20 things to know about meaningful use

The adoption of electronic health records in the United States healthcare industry has skyrocketed in recent years. In 2010, just 16 percent of hospitals had a basic EHR system, and that number grew to 76 percent in 2014, according to CMS. Much of the growth is due to the EHR Incentive Programs that reward hospitals and providers for adopting, implementing and using records to improve care quality.

Here are 20 things to know about meaningful use.

The basics
1. The meaningful use program is the government's EHR incentive program. The program was established under the Health Information Technology for Economic and Clinical Health Act of 2009. Through EHR certification, the program aims to improve healthcare quality, safety, efficiency and reduce health disparities. Additionally, the program drives providers to engage patients and families, improve care coordination and maintain health information and security. If these objectives are met, MU was designed to ultimately improve clinical outcomes, improved population health, increased transparency, empowered patients and more research data. 

2. MU is broken into three stages. The first stage of the program focuses on data capture and sharing. Stage 2 focuses on advanced clinical processes. Stage 3 is geared toward improved outcomes.

3. There are two options within the EHR incentive program: the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program. CMS oversees the Medicare program, while state Medicaid agencies manage the latter. To drive participation in the Medicare and Medicaid programs, demonstrating meaningful use is tied to incentive payments. Eligible professionals would have had to begin participation in 2012 to receive the maximum incentive payment. 4. There are key differences between the Medicare and Medicaid programs.

• The maximum incentive amount through the Medicare program is $43,720, while the maximum amount through the Medicaid program is $63,750.

• Payments through the Medicare program are made over five consecutive years. Payments through the Medicaid program are made over six years, but those years do not have to be consecutive.

• Eligible professionals participating in the Medicare program must demonstrate meaningful use every year to receive incentive payments. On the other hand, those participating in the Medicaid program can receive a payment in the first year for adopting, implementing or upgrading an EHR. Meaningful use must be demonstrated in the subsequent years to receive incentive payments.

5. Eligible hospitals and professionals who decline to participate in the Medicare EHR Incentive Program or fail to demonstrate meaningful use are subject to payment penalties associated with Medicare reimbursement. Beginning this year, payment reduction begins at 1 percent and increase each year eligible hospitals and professionals do not demonstrate meaningful use, up to 5 percent.

There are no payment reductions for eligible providers who choose not to participate in the Medicaid EHR Incentive Program program. 

The rule

Editor's note: From point six onward, "the program" refers to the Medicare EHR Incentive Program, unless otherwise stated.

6. The meaningful use program began in 2011, when eligible hospitals and providers could register for the incentive program (January 2011), attest to the program (April 2011) and CMS began payments (May 2011). Hospitals could begin attesting to stage 2 in 2014 and can begin attesting to stage 3 in 2017. Click here for a timeline of attestation and payment years for the Medicare meaningful use program.

7. In March 2015, CMS released its proposed rule for meaningful use stage 3, which is expected to be the final stage of the federal EHR incentive program. Chief among the changes to the meaningful use program is the proposition to transition the entire industry to a single stage of meaningful use in 2018, meaning all providers would attest to stage 3 that year regardless of their current stage.

8. Responding to comments and criticism from the industry from previous meaningful use stage rules, CMS' proposed rule for stage 3 would allow providers to report on a calendar year instead of the fiscal year as is currently done to align the EHR reporting period with other quality reporting programs, like the Hospital Inpatient Quality Reporting and Physician Quality Reporting System programs.

9. Additionally, the proposed rule seeks to eliminate the 90-day EHR reporting period for new Medicare meaningful users, effective 2017. Instead, new users would be required to report on a full calendar year.

10. In April 2015, HHS released another proposed rule regarding modifications to the meaningful use program between 2015 and 2017. One proposed change that has stirred up some controversy is the proposed threshold for the Patient Electronic Access View, Download, Transmit measure. The proposed modification rule reduced the benchmark for VDT from 5 percent to at least one patient. The industry responded with criticism that the rule demeans patient engagement efforts.

11. In June, CMS announced that hospitals participating in meaningful use for the first time would be allowed to attest this summer, anytime between now and August 14. Previously, hospitals participating for the first time in the federal EHR incentive program were required to wait to attest until Jan. 1, 2016. 

