Meaningful Use Attestations in 2011: CMS/ONC Raw Dataset Tells Hospital Story

CMS and ONC recently released a raw dataset (link) that we’ve been told identifies the certified vendors used by those providers that have attested to meaningful use in FFY 2011. The dataset includes a unique attester id # column and a hospital “specialty” column that make it possible to identify how many hospitals (by hospital type) have attested to meaningful use through November.

Based on a number of assumptions (see end of post), I’ve generated what I believe are pretty good estimates of the percentage of hospitals that have attested to meaningful use in 2011. The nationwide results are directly below. Scroll further down for state-by-state results   

2011 FFY # and % of MU Attesting Hospitals

To assess what this data means, it’s important to understand where we started. Thanks to Neal Neuberger (Executive Director of the Institute for e-Health Policy) and HIMSS, we have the below 2009 percentages for comparison.

2009 HIMSS EMR Adoption Data

Stage 1 meaningful use can be characterized as Stage 4+ on the HIMSS EMR Adoption Scale. Hospitals that had achieved Stage 4 HIMSS EMRAM in 2009 had already performed most of the implementation work required to achieve Stage 1 meaningful use. In 2009, just over 10% of PPS hospitals had achieved Stage 4 and fewer than 3% of critical access hospitals had achieved Stage 4. Compare this to an estimated 18% of PPS hospitals and 9% of CAHs that have attested to meaningful use in 2011.

It was a forgone conclusion that CAHs and small rural PPS hospitals would continue to have lower levels of HIT adoption than large hospitals and systems (see this link for some of the reasons). What’s interesting about the MU attestation results is the extent to which CAHs appear to have increased their EHR adoption rates between 2009 and 2011, arguably more so than PPS hospitals have.

While CAHs have attested at an impressive rate, it should be pointed out that at a recent HIT Policy Committee meeting CMS officials indicated that 277 hospitals had received a Medicare incentive payment, but only 12 of these were CAHs. This means that while 37% of attesting PPS hospitals had received payment, only 10% of attesting CAHs had received payment. Those of us following these issues know that the reason for this is that CAHs have the administrative burden of needing to justify all of their EHR-related costs to their MACs prior to getting payment, whereas PPS hospitals get an incentive payment based on a fixed formula.       

Below find state breakouts and then a list of the assumptions I made to generate the attestation data. 

% of Hospitals that Have Attested to MU in FFY 2011

Assumptions Made to Generate Attestation Percentages:

1. The attester unique id # in the raw data file includes the id# of all providers that have attested to meaningful use  through November 31, 2011 (which is the attestation deadline for hospitals)
2. Each attesting hospital has only 1 unique id# and each unique id# refers to only 1 attesting hospital
3. All CAH attesters are listed as “Critical Access Hospitals” in the Specialty column
4. All non-CAH attesters are PPS hospitals

Note: I believe the above assumptions are correct since by using them I am able to match up the data in the raw data file with my understanding of the attestation status of Wisconsin hospitals

1. American Hospital Directory state-by-state # of hospitals was used to estimate the number of PPS hospitals by state.
2. Flex Monitoring Team state-by-state # of CAHs was used to estimate the number of CAHs by state. 

Please feel free to point out any flaws in the assumptions so I can fine tune these estimates.

2011 Rural HIT Recap: The Year of Meaningful Use

Another eventful year in the world of health information technology!

In 2011 we saw the first providers attest to meaningful use, and HIT incentive funds begin to flow to both meaningful users and implementers through the respective Medicare and Medicaid programs. We also saw significant progress made by Wisconsin’s Information Exchange and Regional Extension Center programs. On the regulatory front, several long-standing questions received FAQ clarifications from CMS, while others remain largely unanswered. Here’s a recap of this year’s HIT highlights.

Medicaid Incentive Working for Wisconsin Hospitals

One of the bright spots of the overall ARRA HIT Incentive Program has been the Medicaid incentive. Unlike the Medicare program, the Medicaid program funds CAHs and PPS hospitals relatively equally and provides a year of incentives for implementation before providers need to achieve meaningful use. This is a fair and rural-friendly approach designed to help providers at early stages of EHR adoption.

The issue for rural providers has been whether they qualify for the Medicaid eligibility threshold (10% for hospitals and 30% for EPs). Here in Wisconsin nearly all of our hospitals qualify and a good majority have applied for the program and received their first year payment. These funds can now be invested into continued HIT implementation work needed to achieve meaningful use and to sustain effective EHR environments.

Kudos to our State Medicaid folks for the work they’ve done to make this a successful program.    

Wisconsin’s Regional Extension Center (WHITEC) Providing Assistance

The Rural Wisconsin Health Cooperative, the Wisconsin Office of Rural Health, and the Wisconsin Hospital Association are working with the great team at WHITEC (a division of Metastar) to make sure rural Wisconsin hospitals have a strong resource to help them with their meaningful use related efforts. The WHITEC rural hospital program has performed over 30 meaningful use gap and financial assessments, and we’ve initiated services to provide assistance with the MU security and quality objectives, as well as with HIT incentive program registration, application, and attestation.

