage 2 and Stage 3 requirements

To help physicians meet MU requirements, the AMA compiled tip sheets on some of the more complex measures.

Patient view, download and transmittal of health information (PDF) (members only)

Transition and summary of care (PDF) (members only)

Security Risk Analysis (PDF) (members only)

Using certified EHR technology

Part of participating in MU involves using technology certified by the U.S. Department of Health and Human Services (HHS). Certified technology includes both complete EHR systems and individual modules. Physicians can either purchase a comprehensive certified package from a single vendor or certified components from different vendors.

Physicians should ask their vendor about certification plans if they are unclear whether their EHR technology or module(s) are certified for use in the incentive program. Physicians can verify whether the equipment is certified at the Office of the National Coordinator for Health IT’s (ONC) website.

Office of the National Coordinator for Health IT’s (ONC)

For additional information about 2015 EHR certification criteria see ONC’s final certification rule.

2015 EHR Final Certification Rule

How to select EHR technology

Together with the AMA, AmericanEHR Partners provides the ability for a physician to rate or comment on EHR systems. There are also message boards that facilitate group discussion and allow users to refine their search for product information by using criteria that are most relevant to them, such as practice size and specialty.

AmericanEHR Partners

All ratings and discussion topics come from 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.

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.

The AMA strongly believes that EHR technology should:

Facilitate a physician’s practice
Improve patient care
Enhance care coordination, practice efficiencies and processes
Support decision-making, not circumvent the need for critical thinking

To improve patient care, EHRs and other health technology must work well for the people who use them. Unfortunately, the swift implementation of EHR technology compelled physicians to purchase tools not yet optimized for patients or doctors. As a result, EHR technology can often impede efficient care by making it difficult to find or understand what clinicians need. Sometimes the technology may be challenging to use effectively, efficiently and safely.

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. This process focuses on analyzing and incorporating user requirements from the beginning of the development cycle. The AMA continues to work with key EHR-industry stakeholders and advocate that ONC include robust UCD when certifying technology.

Federal and State Correspondence Finder

However, EHR design is also heavily influenced by the federal requirements for MU and certification. While there are federal requirements on EHR usability, the design priority of EHR vendors continues to be meeting MU objectives, not the needs of physicians and patients. To help elevate this concern, the AMA worked with MedStar Health to identify issues with EHR certification and the incorporation of better UCD principles in the design of health IT products.

AMA and MedStar Health partner to drive improvements in EHR usability

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Privacy and security

As part of both HIPAA and MU requirements, physicians must conduct or review a security risk analysis at least once during each program year. A practice’s size, complexity, capabilities, risk and cost are used to determine the proper methodology to meet this requirement. Conducting this analysis can provide insight into the vulnerabilities in a practice’s heaIth IT. It is important to note that a health IT system is typically larger than just EHR.

The first step in protecting a practice and patients’ health information from cyber attacks is evaluating a system’s security. The rules for a risk analysis are not prescriptive; a number of different tactics can achieve compliance. The AMA has several free resources in the AMA Education Center for AMA PRA Category 1 Credit™ to help physicians build tailored compliance processes.

Additionally, the HHS has materials to help small-to-medium-sized practices become compliant, HHS EHR contracts: Key contract terms for users to understand. (PDF)

AMA advocacy on the MU program

The AMA continues to advocate for making the MU 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 the most recent comments and letters to the administration and Congress.

As a result of significant AMA advocacy, CMS made several changes to the Stage 2 requirements, reducing the number of overall requirements and including exceptions to certain measures.

Following years of advocacy by the AMA, the CMS has removed the computerized physician order entry (CPOE) and clinical decision support (CDS) measures from the Medicare MU program and the ACI component of the Quality Payment Program (QPP). However, the Medicaid MU program continues to include CPOE and CDS measures.

While CPOE and CDS functionality will still be included in EHRs, CMS will no longer require a certain number of orders, that a physician enter the orders, and that physicians implement a certain number of CDS tools. This means that as of Jan. 1, 2017, physician practices are free to develop policies around CPOE and CDS in ways that blend with their workflows and improve care.

AMA letters

What to do if you are audited

The AMA has received a number of complaints and concerns associated with physicians undergoing an MU audit (currently 5 to 10% of eligible professionals) and is working to improve this process. Physicians should communicate any issues to the MU audit contractor:

Peter Figliozzi
Figliozzi & Company, CPAs P.C.
585 Stewart Avenue Suite 416
Garden City, New York 11530
[email protected]
(516) 745-6400 ext. 302

The biggest issue physicians have faced in an audit was demonstrating the "yes/no" requirements that call for attestation proving the security risk analysis was successfully met. To help with the process, CMS posted information online and provided the following:

Safe Harbor rules—donated EHRs

The HHS Office of the Inspector General (OIG) and CMS published companion rules that allow physicians to accept donations of almost free EHR technology (must pay at least 15% of the cost of the technology) from certain health care entities without violating Stark and anti-kickback rules.

HHS Office of the Inspector General (OIG) - Exception for certain electronic health records arrangements (PDF)

CMS published companion rules - EHR safe harbor under the Anti-Kickback Statute; final rule (PDF)

The exception/safe harbor was scheduled to end on Dec. 31, 2013, but due to AMA advocacy, HHS extended the time through 2021. While the AMA pushed for a permanent exception, the extension brings welcomed relief for physicians continuing to struggle with the high cost of implementing EHR technology. The rules also made several other notable changes:

Excluded labs from the types of entities that may donate EHR technology
Updated the definition of what type of software is considered interoperable for the purposes of donations
Clarified the requirement prohibiting any action that limits or restricts the use, compatibility or interoperability of donated items or services
Removed from the exception the requirement related to electronic prescribing capability

HHS accepted the argument that labs should be removed from the types of entities permitted to donate EHRs to physicians due to concerns that the items could be used to secure inappropriate referrals. However, the AMA advocated that a preferable approach is one focused more on the need for better education around the limits of the safe harbor and exception for EHR donations.