12. As of December 2014, nine out of 10 eligible hospitals had attested to meaningful use, including 89 percent of eligible critical-access hospitals and 91 percent of all other, non-CAH eligible hospitals.

13. As of March 2015, there were 353,350 eligible professionals and 4,811 eligible hospitals participating in Medicare's EHR incentive program. Approximately 177,400 eligible professionals are participating in Medicaid's EHR incentive program. More than $30 billion has been paid out to eligible professionals and hospitals in both the Medicare and Medicaid EHR incentive programs as of March 2015. 

14. However, in January 2015, approximately 257,000 eligible professionals faced a 1 percent Medicare payment reduction for failing to meet meaningful use requirements. Additionally, nearly 28,000 eligible professionals faced a 2 percent payment reduction for failing to comply with both meaningful use and the Electronic Prescribing Incentive Program.

Similar to meaningful use, the eRx Incentive Program used incentive payments and payment adjustments to encourage eligible professionals to use electronic prescriptions. The federally mandated program ended in 2013, but eligible professionals participating in meaningful use who were subject to a 2014 eRx payment adjustment (adjusted for data submitted for 2013) received the payment adjustment in 2015. 

Approximately 200 hospitals that did not meet meaningful use requirements saw Medicare payment adjustments in October 2014. 

15. MEDITECH is the most common EHR used by hospitals attesting to meaningful use, with 946 hospitals using this platform as of March 2015. The second most commonly used vendor is Cerner, with 931 hospitals. Epic's EHR comes in third place with 835 hospitals attesting on its platform. 

16. However, for eligible professionals attesting to meaningful use programs, Epic is the most commonly used platform, with 109,309 meaningful users as of March 2015. Allscripts follows with 49,481 users, and eClinicalWorks has 42,615. 

Controversy and criticism
17. The MU program has garnered criticism from several influential groups in the healthcare space, including the American Medical Association. Earlier this year, a coalition of 35 medical groups led by the AMA sent a letter to National Coordinator Karen DeSalvo, MD, outlining seven proposed changes to meaningful use and EHR certification.

1. Decouple EHR certification from the meaningful use program. EHR certification should focus on performance, quality, safety, efficiency and interoperability, rather than MU compliance measures such as data collection and specific patient participation.
2. Reconsider alternative software testing methods.
3. Establish greater transparency and uniformity on user-centered design testing and process results.
4. Incorporate exception handling into EHR certification. Exception handling would seek to identify how software handles errors, such as a user entering the wrong information.
5. Develop consolidated clinical document architecture guidance and tests to support exchange.
6. Seek further stakeholder feedback.
7. Increase education on EHR implementation.

 Following the release of the stage 3 rule, the AMA sent CMS a comment letter requesting the agency implement its stage 1 and 2 proposed modifications before moving on to stage 3.

18. Thought leaders on the vendor side have also been vocal critics of MU. Jonathan Bush, CEO of athenahealth, often refers to the program as "healthcare information technology's version of cash-for-clunkers," a sentiment included in The New York Times.

19. MU has drawn criticism from individual providers, as well. Niam Yaraghi, PhD, a fellow in the Brookings Institution's Center for Technology Innovation, recently penned a blog post for U.S. News & World Report on the program. Dr. Yaraghi argued the program is failing, but is not without hope for the future. "Although policymakers' hunch about the benefits of IT was correct, it failed to understand a nuanced condition under which this magic wand works: organic and voluntary adoption," he wrote. "Imposing these records on the medical community and forcing them to adopt and use this technology was destined to fail."

He suggests a "one-size-fits-all approach" does not work, and medical providers should be allowed greater autonomy. "HHS should have set efficiency as a goal and let medical practices to find out the best way to achieve it through healthcare IT of their choosing," Dr. Yaraghi wrote. "Instead of mandating physicians to record the smoking statuses and vital signs of all patients, send them reminders about their follow-up visits and communicate with them through secure electronic messages, meaningful use incentives could have been allocated to fund a wide variety of different IT solutions suggested by medical providers."

20. Charles Krauthammer, MD, Pulitzer Prize-winning author and physician, weighed in on EHRs and meaningful use in a Washington Post opinion piece in May. "Virtually every doctor and doctors' group I speak to cites the same litany, with particular bitterness about the EHR mandate," wrote Dr. Krauthammer. He argued the promised savings are nowhere to be seen, while the burden physicians must bear continues to grow. 

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