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November/December 2010

 
Practice Perfect: Information Technology
Feds’ Incentives for EHRs, Part Three: How to Demonstrate Meaningful Use
By Leslie Burling-Phillips, Contributing Editor
 
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Over the next six years, the government is setting aside $27 billion in incentive payments for eligible professionals (EPs) who demonstrate meaningful use of certified electronic health records (EHRs). The last issue of EyeNet discussed certification, while this article explains what you must report in order to demonstrate meaningful use.

Three Stages of Meaningful Use

The government regulators anticipate a phased approach to meaningful use—stages 1, 2 and 3—with the reporting requirements becoming progressively more comprehensive and stringent. If you start participating in the incentive program in 2011, you will need to meet the stage 1 criteria for meaningful use for two years before moving on to the stage 2 criteria in 2013.

The final rule for stage 1 was published in July. It describes 25 meaningful use objectives (15 in a core set and 10 in a menu set), plus 44 clinical quality measures (CQMs).

Each objective is linked to a corresponding measure that defines how the objective must be fulfilled. For instance, the measure for the e-prescribing objective states that “more than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.” This measure involves reporting a denominator—the number of prescriptions—and a numerator—the number of prescriptions in the denominator that were generated and transmitted electronically. In the e-prescribing example, the denominator is limited to those patients whose records are kept in the certified EHR technology, but some of the other percentage-based measures include all patients in the denominator.

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The Core Set

Report on all 15 objectives from the core set. Every EP must report on each of the core set criteria, many of which are considered by CMS as basic to a medical record. “The core set of objectives address rudimentary EHR functionality such as patient demographics and other clinical data that is considered foundational. They are looking for general health care data—that is why so much of it is primary-care focused,” said Julia Lee, JD, who chairs the AAOE’s subcommittee on EHRs and is executive director of Ophthalmic Partners, a multispecialty practice in the Philadelphia area.

The regulations recognize that some measures don’t apply to everyone. “For certain objectives there are exclusions built in that recognize the complex nature of the variety of different medical practices,” said Ms. Lee. For example, said Michael X. Repka, MD, “there are a number of measures that do not apply to ophthalmologists, such as the measure on taking a patient’s vital signs, which is defined to include height, weight, blood pressure and BMI. It is outside of the typical patient encounter to measure and record this data.” Dr. Repka is the Academy secretary for Federal Affairs and professor of ophthalmology and pediatrics at Johns Hopkins University.

Six objectives from the core set include an exclusion option, as do six objectives from the menu set.

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The Menu Set

There are 10 objectives in the menu set of criteria. These items reflect secondary issues related to either patient care or the exchange of patient health information—whether the information is communicated between an EP and a patient, between EPs, or between an EP and public health agencies.

Report on five objectives from the menu set. EPs must select five of the 10 menu set items to report during stage 1. “This gives physicians some latitude to address the different needs that vary among providers and also concedes that not all practices have the same technical capabilities,” said Michael F. Chiang, MD, who chairs the Academy’s committee on Medical Information Technology and is associate professor of ophthalmology and biomedical informatics at Columbia University.

What about multiphysician practices? “Menu set items can be selected by individual physicians within a multiphysician practice because participation, reporting and incentive payments are all done at the physician level rather than the practice level,” said Ms. Lee. “However, for practicality and simplicity—and to the extent that you can pick the same ones—it is probably easier to comply with the program if all the physicians within a practice select the same menu set items. Hopefully within the 10 objectives in the menu set, you can pick five that have the broadest application to all the physicians in your practice.”

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Clinical Quality Measures

To demonstrate meaningful use, EPs are also required to report from a table of 44 clinical quality measures (CQMs). This table features three core CQMs, three alternate CQMs and 38 additional CQMs.

The 3 core and 3 alternate CQMs. “If you report a zero value for one or more of the core clinical quality measures, you are required to report on one or more of the alternate measures. If you cannot satisfy any of the core or alternate CQMs, you will need a total of six zero values in order to be fully excused from that set of requirements,” said Ms. Lee.

The 38 additional CQMs. In addition to reporting three core CQMs (also reporting on alternate CQMs if necessary), EPs must report three of the 38 additional CQMs, four of which are relevant to ophthalmology.

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Getting Incentive Payments

How to register for the incentive program. At time of press, CMS had not yet released the details about how EPs should register, but registration information will be available at the end of 2010. EPs will be able to start registering in January 2011.

How to report on meaningful use of EHRs. Ultimately, it is expected that EHRs will transmit data directly to the CMS. However, the infrastructure for direct electronic reporting will not be in place by January, which is when registration opens. So for 2011, “reporting will be done by attestation—stating that you have been a meaningful user of a certified EHR system for at least 90 days prior to your reporting date. Practices will manually enter numeric values that correspond to the recorded objectives and measures into a web portal,” said Dr. Repka.

What is the reporting period? In your first year, your reporting period is 90 consecutive days. In subsequent years, it is the entire payment year.

When will the checks get processed? CMS will begin accepting data in April 2011, and the first incentive payments are scheduled for disbursement in May 2011.
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ADDENDUM. There is a chart of vendors in this month’s supplement. An expanded version, which adds MDIntelleSys and MedInformatix, is at www.aao.org/ehr.

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Pushback on the Proposed Rule

Earlier this year, the CMS invited feedback on its proposed rule on meaningful use. In July it published a final rule describing what is required for demonstrating stage 1 of meaningful use.

Proposed rule caused alarm. The proposed rule caused understandable angst among physicians, particularly specialists who were dismayed by its stringent guidelines coupled with additional mandatory measures that were outside a specialist’s traditional scope of practice. In response, numerous medical societies—including the Academy—communicated their concerns to CMS with the hope that adjustments would be made so that all physicians could successfully navigate the program. Some of those calls for change were answered.

Modifications mean more flexibility. “The proposed rule received some criticism for taking an all-or-none approach to defining the meaningful use criteria,” said Dr. Chiang. “The thresholds for fulfillment were very high and physicians were concerned that it would be difficult to meet the conditions in order to qualify for the incentive payments. However, the requirements defined in the final rule are significantly more flexible, seem to better promote the goal of meaningful use of EHRs, and can be achieved more easily than those in the proposed rule.”

Final rule is still no pushover. Although the requirements were revised, achieving the meaningful use objectives is still no simple task. “It is a high hurdle for most practices to overcome and will take a lot of effort to accomplish,” said Dr. Repka. Ms. Lee agreed: “There is considerable confusion surrounding the program overall. The regulations themselves are more than 860 pages of text; it is an enormous document. This is not the type of information that the average physician is going to review, so definitive guidelines from medical organizations are a necessity.”

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