While no one should expect that Regional Extension Centers can replace the specialized EHR implementation assistance offered by vendors and consultants that focus on specific platforms, it’s clear that effective RECs make a real difference in supporting and maximizing meaningful use achievement. By acting as trusted expert advisors, by serving as an information resource on complex and evolving meaningful use regulations, by strategically meeting provider needs that are outside the scope of traditional vendor services, and by making sure that provider and patient interests trump vendor implementation expedience, RECs are playing an important role in helping providers work to navigate through Stage 1 meaningful use and beyond.   

Wisconsin’s Information Exchange (WISHIN) Operationalizes “Direct”

One of the greatest challenges of the HIT incentive push has been how to achieve the goal of patient record portability between providers on disparate systems and between providers and patients themselves. Each state has different strategies, and here in Wisconsin our statewide information exchange designated entity, WISHIN, has made great strides this year.

WISHIN has quietly become one of the first state exchanges to implement a functioning “Direct” transport mechanism that allows providers to securely exchange packets of health information. As of last count, providers have signed up for over 200 Direct addresses, and several providers have used this mechanism to meet the meaningful use information exchange requirement. WISHIN staff and associated workgroups are currently working on an RFP that will lead to the development of advanced exchange capabilities, including a provider directory and more granular EHR-enabled exchange of health information.    

Meaningful Use Achieved By 5 Wisconsin Critical Access Hospitals

While it should be pointed out that preliminary 2011 data shows that (as expected) rural and small-volume providers are much less likely to have achieved meaningful use than urban and large providers, there are a good handful of Wisconsin Critical Access Hospitals that should be applauded for having made it to the Stage 1 MU finish line. I know of 5 CAHs (all of which have participated in the WHITEC rural hospital program) that have attested, and there may be more.

Some of these CAHs are supported by a large system, others have collaborated by sharing an EHR platform, and still others have made it to meaningful use independently. What these hospitals share is the fact that they started their EHR implementation journey for its own sake long before the term “meaningful use” was part of the vocabulary. Congratulations!    

Definition of CAH “Reasonable Costs” Remains Ambiguous

The above notwithstanding, as far as I know none of the Wisconsin CAH meaningful users have yet received their Medicare incentive payment. The reasons for this are that (1) the CAH incentive bonus is associated with actual EHR-related costs, (2) EHR costs are ambiguously defined as “reasonable costs for the purchase of certified EHR technology to which purchase depreciation would apply. This would include the computers, and associated hardware and software, necessary to administer certified EHR technology.” (Per CMS FAQ 10720), (3) CMS has been obstinately unwilling to provide detailed clarification of what specific technology costs can be included under this definition, and (4) given the lack of clarity, the CAHs’ Medicare Administrative Contractors (MACs), which need to approve payment, are finding it difficult to navigate providers through an expedited cost review process.

In response to a recent NRHA request for information on this issue, CMS answered nearly all of our detailed questions with “Contact your MAC for more information.” Well, many of us have contacted our MACs, and the MACs generally do not have the answers.  

It’s my understanding that the NRHA is now working with the AHA to start pressing CMS harder to get clarity and fairness for CAH meaningful users. I’ll provide updates in future posts as more information becomes available.

Stage 2 Deadline Moved to 2014 for 2011 Meaningful Use Attesters

In a ruling that only impacts providers that attested to meaningful use in 2011, the Secretary of Health and Human Services recently indicated CMS’s intention to support the HIT Policy Committee’s recommendation and extend the Stage 2 meaningful use deadline for 2011 attesters from 2013 to 2014.

Though the announcement came too late to reasonably impact hospital decision-making, it was the no-brainer right thing to do, since the old timeline was clearly unreasonable, giving vendors and providers just a few months to develop and test major new software enhancements, and then to conduct a safe workflow assessment and implementation process. This would have been the perfect recipe for bad code, bad workflow, and bad patient outcomes.

FAQ Indicates Providers Are Not Responsible For Accuracy of Quality Measure Data

In a FAQ that left some QI people rejoicing and others tearing their hair out, CMS indicated that achieving the CQM objective “does not require any data validation.” As long as the output is generated from the certified EHR technology, hospitals and EPs are allowed to attest to achieving the measure, even if there are concerns about the accuracy of the output. 

From a provider perspective, this was a positive ruling that postponed one of the great MU challenges: making sure that the large amount of data being collected for the quality measures is complete and accurate. The reason this would have been such a challenge is that ONC failed to require that vendors include data accuracy algorithms as part of the QI measure certification process. To perform data validation, many providers would have needed to check for accuracy through manual chart reviews, which would have taken an extraordinary amount of time and resources (and which by the way was not accounted for in CMS’s final rule administrative burden assessment). We can assume that we’ll see adjustments to this oversight in Stage 2 certification and meaningful use rule making.

Stage 2 and 3 Meaningful Use Requirement Recommendations Released  

Early in the year, the HIT Policy Committee provided a glimpse of the framework for Stage 2 and 3 meaningful use requirements. The Committee’s proposals included raising Stage 1 thresholds, making the current menu objectives into core, and adding various new objectives, such as physician electronic notes, medication administration recording, hospital patient portals, and others. The complete list is available here: http://www.worh.org/hit/2011/02/stage-2-and-3-meaningful-use-objective-proposed-recommendations/

We will see much more detail when CMS and ONC issue their proposed Stage 2 rules sometime in the coming months. Many more posts to follow on this.

