(RESTON, VA - American College of Radiology)
The following information is provided in response to inquiries from our members regarding the “meaningful use of certified electronic health record (EHR) technology” incentives program authorized by the American Recovery and Reinvestment Act. This article is for general informational purposes only, and is not a legal document or guidance.
The American Recovery and Reinvestment Act of 2009 (ARRA, or “economic stimulus”) was a supplemental appropriations package signed by President Obama in February 2009. Among the many different programs supported or authorized by ARRA were Medicare and Medicaid programs established to incentivize the meaningful use of certified electronic health records (EHR) technology.
Non-hospital-based eligible professionals — as defined by Section 1861(r) of the Social Security Act which defines the term “physician”— can participate in either the Medicare program or the Medicaid program. However, in order to be eligible for the Medicaid version of the incentive program as a non-pediatrician, at least 30 percent of total patient volume must be supported through Medicaid (for pediatricians, this number is 20 percent). It is unlikely that many non-hospital-based radiologists will meet the threshold for Medicaid incentives, so the following information focuses exclusively on the Medicare program for providers.
The Medicare program for providers is restricted to non-hospital-based physicians, whereby “hospital-based” is defined by the site of service, and not by any employment or billing arrangement. ARRA also established a different meaningful use program for hospitals, but not for physicians in hospitals. This “non-hospital-based” distinction exists because hospital-based physicians are expected to use the facilities and equipment (including the EHR technology) provided to them by the hospital.
The Medicare incentive payments are for the “meaningful use” of certified EHR technology, and not for the purchase, implementation, or maintenance of EHR products. ARRA indicates that meaningful use must entail: 1) the use of e-prescribing as determined to be appropriate by the Secretary of HHS; 2) connection of the certified EHR technology in a manner that provides for the lawful electronic exchange of health information to improve the quality of health care; and 3) the submission of information, in a form and manner specified by the Secretary of HHS, on clinical quality measures and other measures selected by the Secretary of HHS.
Throughout the summer, the HHS Office of the National Coordinator for Health IT (ONC) convened monthly meetings of their HIT Policy Committee and HIT Standards Committee to discuss the definition of meaningful use. These committees created and refined a “meaningful use matrix,” which provides recommendations on meaningful use outcomes and measures for 2011, 2013, and 2015. However, it is important to note that the Centers for Medicare and Medicaid Services (CMS) has the ultimate regulatory authority over meaningful use. CMS will take ONC’s recommendations under advisement as they write the regulations.
Certified EHR Technology
“Certified EHR technology” means those qualified electronic health records certified as meeting the associated HHS standards. To be qualified, the product must include patient demographic and clinical health information (such as medical history and problem lists) and have the capacity to 1) provide clinical decision support, 2) support physician order entry, 3) capture and query information relevant to health care quality, and 4) exchange electronic health information with, and integrate such information from other sources.
While CMS has regulatory authority over meaningful use, ONC has regulatory authority over technology in terms of the criteria/standards and certification/testing of EHR products. Therefore, ONC is responsible for promulgating the regulations related to certification.
Incentives and Reductions
Medicare Incentive Payments (2011 - 2014) – tied to participation in Medicare
1st Payment Year: up to $18k (if 2011 or 2012), up to $15k (if 2013), or up to $12k (if 2014).
2nd Payment Year: up to $12k
3rd Payment Year: up to $8k
4th Payment Year: up to $4k
5th Payment Year: up to $2k
NOTE: For eligible professionals in a HPSA (health professional shortage area), incentive amounts are increased by 10 percent.
Reductions for Non-Participating Eligible Physicians (2015 - onward)
2015: minus 1 percent (total Medicare payments)
2016: minus 2 percent (total Medicare payments)
2017 and each subsequent year: minus three percent (total Medicare payments)
NOTE: If the Secretary of HHS determines that more than 75 percent of eligible providers are not demonstrating meaningful use, they are able to increase the reductions up to 5 percent of total Medicare payments.
Frequently Asked Questions
Q: When are the regulations coming out?
A: The CMS proposed rule will likely be released for public comment in December 2009, and will have an associated 30 or (more likely) 60 day public comment period. The ONC will likely release an interim final rule on certification criteria/standards and also a proposed rule on the certification process in December 2009, with 30- or 60-day public comment periods for each of these items. For the two proposed rules, the comment periods will be followed by several months in which the respective agencies review and address the public comments, culminating in the publication of the final rules sometime in 2010.
