Figure 1. Incentive payments awarded to clinicians in 2011. Graphic adapted from “Medicare & Medicaid EHR Incentive Programs.”12
Figure 2. Steps toward and resources for achieving stage 1 meaningful use in the Medicare EHR Incentive Programs. EHR indicates electronic health record.
Marcotte L, Seidman J, Trudel K, Berwick DM, Blumenthal D, Mostashari F, Jain SH. Achieving Meaningful Use of Health Information TechnologyA Guide for Physicians to the EHR Incentive Programs. Arch Intern Med. 2012;172(9):731-736. doi:10.1001/archinternmed.2012.872
Author Affiliations: Perelman School of Medicine at the University of Pennsylvania, Philadelphia (Ms Marcotte); Meaningful Use Division (Dr Seidman), Office of the National Coordinator for Health Information Technology (Dr Mostashari), US Department of Health and Human Services, Washington, DC; Office of Information Services (Ms Trudel), Center for Medicare & Medicaid Services (CMS) (Dr Berwick), Baltimore, Maryland; Brigham and Women's Hospital (Dr Jain), Harvard Medical School (Dr Blumenthal), Boston, Massachusetts. Dr Berwick is no longer with CMS.
Over 30 000 clinicians have already qualified to receive initial incentive payments for the meaningful use of electronic health records (EHRs) through the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs. However, 2012 is the final year to receive maximum incentive payments, and many physicians still have questions regarding meaningful use objectives and how to register for, report, and attest to meaningful use. We provide herein an overview of the Medicare and Medicaid EHR Incentive Programs and guide physicians in the process of how to demonstrate meaningful use of health information technology.
According to the National Center for Health Statistics,1 physician adoption rates of a basic electronic health record (EHR) system were 17% in 2008 and 24.9% in 2010; the rates of adoption of fully functional systems were even lower at 4.5% in 2008 and 10.1% in 2010. Among the barriers to adoption, physicians cite high costs—not only of purchasing EHR technology, but also from the lost revenues associated with lower productivity during implementation.2,3
In 2009, Congress passed and President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act.4 The HITECH Act makes available funds for clinicians and hospitals to implement EHRs and also to become meaningful users of certified health information technology (IT). Specifically, the intent of the HITECH Act is to encourage the use of health IT to improve health outcomes by improving quality and efficiency of care, enhancing patients' engagement in their care, and building an infrastructure to digitally exchange health information. The legislation is backed by strong evidence suggesting that EHRs can introduce significant quality-of-care improvements in health care.5
The HITECH Act authorized the creation of the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs that offer physicians incentive payments for completing objectives associated with the meaningful use of EHRs. There are expected to be 3 stages of meaningful use that physicians must achieve to qualify for the full amount of available incentive payments. Each stage will build on the previous stage, incrementally requiring advanced use of technology. The first stage focuses on structured data entry in the EHR; the second stage will guide clinicians on the use of technology toward advanced clinical processes; and the third stage will be aimed at achieving and measuring improved patient outcomes.
Although in 2011, over 30 000 clinicians qualified to receive incentive payments (Figure 1), many physicians still remain uncertain about the EHR Incentive Programs and how to register for, report, and attest to meaningful use. We provide herein an overview of the Medicare and Medicaid EHR Incentive Programs and a guide for physicians on how to achieve meaningful use of EHRs and receive incentive payments from Medicare and Medicaid (Figure 2).
Most US physicians qualify to participate in the EHR Incentive Programs, but there are exceptions. The initial step toward receiving the payments is to confirm eligibility. Physicians may determine whether they are eligible for one or both programs on the CMS website with the help of an automated “eligibility wizard” (http://www.cms.gov/EHRIncentivePrograms/15_Eligibility.asp). Medicare and Medicaid programs differ in their eligibility requirements, physician criteria to receive incentive payments, and associated timelines. Currently, 43 states have launched Medicaid EHR Incentive Programs; the District of Columbia and US territories are also eligible to participate. Table 1 summarizes and compares the Medicare and Medicaid programs.