Expectations for 2012: Rumors of World’s Demise Greatly Exaggerated

I’ve spent much of the year talking to and working with representatives from scores of Wisconsin rural hospitals, and from my vantage point it has been an incredibly productive year for the collective rural provider community. EHR adoption efforts have dramatically accelerated. An incredible amount of work has been done. Much more is being planned.

Yes, there are great challenges ahead. Yes, there are those who can’t afford to participate and others who will stumble along the way. But in general, I see mostly people working hard, doing their best, and achieving good progress.

My expectation for 2012 is even greater acceleration of HIT adoption. Instead of 5 CAHs and rural hospitals achieving meaningful use, we are likely to have 20-30. WHITEC and WISHIN will build on their 2011 successes with new and improved services. CMS will finally develop clarity around an equitable “reasonable cost” solution. Above all, as we work on defining Stage 2, the provider, vendor, and federal and state agency communities will continue to effectively collaborate for the benefit of all patients and the providers who serve them. Including rural!

HHS Secretary Intends to Extend Stage 2 MU Deadline

US Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today announced that HHS intends to extend the Stage 2 deadline for 2011 meaningful use attesting providers from 2013 to 2014.

According to a statement from HHS, “Under the current requirements, eligible doctors and hospitals that begin participating in the Medicare EHR Incentive Programs this year would have to meet new standards for the program in 2013. If they did not participate in the program until 2012, they could wait to meet these new standards until 2014 and still be eligible for the same incentive payment.” 

The Secretary indicated that HHS now intends to allow doctors and hospitals to attest to meaningful use in 2011 ”without meeting the new standards until 2014.” 

The HIT Policy Committee voted in June to recommend the extension, but it hasn’t been clear whether CMS would adopt the Committee’s recommendation. With Secretary Sebelius’s statement, this becomes much more likely. 

The provider community has been anxious about this issue because the Stage 2 Final Rule isn’t scheduled to be released until just months before the new requirements would have gone into effect, resulting in a practically impossible deadline for most vendors and providers to meet.   

Today’s announcement is ostensibly intended to encourage providers to move forward with attestation this year.  However, the Secretary’s stroke-of-midnight announcement is unlikely to produce many additional hospital sign-ups. Today is the deadline for 2011 Hospital MU attestation.

Eligible Professionals have until December 31st to complete their 90 day reporting periods and until February 29th, 2012 to attest to meaningful use for the 2011 Calendar Year.

Two New CMS FAQs: Counting Thresholds in Multiple Certified EHR Environments

CMS has issued two new FAQs that address the issue of how providers should count meaningful use objective thresholds when utilizing different certified EHR technologies in different settings. This could be an issue for those that are, for example, utilizing a certified ED EHR that’s different than the hospital’s certified inpatient EHR and not interfacing every objective’s numerator data captured in the ED back to the inpatient (HIS) side (which would be common in this dual-system circumstance).  

According to the FAQs:

For the clinical quality measures objective, “eligible hospitals and CAHs that have multiple systems should generate a report from each of those certified EHR systems and then add the numerators, denominators, and exclusions from each generated report in order to arrive at a number that reflects the total data output for patient encounters in the relevant departments of the eligible hospital or CAH.”

For objectives that require a simple count of actions (such as provide patients with an electronic copy of their health information), “EPs, eligible hospitals, and CAHs can usually add the numerators and denominators calculated by each certified EHR system in order to arrive at an accurate total for the numerator and denominator of the measure.”

For objectives that require an action to be taken on behalf of a percentage of “unique patients” (such as record vital signs), providers must be careful to “ensure that each unique patient is counted only once for each objective.”

Read below for the full FAQ language…

Published 10/20/2011 02:45 PM   |    Updated 10/21/2011 01:54 PM   |    Answer ID 10843

For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, how should an eligible professional (EP), eligible hospital, or critical access hospital (CAH) that sees patients in multiple practice locations equipped with certified EHR technology calculate numerators and denominators for the meaningful use objectives and measures?

EPs, eligible hospitals, and CAHs should look at the measure of each meaningful use objective to determine the appropriate calculation method for numerators and denominators.  The calculation of the numerator and denominator for each measure is explained in the July 28, 2010 final rule (75 FR 44314).

For objectives that require a simple count of actions (e.g., number of permissible prescriptions written, for the objective of “Generate and transmit permissible prescriptions electronically (eRx)”; number of patient requests for an electronic copy of their health information, for the objective of “Provide patients with an electronic copy of their health information”; etc.), EPs, eligible hospitals, and CAHs can usually add the numerators and denominators calculated by each certified EHR system in order to arrive at an accurate total for the numerator and denominator of the measure.

For objectives that require an action to be taken on behalf of a percentage of “unique patients” (e.g., the objectives of “Record demographics”, “Record vital signs”, etc.), EPs, eligible hospitals, and CAHs may not be able to simply add the numerators and denominators calculated by each certified EHR system. The EP, eligible hospital, or CAH must include only unique patients in the numerators and denominators of each objective, and it is the responsibility of the EP, eligible hospital, or CAH to reconcile information from multiple certified EHR systems in order to ensure that each unique patient is counted only once for each objective. Please keep in mind that patients whose records are not maintained in certified EHR technology will need to be added to denominators where applicable in order to provide accurate numbers.