Q: Are radiologists eligible to participate?
A: All non-hospital-based professionals who meet the Social Security Act’s definition of “physician” are eligible to participate, which is why it is so important for CMS to expand the meaningful use definition beyond the ONC’s current primary care focus.
Q: Why is ONC focused on primary care in their recommendations?
A: The HIT Policy Committee made the decision to prioritize primary care given the short timetable mandated by ARRA. The intent of the committee was to revisit the issue of meaningful use for specialties in October and in the future. Currently, the HIT Policy Committee is exploring “tagging” or “mapping” certain meaningful use criteria to specific specialties for 2011, and then adding new criteria for specialties in the 2013 and 2015 iterations of meaningful use. The ACR looks forward to working with them on this activity.
Q: How will CMS move forward with addressing specialties in the regulations?
A: There are a variety of options CMS has at their disposal to address specialties, such as the use of existing national registries (PQRI, etc.) to report meaningful use. In general, CMS may be unable to realistically implement several of ONC’s recommendations with their existing technology, so we could see modifications to the definition of meaningful use in the regulations to reflect CMS’s reporting and data capture capabilities.
Q: If I currently own a CCHIT certified EHR product, will I be able to participate in the program beginning in 2011?
A: This is currently unknown. CCHIT created a new certification paradigm called “Preliminary ARRA 2011” for EHR products that fit the initial 2011 meaningful use recommendations of the ONC advisory committees; however, this is based on recommendations and not regulations, so consumers of these products are taking a risk. The ONC’s advisory committees are exploring various ways to avoid penalizing pre-ARRA implementers of EHRs.
Q: What will CCHIT’s future role be in terms of meaningful use?
A: The HIT Policy Committee recommended there be a distinct separation between the criteria development and product testing aspects of certification. Additionally, the HIT Policy Committee recommended multiple testing bodies. CCHIT will probably seek to become a recognized product testing body, and so may other organizations who meet ONC and National Institute of Standards and Technology (NIST) criteria.
Q: Are physicians who lease office space in hospitals, or even physician contractors, considered “hospital-based?”
A: In ARRA’s legislative language, “hospital-based” is defined by the site of service and not by any employment or billing arrangement. However, the language could be interpreted in such a way as to allow some physicians in hospitals to participate in the program for providers if they do not use the facilities or equipment (including the EHRs) provided by the hospital. These questions will be addressed in the future regulations.
Q: Are RIS/PACS products considered EHR technology?
A: It is unlikely that most existing RIS and/or PACS products would meet the necessary requirements, although the legislative language gives a certain degree of flexibility to regulators as to what constitutes EHR technology. It is important to note that ONC is exploring developing one or more modular/component HHS certification pathways for non-comprehensive EHR technologies. Some type of modular/component certification could prove to be important to a specialty like radiology which may not utilize all the functionalities and options of comprehensive EHR products.
Q: Are exemptions possible to avoid the reductions beginning in 2015?
A: ARRA does give certain authority to HHS to provide exemptions; however, this authority is intended to be used for rural providers who may not have access to broadband or other requisite technologies. CMS could consider extending exemptions to certain specialists if those specialties are not provided an appropriate pathway to meaningful use.
Q: How will meaningful use impact referring physicians?
A: To date, the ONC advisory committees have recommended several meaningful use aspects related to computerized physician order entry systems (CPOE), exchange of radiology reports, reduction of inappropriate utilization of imaging, and even inclusion of multimedia in patients’ records by 2015. ACR supported many of these recommendations in comments submitted to ONC and the HIT Policy Committee in June.
Q: What else has ACR been doing on the meaningful use issue?
A: ACR has participated extensively with the federal government and private sector on the “meaningful use of certified EHR technology” issue over the past year, and we continue to do so moving forward. Some of our actions include working within a coalition on a meaningful use matrix for radiologists; submitting written testimony to the ONC and HIT Policy Committee; monitoring relevant public meetings, including the monthly meetings of the ONC’s advisory committees; communicating with CMS, ONC advisors, and HIT Policy Committee members regarding radiology's issues and concerns; and submitting letters to ONC and CMS together with other medical specialties.
If you have questions about meaningful use that were not addressed by this article, please contact Michael Peters, Assistant Director of Regulatory and Legislative Portfolio, ACR Government Relations Department, at firstname.lastname@example.org or 703-716-7546.