HIT and Meaningful Use

Washington, D.C. November 11 2009 —The American Recovery and Reinvestment Act (ARRA) which was signed into law on February 17 creates two key concepts to determine whether eligible professionals qualify for HIT incentive payments - they must make “meaningful use” of HIT and in addition use a qualified or certified electronic health record.

The Centers for Medicare and Medicaid Services (CMS) is developing the proposed rule defining meaningful use criteria to be published by December 31, 2009. This rule will have a 60 day comment period. The final rule will be published by May 2010 and implementation will begin in 2011. It is anticipated 2011 criteria will include evidence that clinicians have purchased and are using EHRs, and the E HR has the ability to capture and share data. For 2013, it is anticipated that the focus will be on process measures, to include advanced care processes with decision support. For 2015, it is anticipated that the focus will be on improved health care outcomes.

In regards to certification, the Office of the National Coordinator for HIT (ONC) will develop two rules for publication by December 31, 2009. One rule will be an interim final rule published on certification standards and criteria. The other will be a proposed rule defining the certification process. It is anticipated that both rules will have either a 30 or 60 day comment period and both final rules will be published in the spring of 2010. A separate memo will be issued on certification.

Note: It is anticipated that the rules will be highly technical in nature and any comments submitted will require a high level of specificity to address the rule’s requirements. In preparation for the release of the proposed rule on meaningful use, here is a summary of the actions that have taken place so far and related concerns.

Summary:
In May 2009, HHS announced the members of two committees that were created under ARRA to advise the National Coordinator of HIT (Dr. David Blumenthal) on the implementation of HIT– the HHS HIT Policy Committee and HHS HIT Standards Committee. The HIT Policy Committee presented its initial set of recommendations regarding meaningful use in June and requested public comment. The American Medical Association (AMA) submitted a detailed comment letter to the committee on the draft definition of meaningful use on June 26. The AOA was one of several health care organizations that signed on to the AMA comment letter. The letter addressed key topics such as the timeframe for adoption, and also noted that the meaningful use definition must accommodate a variety of physician practice settings.

Over 700 comments were received on the draft meaningful use definition from a variety of stakeholders across the health care system. The meaningful use final recommendations matrix was submitted to ONC in August 2009. Attached is a copy of the recommendations. Recurring themes that emerged include:

• Focus – The focus of meaningful use must be on improving health outcomes, not simply to promote the adoption of technology.
• Timeline – Comments reflected concerns about the aggressiveness of the meaningful use timeline. Respondents felt that 2011 goals should be realistic to achieve. It was noted by some provider organizations that the timeline outlined is too ambitious for clinicians and small practices that are just beginning to look at purchasing and integrating E HRs into their practice setting. The timeline for incentive payments commences in January 2011. In 2015, payment adjustments will be imposed on eligible professionals who are not meaningful E HR users.
• Cost – Respondents in smaller physician practices noted that incentives offered are not enough to encourage adoption, because funds would be received too late in the process. Partial incentives were mentioned as a potential solution. Partial incentives would provide some funding for meeting interim goals on the way to full implementation of a HIT system.

As the result of comments received from the committee and the public, the Committee revised its recommendations in July. Under the revised definition, more time would be provided to physicians and hospitals to meet meaningful use criteria. The committee recommended an “adoption year”, rather than a calendar year timeframe which would include 2011 measures applicable to the first year of HIT adoption, even if HIT is adopted in the year 2013. The 2013 measures then would be applicable to the third year of adoption. Most clinicians would be able to participate and receive partial funds under the stimulus bill and have the flexibility to meet criteria in later years of the program. More information will be outlined in the proposed rule to be released by CMS.

The incentive payment is equal to 75 percent of Medicare allowable charges for covered services and is subject to a maximum payment in the first year ($15,000), second year ($12,000), third year ($8,000), fourth year ($4,000) and fifth year ($2,000). For those whose first adoption year is 2011 or 2012, the maximum payment is $18,000. Beginning in 2015, penalties will be imposed on eligible professionals who are not meaningful E HR users. The Medicare fee schedule amount for eligible professionals who are not using an E HR meaningfully would be reduced by 1 percent in 2015, 2 percent in 2016, 3 percent in 2017 and between 3 to 5 percent in future years.

Anticipated Issues of Concern:
It is anticipated that problems will emerge in the implementation of HIT which include:

• Timeframe – Since meaningful use criteria have not been officially defined yet, it is somewhat difficult now for physicians to prepare to have HIT installed to qualify for maximum incentive payment in 2011. It takes a good year or more to get a system in place and become fully functioning. Vendors have expressed concern as well – they have stated that they need to have specifications as soon as possible in order to configure systems to meet meaningful use criteria. The average timeframe cycle for system development is 18 months or more.
• Process – In attending meetings and discussions on this issue, it is our observation that many un-answered questions remain. It is anticipated that 2010 will involve a mad rush to meeting meaningful use requirements.
• Other requirements – How will meaningful use be implemented to work in conjunction with other forthcoming regulatory requirements that will be imposed on health professionals such as ICD-10 and Version 5010? In addition, how will it interface with other HIT requirements currently being worked on?

Next Steps:
Here is the timeline for work over the next year on meaningful use:

• Third Quarter 2009 – A process will be developed for updating meaningful use objectives and measures to include 2011 measures for specialties. It will include working with the National Priorities Partnership and HealthyPeople programs to identify meaningful use criteria for 2013 and 2015.
• On October 27 and 28, 2009 informational hearings were held by the HIT Policy Committee to receive feedback from provider organizations for meaningful use criteria for 2013-2015. They are seeking feedback from a wide spectrum of physician practices and hospitals on the mapping of core meaningful use objectives and existing measures to medical specialties, small practices, and small hospitals. It was noted by several organizations testifying that start up capital is needed by many health providers - funds are needed up front to implement HIT systems. This is a burden especially for small practices and safety net providers. Concerns were expressed about small providers opting out – that the benefit will not be worth the effort to participate.
• 2010 – Work will continue on updating 2013 and 2015 criteria, working with the HIT Standards Committee to determine availability of relevant standards, refining 2013 meaningful use criteria, and assessing preparedness of industry to meet 2011 and 2013 meaningful use criteria.

Here is the link to the final meaningful use recommendations:
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_888532_0_0_18/FINAL%20MU%20RECOMMENDATIONS%20TABLE.pdf