For more information about which objectives require a simple count of actions and which require an action taken on behalf of a percentage of unique patients, please consult our Meaningful Use Specification Sheets for EPs (http://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf) and eligible hospitals and CAHs (http://www.cms.gov/EHRIncentivePrograms/Downloads/Hosp_CAH_MU-TOC.pdf).

To report clinical quality measures, EPs who practice in multiple locations that are equipped with certified EHR technology should generate a report from each of those certified EHR systems and then add the numerators, denominators, and exclusions from each generated report in order to arrive at a number that reflects the total data output for patient encounters at those locations. To report clinical quality measures, eligible hospitals and CAHs that have multiple systems should generate a report from each of those certified EHR systems and then add the numerators, denominators, and exclusions from each generated report in order to arrive at a number that reflects the total data output for patient encounters in the relevant departments of the eligible hospital or CAH (e.g., inpatient or emergency department (POS 21 or 23)).

Published 10/20/2011 03:03 PM   |    Updated 10/21/2011 01:55 PM   |    Answer ID 10844

For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, how should an eligible hospital or critical access hospital (CAH) with multiple certified EHR systems report their clinical quality measures?

To report clinical quality measures, eligible hospitals and CAHs that have multiple systems should generate a report from each of those certified EHR systems and then add the numerators, denominators, and exclusions from each generated report in order to arrive at a number that reflects the total data output for patient encounters in the relevant departments of the eligible hospital or CAH (e.g., inpatient or emergency department (POS 21 or 23)).

CMS Issues Clarification on CQM Meaningful Use Attestation

CMS today clarified what eligible hospitals must attest to in order to achieve meaningful use.   

For the Clinical Quality Measure (CQM) objective, CMS has for the first time indicated that achieving the CQM objective “does not require any data validation.” As long as the output is generated from the certified EHR technology, hospitals are allowed to attest to achieving the measure, even if there are concerns about the accuracy of the output. (Hospitals with concerns are instructed to work with their vendors and/or ONC to improve their accuracy)    

For all of the other meaningful use objectives, the Eligible Hospital must agree that the information submitted:

• is accurate to the knowledge and belief of the hospital or the person submitting on behalf of the hospital.
• is accurate and complete for numerators, denominators, exclusions, and measures applicable to the hospital.
• includes information on all patients to whom the measure applies.
• for clinical quality measures (CQMs), was generated as output from an identified certified EHR technology.

Read below for the CMS language. 

October 18th, 2011 CMS News Update: What Does Attestation for the EHR Incentive Programs Entail?

Over 114,000 eligible professionals and hospitals have registered for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. As more hospitals move towards meeting meaningful use and attesting, the Centers for Medicare & Medicaid Services (CMS) wants to make sure everyone understands what attestation entails.

In order to attest, successfully demonstrate meaningful use, and receive an incentive payment under the Medicare EHR Incentive Program, eligible hospitals must indicate that they agree with several attestation statements.

Eligible hospitals must agree that the information submitted:

• is accurate to the knowledge and belief of the hospital or the person submitting on behalf of the hospital.
• is accurate and complete for numerators, denominators, exclusions, and measures applicable to the hospital.
• includes information on all patients to whom the measure applies.
• for clinical quality measures (CQMs), was generated as output from an identified certified EHR technology.

By agreeing to the above statements, the hospital is attesting to providing all of the information necessary from certified EHR technology, uncertified EHR technology, and/or paper-based records in order to render complete and accurate information for all meaningful use core and menu set measures except CQMs.

Attesting to CQM Data’s Validity

CMS considers information to be accurate and complete for CQMs to the extent that it is identical to the output that was generated from certified EHR technology. In other words, the hospital is only attesting that what was put in the attestation module is identical to the output generated by its certified EHR technology. Therefore, the numerator, denominator, and exclusion information for CQMs must be reported directly from information generated by certified EHR technology.

CMS, through meaningful use, does not require any data validation. Eligible hospitals are not required to provide any additional information beyond what is generated from certified EHR technology in order to satisfy the requirement for submitting CQM information, even if the reported values include zeros. If a hospital has concerns about the accuracy of its output, the hospital can still attest but should work with its vendor and/or the Office of the National Coordinator for Health Information Technology to improve the accuracy of the individual product and/or the level of accuracy guaranteed by certification.

CMS recommends that hospitals print out or save an electronic copy of the CQM report used at attestation from their certified EHR. The eligible hospital should retain this copy for its records so that the hospital can show its numbers in the event of an audit. Upon audit, this documentation will be used to validate that the hospital accurately attested and submitted CQMs.

For more information about the Medicare and Medicaid EHR Incentive Programs, please visit the CMS EHR website, and see the Frequently Asked Questions page for answers on various topic areas of the programs.

HIT Loans To Become Available Through New Rural Jobs Initiative

On August 16th, President Obama announced new jobs initiatives recommended by the White House Rural Council for growing the economy and creating jobs in rural America.

According to a White House factsheet, one of the initiatives includes expanding Health Information Technology (IT) in rural America. 

As indicated in the factsheet: “USDA and HHS will sign an agreement linking rural hospitals and clinicians to existing capital loan programs that enable them to purchase software and hardware needed to implement health information technology (HIT). Under current conditions, rural health care providers face challenges in harnessing the benefits of HIT due to limited access to capital and workforce challenges.  Rural hospitals tend to have lower financial operating margins and limited capital to make the investments needed to purchase hardware, software and other equipment.”

