April 26, 2010

The Health Information Technology for Economic and Clinical Health Act (HITECH) provisions of the 2009 Recovery Act establish financial incentives starting in 2011 for “eligible professionals” (EPs) who are meaningful users of certified electronic health record (EHR) technology. EPs who qualify may receive up to $44,000 over 5 years, beginning in 2011.

On December 30, 2009, CMS and the Office of the National Coordinator for Health Information Technology (ONC) released tandem interim final rulings on the definitions of meaningful use and certified EHR technology, respectively. Our April 12, 2010 Alert looked at whether the HITECH Act EHR incentive programs under Medicare and Medicaid, as they would be implemented under the interim final rules constituted a bonus or a penalty for anesthesiologists. This week, we will examine the EHR incentive programs' application to independent pain practices. Please note that the two agencies are currently reviewing public comments on the interim rules and that the incentive program may be quite different when the final rules appear later this year.

Perhaps the final rule will be sufficiently flexible to allow the typical pain medicine practice to qualify for the incentive. (Physicians will have to choose between the Medicare and the Medicaid programs, if they qualify for both. The balance of this article will address Medicare alone.) Right now, it would be difficult to locate an EHR that permits “meaningful use” by the pain specialist. We are not aware of any EHR that contains all of the functionalities listed in Table 1, much less of any that is likely to be certified in time for use in 2011. A number of those functionalities do not pertain to pain medicine. Additionally, the clinical quality measures that an EP must report to qualify for the incentive have not yet been defined for pain medicine. These concepts are explained in greater detail below.

The basic requirements for the physician incentive program are simple:

• Be a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, who is legally authorized to practice under state law. EPs do not include hospital-based physicians, i.e., those who provide more than 90% of their professional services in the inpatient or emergency setting. (The Continuing Extension Act of 2010 (H.R. 4851), signed on April 15th, clarified that physicians providing services in ^outpatient hospital settings may qualifty for the EHR incentives.)

• Demonstrate meaningful use

• of EHR technology

• that is certified

• for the EHR reporting period.

Meaningful Use

The HITECH Act specifies three types of requirements for meaningful use:

1. Use of certified EHR technology in a meaningful manner (for example, electronic prescribing);
2. Certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and
3. Provider submits information on clinical quality measures to HHS using certified EHR technology.

“Meaningful use” measured in goals and objectives. In order to demonstrate the “meaningful” use of an EHR, the EP must be working toward four broad goals:

1. Improve quality, safety, and efficiency of patient care
2. Reduce health disparities through public data sharing
3. Engage patients more effectively
4. Ensure privacy and security of patient information

In the December 30 Interim Final Rule, CMS issued a set of twenty-five (25) objectives reflecting those four goals for the first phase of the incentive program. It will refine those objectives reflecting those four goals in Phases Two and Three over the next several years. Each objective is associated with a yes/no, numerical or performance rate measure, and the EP must be able to show compliance with each of the twenty-five. Table 1 below lists the objectives and measures.

Table 1. Meaningful Use Objectives

Submit information on clinical quality through EHR technology to HHS. This element of “meaningful use” assumes the existence of an HHS registry or other database that can receive electronic information on quality measures. There is no such registry yet, so for 2011, CMS instructs EPs to use a simple attestation methodology.

Which clinical quality measures should a pain medicine practice report? CMS defines them, in the interim final rule, “to consist of measures of processes, experience, and/ or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care.”

CMS identifies a set of three “core" quality measures that it believes every EP should be able to report:

1. Preventive care and screening: Inquiry Regarding Tobacco Use.
2. Blood pressure measurement
3. [Low number of] Drugs to be avoided in the elderly:
   • Patients who receive at least one drug to be avoided.
   • Patients who receive at least two different drugs to be avoided.

and a more extensive set of specialty measures. All EPs would have to report on (1) all core measures that apply to their patients and (2) at least one set of the the 90 specialty measures. The specialty groups, and number of measures that comprise each, include: Cardiology (10); Pulmonology (8); Endocrinology (9); Onocology (6); Proceduralist/Surgery (6); Primary care Physicians (29); Pediatrics (9); Obstetrics and Gynecology (9); Neurology (5); Psychiatry (6); Ophthalmology (3); Podiatry (3); Radiology (7); Gastroenterology (6); and Nephrology (6). The Agency has stated repeatedly that it would like to hear from the public if there are any specialists who could not report on the core measures and/or to whom none of the specialty measures apply. We consider it unlikely that the present specialty measures apply to pain medicine.

The bottom line for pain practices, pending publication of the final rule, is that they should start tracking the core measures by January 2011 if they wish to qualify for the EHR incentive. That may not be enough, but it will be indispensable. Although the individual measures need not be reported electronically in 2011, attestation being sufficient, pain physicians should find out whether the EMRs they are using or considering will be able to report clinical quality measures as these are identified. The attestation will be a statement that the physician is using a certified EHR system to capture the data elements and calculate the resiults for the applicable clinical quality measures. In 2012, CMS proposes to require the direct submission of clinical quality measures to CMS through certified EHR technology.

Certified EHR Technology

As of now there is no government program in place to accredit the organizinations that will certify EHRs. Nor are the final criteria or test procedures for certification in place. Until they are, any pain practice that invests in EHR technology should do so without counting on a Medicare or Medicaid incentive payment. EHRs may be a wise investment, however, even if no incentive is available. It is worth exploring how well prepared any EHR vendor might be for the final HITECH Act requirements, which we expect to see later this spring.

With best wishes,

Tony Mira
President and CEO