May 18, 2009

Beginning in 2011, eligible professionals may apply to receive Medicare “incentive payments” for the meaningful use of a certified Electronic Health Record (EHR) system. EHR systems include an electronic record of health-related information on an individual patient that contains demographic and clinical health information and has the capacity to provide clinical decision support, support physician order entry, capture and query information relevant to healthcare quality, and exchange electronic health information with, and integrate such information from, other sources. Medicare will pay eligible professionals, defined as physicians, up to $44,000 over a 5-year period if they:

1. Demonstrate use of certified EHR technology in a meaningful way, including use of electronic prescribing; and
2. Demonstrate that the use of certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of healthcare, such as promoting care coordination, and
3. Submit information on clinical quality measures and other measures to be selected by the Secretary of the Department of Health and Human Services (HHS).

Anesthesiologists should not count on receiving, at least in the near future, any portion of the $17 billion provided for HIT incentive payments to physicians and hospitals in the federal Stimulus Bill signed into law on February 17, 2009 (officially known as the Health Information Technology for Economic and Clinical Health Act, or HITECH Act, which is part of the American Recovery and Reinvestment Act of 2009). As a result of this legislation, the Congressional Budget Office estimates that approximately 90% of doctors and 70% of hospitals will be using comprehensive electronic health records within the next decade. There are several reasons why the Stimulus Bill incentive payments, however, should not drive the decision to invest in an EHR now:

1. No payments at all will be made before 2011.
2. The standards and implementation specifications for certifying EHR technology is "certified" won’t be published until the end of 2009 – if then.
   1. The government has not yet made any reference to any partners who will be able to install certified EHRs.
3. Similarly, the Secretary has yet to describe the criteria for “meaningful” use of EHR technology. Meaningful use will be based upon the clinical quality measures and other requirements to be determined by the HHS. Secretary Kathleen Sebelius may provide for alternative methods means for meeting the "meaningful use" standard. She may also require more stringent measures of "meaningful use" to seek to improve the use of electronic health records.
4. In general, hospital-based eligible professionals (such as anesthesiologists, pathologists and emergency physicians) who furnish substantially all their covered professional services in a hospital setting, whether inpatient or outpatient, through the use of the facilities and equipment, including qualified electronic health records, at the hospital will not be eligible for the HITECH Act incentive payments.

If the anesthesiologists must purchase and install EHR systems of their own because the hospital is not providing the appropriate certified technology, however, they should be able to apply for incentive payments between 2011 and 2014, especially since it appears that they will be subject to the same reduction in payments as other eligible professionals if they do not adopt certified EHR technology by 2015. These reductions would result in a percentage point decrease in payment for services provided to Medicare beneficiaries, thus:

In 2018 and subsequent years, if fewer than 75% of eligible professionals are meaningful EHR users, the Secretary may decrease the applicable percent by one percentage point from the applicable percent in the preceding year, but in no event can the percentage amount be less than 95%.

Will hospitals make certified EHRs available – that anesthesiologists will be able to use in a “meaningful” way? One of the higher estimates of the proportion of hospitals that already have even basic EHRs installed is 10 percent¹. Under the HITECH Act, meaningful use of EHRs in 2011 will earn hospitals a one-time bonus payment of $2 million plus an add-on to the Medicare fee based on the diagnosis-related group (DRG). The add-on, which would phase out over a 4-year period, would apply to every admission up to a (yet-to-be-designated) maximum amount.

Like physicians, hospitals will receive reduced payments from Medicare if they do not become meaningful users of EHR technology by 2015. The reduction to hospitals’ annual Medicare update is phased in over three years beginning in 2015 with a 25% reduction in 2015, a 50% reduction in 2016, and a 75% reduction in 2017.

These carrots and sticks should motivate hospitals to get to work on designing and implementing their EHRs. It is likely to be up to the hospital-based physicians, including anesthesiologists, to make sure that the hospital EHRs captures the patient and OR information required by the physicians. ABC is developing specifications and technologies to further this effort.

Anesthesiologists should also prepare to their hospitals (and surgery centers) to participate in the Anesthesia Quality Institute, Inc., the American Society of Anesthesiologists' clinical data registry, when that new entity begins operations. The ASA brought the Quality Institute to the attention of President Obama and both the Senate and the House of Representatives in letters sent early this year “applaud[ing] your vision for moving HIT forward now and look[ing] for the early enactment of this measure through the economic stimulus bill.”

Sincerely,
Tony Mira
President and CEO

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¹Blumenthal D. Stimulating the Adoption of Health Information Technology. N Engl J Med 360;15 nejm.org April 9, 2009, accessed May 16, 2009.