We have been advocated for such a program since the HITECH provisions of ARRA “allowed” the National Coordinator to award grants to States or Indian tribes for loan programs for the purchase of certified EHR technology. But the ARRA loan provision program was never established.

While it would have been preferable for an HIT loan program to get off the ground much earlier, this new initiative is welcome. Depending on the timing of the loans, the initiative could help some rural hospitals to achieve meaningful use in the last few years of the HIT Incentive program.

Wisconsin Medicaid Program Underway

This week Wisconsin Medicaid announced the initiation of the Wisconsin Medicaid HIT incentive program. Detailed information on how to register and receive payment has been distributed to Wisconsin providers and is available at this link.

Key dates include:

August 1^st: Eligible hospitals may register with the Medicare and Medicaid EHR Incentive Program Registration and Attestation System (link). Also, Eligible Hospitals will be able to assign the new “EHR Incentive Clerk” role on the ForwardHealth Portal (link).

August 22^nd: Eligible hospitals may begin to apply with the Wisconsin Medicaid Incentive Program through the Provider area of the ForwardHealth Portal

September 30^th: To receive payment for federal fiscal year (FFY) 2011, Eligible Hospitals must complete and submit an application by September 30, 2011

Payments will be made within 45 days of the approval of a Wisconsin Medicaid EHR Incentive Program application.

Providers are required to wait at least 90 days between submitting applications for the Wisconsin Medicaid EHR Incentive Program for different FFYs.

Important Note: The first payment year does not require meaningful use, but only that providers achieve the “adopt/implement/upgrade” standard described in the Program Fact Sheet. However, meaningful use is required for the second and third payment years.

Again, more information is available in the Wisconsin Medicaid EHR Incentive Program Fact Sheet.

CMS Issues Restrictive “EHR Cost” (and other) FAQs For CAHs

CMS has just issued 8 new HIT Incentive Program FAQs that relate to CAHs, including 2 FAQs with language that resticts what qualifies as certified EHR expenses that can be applied to the incentive bonus, and 3 FAQs that deal with how costs incurred by home offices and collaborative networks on behalf of CAHs are to be handled. Below are quick summaries, followed by the full FAQ language. 

1. When will a CAH receive its incentive payment? “In order for the incentive payment to be calculated, the CAH must submit documentation to its Medicare contractor (Fiscal Intermediary/Medicare Administrative Contractor) to support the costs incurred for certified EHR technology. Once the Medicare contractor calculates the allowable amount and Medicare Share the CAH should expect its interim incentive payment within 4 to 6 weeks.” (This leaves us with the question: how long will it take MACs to calculate the allowable amount?)

2. What costs can be included in the CAHs incentive payment? “reasonable costs for the purchase of certified EHR technology to which purchase depreciation would apply. This would include the computers, and associated hardware and software, necessary to administer certified EHR technology.” (This is the same answer that we have heard since the release of the final rule, and fails to provide definitions for “associated” and “necessary to administer.”)

 3. Can Critical Access Hospital costs only be included in the first year for Medicare EHR incentive payments? No, they can receive 4 years of bonus payments including for new costs. (No surprise here.)

4. What if the Home Office purchases the certified EHR technology for the CAH? These can be included if “directly attributable to the CAH, separately identifiable, and cannot be included in a pooled allocation of cost to the CAH on the Home Office Cost Statement.” (No surprise here, but good news, as many were worried about this.)

5. What if the Home Office leases the certified EHR technology and allocates it to the CAH? “It cannot be included in the Medicare EHR incentive payments.  The costs allowable for the EHR incentive payment are only the reasonable costs to which purchase depreciation would apply.” (No surprise here.)

6. What if a group of providers purchase and share certified EHR technology? Can the CAH include the cost in the Medicare EHR incentive payment? Yes, but only the portion that applies specifically to the CAH. (Again, no surprise here, but good news.)

7. What if a Critical Access Hospital (CAH) purchases certified EHR technology, but it also includes other non-EHR functionality? Can the CAH include the cost in the Medicare EHR incentive payment? “The CAH may only include the portion of the reasonable costs of the system that pertains to certified EHR technology (what is required to achieve Meaningful Use).” (This language implies a restrictive definition of ”necessary to administer”)  

8. What if a CAH purchases certified EHR technology, and the hardware needed to support it is shared with other systems? “The CAH may only include the portion of the reasonable costs of the hardware that pertains to certified EHR technology (what is required to achieve Meaningful Use).”  (This language implies a restrictive definition of ”necessary to administer”)     

Complete CMS FAQ Response Language 

When will a Critical Access Hospital (CAH) receive its Medicare EHR incentive payment?

Published 07/11/2011 12:28 PM   |    Updated 07/12/2011 11:38 AM   |    Answer ID 10719

When will a Critical Access Hospital (CAH) receive its Medicare EHR incentive payment?

Upon submission of a successful attestation, the CAH will be eligible for an EHR incentive payment. In order for the incentive payment to be calculated, the CAH must submit documentation to its Medicare contractor (Fiscal Intermediary/Medicare Administrative Contractor) to support the costs incurred for certified EHR technology. Once the Medicare contractor calculates the allowable amount and Medicare Share the CAH should expect its interim incentive payment within 4 to 6 weeks.