Physicians must attest to fulfilling meaningful use criteria using certified EHR technology. Certification implies that clinicians using the technology can achieve at least one of the criteria for meaningful use listed in Table 2. A clinician may elect to purchase a complete certified EHR system or to adopt several modules, or software components, that collectively meet the certification criteria. Electronic health records and modules that are certified can be found on the Certified Health IT Product List (CHPL) (http://onc-chpl.force.com/ehrcert), which currently contains over 900 certified health IT products for ambulatory settings.
The HITECH Act stipulated that the EHR Incentive Programs should not be a 1-time incentive opportunity but should help to guide physicians and hospitals in effectively using technology to improve clinical outcomes. Currently, only the criteria for stage 1 meaningful use are finalized. Stage 2 criteria are in the pre–rule-making process; the notice of proposed rule making has been released. Stage 3 meaningful use criteria will be released in 2014.
Stage 1 meaningful use was developed by a transparent, consensus policy process; various stakeholders and experts proposed an initial set of objectives to the US Department of Health and Human Services (HHS), which then published a proposed rule. That rule was then modified after the input of more than 2000 comments from the public. Physicians and hospitals were first able to attest to achieving stage 1 meaningful use and begin receiving incentive payments in April 2011.Table 2 lists stage 1 objectives.
The objectives in stage 1 meaningful use focus on the basic functionality in EHRs necessary to use technology to improve patient care and outcomes. Even if implemented alone, several objectives would introduce important practice improvements. For example, the objective to implement at least 1 clinical decision support rule may help clinicians avoid ordering repetitive radiology and laboratory tests; medication-allergy checks and electronic prescribing can prevent adverse drug events. The real potential for meaningful use, however, lies in meeting the objectives as a set. The stage 1 objectives were carefully chosen so that physicians may use the EHR functionalities collectively to achieve priority health care goals. Subsequent stages will aim to build on the technology capabilities and improved patient outcomes.
While stage 1 meaningful use focuses on establishing a foundation for effective integration of health IT into clinical practice, later stages will focus on some of the more difficult capabilities such as health information exchange, quality reporting, and population management. Specifically, physicians can expect in stage 2 meaningful use more ambitious thresholds for e-prescribing and the incorporation of laboratory results into the EHR, as well as requirements for increased accessibility of data by patients and transmission of patient care summaries electronically. Stage 3 will concentrate on, among other things, measured improved outcomes, clinical decision support for national health priorities, self-management tools accessible to patients, and fully operational and patient-centered Health Information Exchanges from which clinicians and patients may have full access to patient data.
In sum, the meaningful use objectives aim to harness the power of technology to improve health care delivery in a patient-centered context. The stage 1 objectives set the stage for accelerated improvement as adoption and use of health IT increase and clinicians and hospitals advance toward stages 2 and 3.
To receive incentive payments, physicians must attest to meeting the meaningful use objectives. In attestation, the physician signing the report takes legal responsibility for the information submitted. To successfully attest to stage 1 meaningful use, physicians must meet the thresholds for the 15 core objectives and at least 5 of the 10 menu or optional objectives (Table 2).
Certified EHR technology has the capability to report on the attainment of each meaningful use objective. Most objectives require clinicians to report a numerator and denominator. For example, physicians must record smoking status for more than 50% of unique patients 13 years or older. In this case, the denominator is all patients 13 years or older seen within the reporting period, and the numerator is the number of those patients who have smoking status recorded as structured data in the EHR. Some objectives require the physician to attest either “yes” or “no” for such items as the implementation of drug-drug/drug-allergy interaction checks. Exclusion criteria are included in objectives to allow maximum flexibility, so that physicians of all specialties and other health care professionals may participate in the EHR Incentive Programs. Detailed specification sheets for meeting each of the meaningful use objectives can be found on the CMS Web site (https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp).
One of the stage 1 meaningful use requirements is the reporting of numerators, denominators, and/or exclusion criteria for at least 6 electronic clinical quality measures, which should be automatically computed by certified EHR technology. There are 3 core measures that most physicians will report in stage 1 meaningful use. The core measures assess high-priority population health concerns, namely indicators of blood pressure, obesity, and smoking. An alternate core measure set (childhood obesity, childhood immunization status, and influenza vaccination for patients older than 50 years) may be selected from if any of the core measures are not applicable to a clinician's practice.
