The MMA has partnered with the Regional Extension Assistance Center for HIT (REACH) and HIT expert Paul Kleeberg, M.D., to answer your questions about becoming a “meaningful user” of electronic health record systems, so that you and your clinic can secure federal bonuses and avoid penalties.

Submit your questions about meaningful use of EHRs to have them answered here by Paul Kleeberg, M.D., clinical director for REACH, which serves Minnesota and North Dakota.

Q: I heard you can receive money as late as 2021. Is that true?

A: If you are eligible for Medicaid incentives, that is correct. In the last issue we discussed the differences between Medicare and Medicaid and that it would be better to go with the Medicaid program if you are eligible. Previously we stated that in order to be eligible for Medicaid, either all or some portion of more than 30 percent of your visits must be paid by Medicaid. If you are a pediatrician, you are eligible if your patient mix is over 20 percent. If you work in a federally qualified health care center, you are eligible if more than 30 percent of your patient mix is "needy individuals" as defined by the Social Security Act.

• Medicaid and Medicaid handle the payments in different ways:
• Medicaid: It is possible for you to receive six incentive payments. The first payment can be as early as 2011 or as late as 2016.
• Medicare: The first payment can occur if you adopt or implement a certified EHR or upgrade your current EHR to one that is certified.
• Medicaid: The remaining payments will occur when you demonstrate meaningful use.
• Medicare: The second payment would be for 90 continuous days in a calendar year of demonstrating meaningful use, and the third through sixth payment would be meaningful use for the entire year.

The benefit to Medicaid is that if you do not qualify for meaningful use for one of those years, you don't miss out on a payment year if your first year of receiving a payment was before 2016. Medicaid payment years do not need to be consecutive. However, if you wish to receive all six payments, and your first payment year is 2016, your payment years will need to be consecutive. 2021 is the last year you can receive a payment from the Medicaid program.

Q: What happens if I decide not to implement an electronic health record? I have hardly any Medicare or Medicaid patients so won't it affect me, or will it?

A: At this stage, it would not affect you. You should be aware, however, that some of the major private health plans are considering providing differential reimbursement based upon whether a provider is meaningfully using a certified electronic health record (EHR). As you can imagine, health plans will be a beneficiary of EHRs. They will be able to more accurately judge our quality and whether we are using resources well. It also has been stated that the quality measures that we will report with our EHRs will come into play for Medicare and Medicaid payments. I think it is safe to say that large health plans will do the same.

We firmly believe that there are financial benefits to providers who effectively use an EHR. It is true that insurance plans will benefit as well, but it is not as if they are the only beneficiaries. A recent study released by the Medical Group Management Association demonstrated that small independent practices realized a net increase of close to $50,000 Increase in savings, or revenue? per provider per year after five years of EHR use as compared with clinics that didn’t use an EHR. So although health plans will see a benefit from using an EHR, we will as well.

It is safe to say that by 2015 you will begin to feel some effect, which will grow more significant over time.

Q: I have a computer in my office, and I believe I will achieve meaningful use right away. If that is true, how soon will I be paid?

A: The first thing I recommend is to determine whether the EHR you use is eligible for the incentive. You can do that by checking the Office of the National Coordinator (ONC) certified HIT products list at http://healthit.hhs.gov/chpl. This Web site lists all the products that have been approved by the ONC’s authorized testing and certification body. You can search by your vendor's name or the product name. Once you find your EHR, make sure that the approved version number is the same version number that you use. If it is, you have an eligible EHR, which will allow you to achieve the incentive.

Payment depends upon which program you choose. If you register to receive Medicare, you must attest to the fact that you have achieved meaningful use for a continuous 90-day period. Once you attest to that fact, you will be paid the first-year incentive when you have achieved the maximum incentive for the year, or at the end of the calendar year, whichever comes first. The maximum incentive is 75% of the allowed portion of your part B Medicare charges or $24,000, whichever is less.

If you choose Medicaid, you will be paid as soon as the program is available. The Minnesota Department of Human Services has stated it will be ready to make payments sometime this fall. Once ready, Medicaid will pay providers who have purchased a certified EHR or who have upgraded an existing EHR to certification. Demonstration of meaningful use is not necessary in the first payment year under Medicaid.

To sum it up, you'll be paid under Medicare once you achieve meaningful use, and your charges equal the maximum allowed, or at the end of the year, whichever comes first. Whereas under Medicaid, you will be paid as soon as the program is ready if you are using or upgrading a certified EHR.

Q: Should I go with Medicare or Medicaid? Which program is better?

A: The answer to that question depends upon your practice. By and large, Medicaid is the better choice if you are eligible for it. If you remain eligible for Medicaid throughout the program, you have the potential to receive a much higher reimbursement than you would from Medicare – a total of $63,750 as opposed to a maximum of $44,000.