The CAH will receive an interim incentive payment that will later be reconciled on the Medicare cost report. The interim payment will be calculated using the Medicare Share based on the data reported on the hospital’s latest submitted 12-month cost report.

The interim payment will be included on the CAH’s cost report that begins during the payment year, and will be reconciled to the actual amounts at final settlement of the cost report.

Example – If a hospital has a December 31 fiscal year end, and attests as a meaningful user on August 1, 2011:

The latest filed cost report when the CAH attests will most likely be the fiscal year end December 31, 2010 cost report. The data on that cost report will be used to calculate the Medicare Share for the initial payment.

The cost reporting period that begins during the HITECH payment year (which is the federal fiscal year) is the fiscal year ending December 31, 2011 cost reporting period (since the begin date of January 1, 2011 falls within the fiscal year 2011 HITECH year). The interim payment will be reconciled at final settlement of the cost report for this period.

The new Medicare hospital cost report, Form CMS 2552-10, will contain worksheets to accommodate the EHR incentive payments.
Note – the EHR incentive payments will be made by a single payment contractor, and not by the hospitals’ Medicare contractor (Fiscal Intermediary/Medicare Administrative Contractor).

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

What costs can be included in the Critical Access Hospital’s Medicare EHR incentive payment?

Published 07/11/2011 12:34 PM | Updated 07/12/2011 11:39 AM | Answer ID 10720

What costs can be included in the Critical Access Hospital’s Medicare EHR incentive payment?

The EHR incentive payment shall only include reasonable costs for the purchase of certified EHR technology to which purchase depreciation would apply. This would include the computers, and associated hardware and software, necessary to administer certified EHR technology.

If the cost cannot be included as a depreciable asset under normal Medicare cost reporting principles, it cannot be included in the EHR incentive payment. However, the CAH may continue to report all other costs on the Medicare Cost Report, and be reimbursed under reasonable costs principles.

Since the reasonable costs of the depreciable assets being included in the EHR incentive payment are allowed to be expensed in their entirety in the year incurred, the CAH must ensure that the resulting depreciation on those assets is not included in subsequent cost reports.

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

Can Critical Access Hospital costs only be included in the first year for Medicare EHR incentive payments?

Published 07/11/2011 12:36 PM   |    Updated 07/12/2011 11:39 AM   |    Answer ID 10721

Can Critical Access Hospital (CAH) costs only be included in the first year for Medicare EHR incentive payments?

 No, if the CAH incurs reasonable costs for certified EHR technology in subsequent payment years, it may receive additional incentive payments.  The documentation to support the cost may be sent to the Medicare contractor (FI/MAC) after the attestation for that payment year.    

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

What if the Home Office purchases the certified EHR technology for the CAH?

Published 07/11/2011 12:46 PM   |    Updated 07/12/2011 11:40 AM   |    Answer ID 10723

What if the Home Office purchases the certified EHR technology for the Critical Access Hospital (CAH)?

If the certified EHR technology assets were purchased by the Home Office for the CAH, and the CAH meets the Meaningful Use criteria, the cost may be included in the Medicare EHR incentive payment calculation for the CAH. The cost must be directly attributable to the CAH, separately identifiable, and cannot be included in a pooled allocation of cost to the CAH on the Home Office Cost Statement. The CAH must be able to separately identify the assets to ensure that subsequent depreciation is not included. The CAH must maintain documentation to support the direct or functional allocation and to ensure that subsequent deprecation is not included in pooled allocations, as the Medicare contractor may need to review it to determine the allowable amount.

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

What if the Home Office leases the certified EHR technology and allocates it to the CAH?

Published 07/11/2011 12:55 PM   |    Updated 07/12/2011 11:40 AM   |    Answer ID 10724

What if the Home Office leases the certified EHR technology and allocates it to the Critical Access Hospital (CAH)?

If the Home Office is leasing the certified EHR technology, and allocating cost to the CAH, it cannot be included in the Medicare EHR incentive payments.  The costs allowable for the EHR incentive payment are only the reasonable costs to which purchase depreciation would apply. 

The CAH may, however, continue to include the lease costs on its cost report, subject to reasonable cost principles.  

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

What if a group of providers purchase and share certified EHR technology? Can the CAH include the cost in the Medicare EHR incentive payment?

Published 07/11/2011 12:58 PM   |    Updated 07/12/2011 11:40 AM   |    Answer ID 10725

What if a group of providers purchase and share certified EHR technology? Can the Critical Access Hospital (CAH) include the cost in the Medicare EHR incentive payment?  

Yes, but only the portion that pertains to the specific CAH.  

If there is a special arrangement where a group of providers purchase and share certified EHR technology, the specific CAH may only include the actual costs it incurred. For EHR incentive payments, the CAH may only include the costs of certified EHR technology to which purchase depreciation would apply. The CAH must maintain documentation to support the process of allocating the costs, as the Medicare contractor may need to review it to determine the allowable amount. The CAH must also have documentation to support that it has ownership in the assets, and is not renting/leasing the certified EHR technology.    

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

What if a Critical Access Hospital (CAH) purchases certified EHR technology, but it also includes other non-EHR functionality? Can the CAH include the cost in the Medicare EHR incentive payment?