These reported clinical quality measures will eventually help to assess the effect of meaningful use on clinical outcomes and can contribute to other federal, state, and commercial quality programs; however, no outcome-related thresholds or benchmarks must be met for stage 1 clinical quality measures. As long as clinicians report specified indicators as calculated by the certified EHR technology, the information is considered to be accurate and complete.
The first step to receiving the Medicare and Medicaid EHR incentive payments is to register on the CMS website (http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp). Registration first opened in January 2011 and involves entering information such as National Provider Identifier number, provider type, and business address. In addition, clinicians can enter either the Medicare or Medicaid program in which they plan to participate and may submit the EHR certification number if available. (Clinicians do not have to have already purchased a certified EHR to register for either program.) Office managers or administrators may complete registration and subsequently document attestation for clinicians. As of December 31, 2011, more than 172 000 clinicians were registered for the EHR Incentive Programs, and over 30 000 clinicians had successfully attested to meaningful use of EHRs.6
Reporting and attestation are the final steps to attaining incentive payments from the EHR Incentive Programs. The requirements for attesting in the first payment year are considerably different for the Medicare and Medicaid programs. A summary comparison of the 2 programs is provided in Table 1.
To receive incentive payments from the Medicare program, a clinician must attest to meeting all of the required objectives using certified EHR technology during the reporting period—90 days in the first payment year and a full year beginning the second payment year. Attestation user guides and an attestation calculator available through the CMS website (http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp) may be helpful resources for clinicians before attesting to assess whether they have met all of the meaningful use objectives.
While registration for every state's Medicaid incentive program occurs via the CMS registration site, each state must establish its own system for collecting attestations and rendering payments. Details regarding Medicaid attestation and incentives payments are state specific, and questions should be directed to individual states. Information on participating states may be found on the CMS website (http://www.cms.gov/EHRIncentivePrograms/40_MedicaidStateInfo.asp).
In the first payment year, Medicaid programs offer physicians the option of receiving incentives for the adoption, implementation, or upgrade of certified EHR technologies without the requirement to report on meaningful use objectives. Therefore, physicians who receive Medicaid incentives in the first participation year do not have to attest to stage 1 meaningful use. However, to receive incentive payments after the first year, they will need to attest to meeting meaningful use objectives.
Incentive payments aim to alleviate the cost of implementing an EHR system. However, they do not necessarily reflect the cost for individual physicians or practices, which may be greater or less than meaningful use payments. To receive the maximum amount of incentive payments, physicians must enter the program by 2012 for Medicare and 2016 for Medicaid.
Physicians may receive up to $44 000 in incentive payments if they achieve meaningful use for 5 consecutive years, beginning in either 2011 or 2012. Physicians who initiate participation in the program in 2013 or 2014 will still be eligible for incentive payments, but the amount of available incentives will decrease. Table 3 outlines the Medicare payment schedule based on year of entering the program. Those clinicians who choose not to participate will face a 1% decrease in Medicare reimbursements as of 2015 with an additional 1% decrease in each successive year, although maximum reimbursement cuts may not exceed 5%.
The Medicaid EHR Incentive Program offers physicians a greater maximum incentive payment than Medicare does—up to $63 750 over 6 years between 2011 and 2021. Table 4 outlines the Medicaid payment schedule. Physicians must receive their first incentive payment by 2016 to participate in the Medicaid EHR Incentive Program. However, whether physicians attest in 2011 or 2016, the incentive payment is $21 250 for the first participation year and $8500 for each subsequent year of participation. The Medicaid meaningful use program does not assess penalties or reduce reimbursement to physicians who do not participate in the program.
The Office of the National Coordinator for Health Information Technology provides support to physicians adopting EHRs through 62 not-for-profit Regional Extension Centers (RECs).7 These centers help clinicians to implement and meaningfully use health IT. Although the RECs differ slightly in the services they provide, all can assist clinicians in EHR product selection, the difficult transition from paper records to EHRs, assessment of meaningful use objectives with helpful interventions for difficult objectives, and the reporting and attestation process.