In order to be eligible for Medicaid, some portion of more than 30% of your visits must be paid by Medicaid. If you are a pediatrician, you could be eligible for two- thirds of the total incentive if your patient mix is between 20% and 30%. If your patient mix is more than 30%, you would receive the full incentive. If you work in a federally qualified health care center, you are eligible if greater than 30% of your patients meet the needy-individuals requirements, as defined by the Social Security Act.

A major advantage of Medicaid, aside from higher reimbursement, is that you can receive the full incentive in your first year for just adopting, implementing, or upgrading your current EHR system. You do not need to demonstrate meaningful use in the first payment year with Medicaid, which is not true for Medicare. To receive incentive dollars for Medicare, you must demonstrate meaningful use.

Another advantage to Medicaid is that you do not need to achieve meaningful use in consecutive years. If you do not achieve meaningful use for one year, you will not be penalized, and you will not lose a payment year. With Medicaid, you get a total of six payments, which can start in 2011 and extend to 2021 so you have 11 years in which to receive the six payments. Be aware, however, that if you are billing Medicare and you're not a meaningful user for any year after 2014, your Medicare reimbursement will be reduced.

For more information about the Medicaid program, please see the Minnesota Department of Human Services Web page: http://www.dhs.state.mn.us/ehrincentives

Q: I am using an electronic health record, but none of my other partners are using it very well. Could I still be able to achieve meaningful use if they don't?

A: Yes, you will still be able to achieve meaningful use because meaningful use is measured on an individual basis. However, it will be more difficult for you to maintain accurate and up-to-date problem lists, medication lists, medical and surgical histories if you share patients with your partners and they're not using the EHR well. Though it will not prevent you from achieving meaningful use, it may mean that you will need to do the lion's share of the work for keeping patient information current. If you do not share patients except for the occasional time when you're on call or covering for your partner, this would be much less of a problem.

If you have not already, I would suggest having a conversation with your partners to discuss how you should move forward as a group. Having charts that are partly on paper and partly electronic will lead to errors and jeopardize patient safety. I suggest that you come together as a practice and discuss this unless you're practices are truly separate.

Q: How do we know if straight licensure, ASP/SaaS, and community offering is the right choice for our EHR?

There is no easy answer to this question and really depends on your situation. Deciding which model to choose is an involved process which requires you to look at your financial situation, your technical skills, and the pluses and minuses of each type of licensure. One should also look at your community and see what options are being used in your community.

Straight licensure of electronic health record means that you purchase the software, the hardware and receive support from your mentor while housing both the hardware and software at your facility. With the ASP and SaaS models, your data is housed off-site and support and maintenance of the hardware is also off-site. The community offering is somewhat similar to the ASP and SaaS model one where you sublicense an electronic health record from another facility such as a hospital or integrated delivery network and they provide software hardware and support.

Typically an ASP or SaaS model requires less cash up front then the straight licensure model will. It is a lot like leasing a car versus purchasing a car. The community offering is one in which you lease software from a large clinic or health system.

This is one of the most important decisions you'll need to make when narrowing your vendor choice. REACH has a number of resources that can help walk you through this process.

Q: I am working with a vendor to install an EHR. How do I check that its system is capable of getting us to meaningful use?

A: Your vendor should be able to tell you. If you want to check if your EHR has been certified by the new process established by the Office of the National Coordinator of Health Information Technology (ONC), the ONC Web site lists all of the products that are certified, http://onc-chpl.force.com/ehrcert. Products continue to be added to the list as they are certified. Most of the reputable EHR vendors plan to become certified since it is essentially a requirement to stay in business. If providers do not wish to be penalized after 2015 or if they wish to get incentives, they will need to be utilizing a certified EHR product. When you check the list, be sure to see if the version of the software that is being installed in your clinic is the version that was certified by the ONC. Vendors often have multiple versions of software and some have had to make significant changes in order to meet meaningful use requirements.

CCHIT certification is not ONC certification. CCHIT certification does guarantee that the product meets certain standards, such as drug interaction checking, problem lists, and data exchange. However, CCHIT did not require all the standards that are required in the ONC certification. Though CCHIT certification is a good foundation, be sure to verify that your vendor is installing a product that is an ONC Authorized Testing and Certification Body (ONC-ATCB) certified product.

Q: I looked at the CCHIT Web site, what’s the difference between pre-market EHRs and approved products?

A: CCHIT will certify a product based upon testing in its laboratory; however, it only gets final approval after it has been installed in a certain number of practices and is being used. I have seen several products that have remained on the premarket certification list for some time without achieving full certification. Again, for meaningful use incentives, CCHIT certification or premarket certification is not required. The only thing that is required is ONC-ATCB certification.