Published 07/11/2011 01:02 PM   |    Updated 07/12/2011 11:41 AM   |    Answer ID 10726

What if a Critical Access Hospital (CAH) purchases certified EHR technology, but it also includes other non-EHR functionality? Can the CAH include the cost in the Medicare EHR incentive payment?

The CAH may only include the portion of the reasonable costs of the system that pertains to certified EHR technology (what is required to achieve Meaningful Use). For example, if a certified system is purchased, and it also includes a payroll or other non-EHR module, only the portion of the reasonable costs pertaining to the certified EHR technology may be included in the EHR incentive payment. The CAH must be able to provide documentation to the Medicare contractor (FI/MAC) to support the portion that it intends to claim.  

Any other costs may continue to be included in the Medicare cost report, subject to reasonable cost principles.  

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

What if a CAH purchases certified EHR technology, and the hardware needed to support it is shared with other systems?

Published 07/11/2011 01:04 PM   |    Updated 07/12/2011 11:41 AM   |    Answer ID 10727

What if a Critical Access Hospital (CAH) purchases certified EHR technology, and the hardware needed to support it is shared with other systems?

The CAH may only include the portion of the reasonable costs of the hardware that pertains to certified EHR technology (what is required to achieve Meaningful Use).  For example, if a certified system is purchased, and is housed on a server that contains other non-EHR systems, only the portion of the reasonable costs that pertains to the certified EHR technology may be included in the Medicare EHR incentive payment.  The CAH must be able to provide documentation to the Medicare contractor (FI/MAC) to support the portion that it intends to claim.  

Any other costs may continue to be included in the Medicare cost report, subject to reasonable cost principles.  

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

Stage 2 Meaningful Use Delay Recommended

The HIT Policy Committee has voted to recommend delaying the implementation of Stage 2 meaningful use by one year until 2014. This change affects Eligible Professionals and Hospitals that have attested or plan to attest to meaningful use Stage 1 in 2011. According to the HIT Incentive Final Rule, 2011 attesters would have needed to begin meeting Stage 2 meaningful use requirements by October 1^st 2012, just a few months after the final Stage 2 regulations are expected to be released.

It now appears that 2011 attesters are likely to be granted a slight reprieve from what I have previously called a ridiculous timeframe.

According to the Policy Committee’s June 8th Recommendation Announcement issued by Vice Chair, Paul Tang:  

“With the anticipated release of the final rule for stage 2 in June, 2012, it would require EHR vendors to design, develop, and release new functionality, and for eligible hospitals to upgrade, implement and begin using the new functionality by the beginning of the reporting year in October of 2012. After careful consideration of the trade-offs between the urgency with which new functionality is needed and the ability to safely deliver and to effectively use the new functionality, the HITPC recommends that—only for those who begin to attest to MU in 2011—an extra year be provided to phase in the stage 2 expectations (2014).”

What Does This Tell Us About The HIT Policy Committee?

The majority of the Committee voted in favor of this compromise, with some Committee members voting against because they felt a delay was not needed, and others voting against because they felt the delay was not enough.

With reasonable achievability as one of the ground rules that the Committee members originally agreed to, it’s head scratching that there are representatives who feel that it’s reasonable to provide only months for complex requirements to be appropriately programmed, tested, certified, and released to the provider community, all this prior to the significant workflow changes that will need to be implemented for providers to then utilize the functionality.

Ironically, it is those who consider themselves patient advocates who have been spearheading the charge to force feed poorly designed software that will likely lead to patient harm.   

What Does This Mean For Hospitals That Attested (Or Plan to Attest) in 2011?

While this does give an extra year for 2011-attesting EPs and hospitals to achieve Stage 2, it appears that it may also involve a delay in payment for these EPs and hospitals.  

According to the HIT Incentive Final Rule, “We proposed that Medicare EPs, eligible hospitals, and CAHs whose first payment year is 2011 must satisfy the requirements of the Stage 1 criteria of meaningful use in their first and second payment years (2011 and 2012) to receive the incentive payments. We anticipate updating the criteria of meaningful use to Stage 2 in time for the 2013 payment year and therefore anticipate for their third and fourth payment years (2013 and 2014), an EP, eligible hospital, or CAH whose first payment year is 2011 would have to satisfy the Stage 2 criteria of meaningful use to receive the incentive payments.”

According to Government Health IT: “…as a result, stage 1 demonstration and attestation would continue through 2013; stage 2 would start in 2014; and stage 3 in 2015. With the revised timing, providers will still receive the same payments as originally planned. Instead of 2013, however, early entrants will have to wait to attest and receive payments for stage 2 in 2014.” 

If this is true, then these 2011-attesting providers will also likely need to wait until 2014 to receive their 3^rd Year Medicaid (as opposed to Medicare) incentive payment. Whereas EPs and Hospitals that apply for the Medicaid Year 1 adopt/implement/upgrade criteria in 2011, and then attest to meaningful use in 2012 and 2013, will get their 3^rd Year Medicaid Payment in 2013. This is likely to become the primary reason that many providers able to achieve Stage 1 in 2011 will continue to wait to attest until 2012.

But I would think that CMS has the authority to allow 2011-attesting providers to receive Medicare and Medicaid incentives in 2013 for continuing to meet existing (Stage 1) requirements (rather than needing to wait until 2014 to meet Stage 2).  Something that everyone should consider advocating for during the eventual comment period.