Working with several clinicians aiming to achieve meaningful use, RECs have valuable knowledge regarding who the early adopters are in the region, what products are most popular, and which meaningful use objectives are most challenging. All RECs are focused on helping clinicians to improve clinical outcomes through the use of health IT. Seventeen of the RECs are also Quality Improvement Organizations (QIOs), and many more subcontract with QIOs.
The HITECH Act was designed to provide direct service to those providers who faced the greatest barriers in adopting and meaningfully using EHRs. Therefore, the statute created grant funding for primary care providers who practice in small clinics or safety-net settings. Regional Extension Center services are free or low cost to small practice primary care clinicians and critical access hospitals as well as to other providers that serve vulnerable populations, such as federally qualified health centers, free clinics, and rural health centers. The RECs have collectively enrolled over 140 000 primary care health care providers, and some RECs serve specialists as well. In rural areas, 70% of small-practice primary care providers have signed up with RECs.
Many of the RECs offer valuable resources to all through their websites. For example, HITEC LA, an REC in Los Angeles, offers a simple, 2-page checklist on their site to help clinicians keep track of criteria to fulfill stage 1 meaningful use (http://www.hitecla.org/mu_checklist).
Additional resources may be found at www.healthIT.gov. The website features a step-by-step approach for clinicians to effectively use health IT, from assessing practice readiness for EHR implementation to meeting all of the core and menu objectives in stage 1 meaningful use. Validated tools are suggested to help a clinical practice in each step.
Even the strongest enthusiasts for EHRs recognize that their adoption involves significant changes for physicians, with attendant dislocations in workflows, investments, and habits of practice. Although the ultimate benefits for both practice management and health care almost certainly make this transition worthwhile, the discomfort for physicians during the transition ought not to be underestimated. Thus, crafting effective and respectful policies regarding meaningful use and related incentives is an exercise in balance and moderation. Beyond the federal incentive programs, successful nationwide adoption of health IT will require partnership and assistance from the private sector; recognition of meaningful use as a key capability in readiness for payment reform; and incorporation of relevant competencies into medical education and training.
Private sector initiatives that complement public sector efforts will help accelerate the transition to prevalent and meaningful use of EHRs. Jain et al8 suggest how employers, commercial payers, consumer groups, regulatory bodies, and others might create motivation and support for physicians to become meaningful users in conjunction with the CMS EHR Incentive Programs.
In addition, the meaningful use of health IT will be greatly expanded to the extent that it is recognized as essential in the establishment of integrated, team-based health care delivery models such as accountable care organizations and the patient-centered medical home.9,10
Finally, as health IT is integrated into clinical practice, medical education should reflect this transformation and prepare physicians in training to practice medicine in an electronic environment. Graham-Jones et al11 have outlined various policy levers that might encourage the incorporation of health IT into undergraduate, graduate, and continuing medical education.
Meeting stage 1 objectives is the initial step; however, it will likely be the most difficult one, especially for those physicians transitioning from paper medical charts. Subsequent stages of meaningful use will serve as a glide path from stage 1 toward improved quality, efficiency, and patient-centeredness of care with effects extending far beyond the availability of incentive payments.
Correspondence: Joshua Seidman, PhD, Switzer Building, Ste 1100, 330 C St SW, Washington, DC 20201 (Joshua.Seidman@hhs.gov).
Accepted for Publication: February 13, 2012.
Author Contributions:Study concept and design: Marcotte, Seidman, Berwick, Blumenthal, Mostashari, and Jain. Acquisition of data: Marcotte, Trudel, and Jain. Analysis and interpretation of data: Trudel and Jain. Drafting of the manuscript: Marcotte, Seidman, Berwick, and Jain. Critical revision of the manuscript for important intellectual content: Seidman, Trudel, Blumenthal, Mostashari, and Jain. Obtained funding: Blumenthal. Administrative, technical, and material support: Marcotte, Blumenthal, Mostashari, and Jain. Study supervision: Seidman, Berwick, Blumenthal, Mostashari, and Jain.
Financial Disclosure: None reported.
Additional Information: Dr Berwick was Administrator of CMS at the time this article was written. He no longer works at CMS.