Q: What’s the minimum I need to do to meet meaningful use requirements?

A: At a minimum you’ll have to be using an electronic health record (EHR) that is certified by the new process established by the Office of the National Coordinator (ONC) for Health Information Technology. With that in place, you will then need to meet 15 core and five or more menu criteria that you select in order to be eligible for incentives. Some of these criteria will be completed by your staff; others can be accomplished with the help of your staff in order to increase your efficiency. Some you will need to complete yourself. I won't go into the details of the criteria here; however, it’s important to note that these are just the first steps in effectively using an EHR and using it to provide higher-quality, more coordinated care. Consider these issues:

• Doing the minimum to meet stage 1 may set you up for failure when the stage 2 criteria come along. These have yet to be defined, but rest assured they’ll be more rigorous than the stage 1 criteria.
• Determine the value you want to get out of your EHR for both you and your patients. Having just one medication on the medication list, having just one problem on the problem list or having an incomplete allergy list can lead to problems down the line because you may not know which patients have complete or incomplete records.
• One of the stage 1 requirements is to give your patient an after visit summary containing medications, problems and diagnosis for the visit and a follow-up plan. Your patient is likely to complain when the summary is incomplete. Worse, they could stop taking medications that you haven't included on the list.

I think it’s important to see this as an opportunity to make a complete transformation in the delivery of care and embrace this new technology as a way to assist you in providing higher-quality, more coordinated, more cost-effective care.

Q: We have an EHR. How do we know if it’ll pass stage 1 meaningful use?

A: ONC has created a new process for certifying electronic health records. This new certification process is meant to assure that any EHR certified by this process is capable of achieving all of the meaningful use criteria. As of this writing, three ONC Accredited Testing and Certification Bodies (ATCBs) already have certified a number of EHRs. The list is at http://onc-chpl.force.com/ehrcert.

If you don’t see your EHR on this list, be sure to ask your vendor if it’s planning on using the new ONC-ATCB process. You also should ask what version it plans on using to certify. It may not be the version you're currently using. Although being certified by the Certification Commission for Health Information Technology (CCHIT) was previously the only available indicator of getting a capable EHR product, being certified by CCHIT does not automatically make an EHR certified under the new process.

Having a certified EHR is only one step. Meaningful use is far more than a technology project. You also need to have your people and processes ready as well.

Q: What’s HIT?

A: This was the most frequent question we were asked at the MMA meeting up at Breezy Point. As physicians went by our booth and read our sign “Regional Extension Assistance Center for HIT”, they would pause for a moment looking perplexed. They’d asked, “What's HIT?” We discovered they were thinking of heparin-induced thrombocytopenia, putting their thoughts miles from health information technology (HIT). For those of you who don't know, health information technology is a general concept describing computerized or technological information systems supporting the management of health information. It includes electronic health records but can also include barcode scanners, smart pumps, home monitoring devices or ED tracking boards. The HITECH Act is incentivizing use of electronic health records and HIT for the improvement of quality, safety, and efficiency of care. REACH is a program supported by the HITECH Act to provide subsidized help to primary care providers and small hospitals in adopting, implementing, and becoming meaningful users of electronic health records and health information technology (the other HIT).

Q: At first we heard we qualified to have discounted technical assistance through REACH and then we heard we don't qualify. Which is true?

A: I can understand the confusion, as the rules for qualification changed. In February, when REACH was approved to serve primary care providers in North Dakota and Minnesota, we understood that we could work with all primary care providers and receive subsidies for the first 10 in any particular clinic. In mid-June, the Office of Management and Budget (OMB) released a notice which greatly reduced the number of providers eligible for the subsidized services. Since that time we have been working with the Office of the National Coordinator (ONC) to clarify these new rules. We’ve explained that many small clinics in Minnesota and North Dakota have grouped together in order to be able to continue to provide care in their communities. We have been working with ONC to more clearly define underserved areas. They are now finalizing a new definition which will increase the number providers for whom we can provide subsidized services. So if you heard that you were ineligible, yet you think you might be eligible, we suggest that you register on our Web site to request subsidized services for adopting, implementing and becoming a meaningful user of an EHR. Registering does not commit you to using REACH services. If you have registered with us and heard that you did not qualify, we will be reviewing all previous registrations once the rules are clarified and contacting you if you now qualify. If you are anxious to get started, feel free to give us a call.

REACH provides health information technology services to assist providers in Minnesota and North Dakota with their EHR planning, implementation and achieving meaningful use of their EHR.

877-331-8783, ext. 222, info@khaREACH.org, www.khaREACH.org