Unfortunately, we may not know the answer to how this will be handled until after the September 30th deadline for attesting in 2011. If anyone has additional information, please post as comment.

CMS issues 5 New Meaningful Use FAQs:

Nothing earth shattering here. FAQ 1 is no surprise, and some additional flexibility has been granted with FAQs 2-4.

(1) For the information exchange objective, can this be met by exchanging physical media: (No)

(2) For the EP CPOE objective, how to handle unique patients with medications on the medication list ordered by others: (These EPs “may limit their denominator to only those patients for whom the EP has previously ordered medication”)

(3) Regarding whether swing bed patients can/should be counted for the meaningful use measures: (Depends: “unique swing bed patients who receive inpatient care should be included in the denominators of meaningful use measures. However, if the eligible hospital or CAH’s certified EHR technology cannot readily identify and include unique swing bed patients who have received inpatient care, those patients may be excluded from the calculations for the denominators of meaningful use measures”)

(4) Regarding whether nursery dat patients can/should be counted for the meaningful use measures: (Depends: “nursery day patients should not be included in the denominators of meaningful use measures. However, if the eligible hospital or critical access hospital’s (CAH’s) certified EHR technology cannot readily identify and exclude nursery day patients, those patients may be included in the calculations for the denominators of meaningful use measures.”

(5) Regarding what lab tests should be included in the denominator of the measure “incorporate clinical lab-test results”: (“the denominator consists of the number of lab tests ordered … for patients (in POS 21 and 23)… whose results are expressed in a positive or negative affirmation or as a number. Providers may limit the denominator to only those lab tests that were ordered during the EHR reporting period and for which results were received during the same EHR reporting period.”)

See below for complete FAQ language…

1. For the meaningful use objective of “capability to exchange key clinical information” for the Medicare and Medicaid EHR Incentive Programs, does exchange of electronic information using physical media, such as USB, CD-ROM, or other formats, meet the measure of this objective?

2. For the Medicare and Medicaid EHR Incentive Programs, how should an eligible professional (EP) who orders medications infrequently calculate the measure for the “computerized provider order entry (CPOE)” objective if the EP sees patients whose medications are maintained in the medication list by the EP but were not ordered or prescribed by the EP?

Published 05/17/2011 11:29 AM   |    Updated 05/18/2011 02:09 PM   |    Answer ID 10639

The CPOE measure is structured to minimize reporting burden.  However, if all of the following conditions are met it can also create a unique situation that could prevent an EP from successfully demonstrating meaningful use. An EP who:

1. prescribes more than 100 medications during the EHR reporting period;
2. maintains medication lists that include medications that they did not order; and
3. orders medications for less than 30 percent of patients with a medication in their medication list during the EHR reporting period.

In these circumstances, an EP may be both unable to meet this measure and unable to qualify for the exclusion. In the unique situation where all three criteria listed above apply, an EPs may limit their denominator to only those patients for whom the EP has previously ordered medication, if they so choose. EPs who do not meet the three criteria listed above must still base their calculation on the number of unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period regardless of who ordered the medication or medications in the patient’s medication list.

3. How should patients in swing beds be counted in the denominators of meaningful use measures for eligible hospitals and critical access hospitals (CAHs) for the Medicare and Medicaid EHR Incentive Programs?

Published 05/17/2011 11:39 AM   |    Updated 05/18/2011 02:10 PM   |    Answer ID 10640

A number of the meaningful use measures for eligible hospitals and CAHs require the denominator to be based on the number of unique patients admitted to the inpatient or emergency department during the EHR reporting period.  Unique swing bed patients who receive inpatient care should be included in the denominators of meaningful use measures. However, if the eligible hospital or CAH’s certified EHR technology cannot readily identify and include unique swing bed patients who have received inpatient care, those patients may be excluded from the calculations for the denominators of meaningful use measures.

4. How should nursery day patients be counted in the denominators of meaningful use measures for eligible hospitals and CAHs for the Medicare and Medicaid EHR Incentive Programs?

Published 05/17/2011 11:41 AM   |    Updated 05/18/2011 02:10 PM   |    Answer ID 10641

Nursery days are excluded from the calculation of hospital incentives because they are not considered inpatient-bed-days based on the level of care provided during a normal nursery stay. In addition, nursery day patients should not be included in the denominators of meaningful use measures. However, if the eligible hospital or critical access hospital’s (CAH’s) certified EHR technology cannot readily identify and exclude nursery day patients, those patients may be included in the calculations for the denominators of meaningful use measures.

5. What lab tests should be included in the denominator of the measure for the “incorporate clinical lab-test results” objective under the Medicare and Medicaid EHR Incentive Programs?

Published 05/17/2011 03:22 PM   |    Updated 05/18/2011 02:11 PM   |    Answer ID 10642

For the “incorporate clinical lab-test results” objective, the denominator consists of the number of lab tests ordered during the EHR reporting period by the eligible professional (or authorized providers of the eligible hospital or critical access hospital (CAH) for patients admitted to an eligible hospital’s or CAH’s inpatient or emergency department (POS 21 and 23)) whose results are expressed in a positive or negative affirmation or as a number. Providers may limit the denominator to only those lab tests that were ordered during the EHR reporting period and for which results were received during the same EHR reporting period.