Location:
PATIENTS' RIGHTS;
Scope:
Federal laws/regulations; Program Description;

OLR Research Report


October 12, 2010

 

2010-R-0402

OLR BACKGROUNDER: ELECTRONIC HEALTH RECORDS AND “MEANINGFUL USE”

By: John Kasprak, Senior Attorney

INTRODUCTION

The country's health care system is undergoing significant changes as efforts are made to improve the quality, safety, and efficiency of health care. One of the elements of this effort is the use of electronic health records (EHR) by health care providers and institutions. The federal “Health Information Technology for Economic and Clinical Care Act” (HITECH), passed in 2009, will provide incentive payments under Medicaid and Medicare to eligible providers and hospitals for the “meaningful use” of certified EHR technology. The payment program begins in 2011. These incentive programs are designed to support providers as they make the transition to health information technology (HIT) and encourage the use of EHRs to help improve patient health care delivery and outcomes.

THE HITECH ACT

In February 2009, Congress passed the HITECH Act as part of the American Recovery and Reinvestment Act (ARRA, P.L. 111-5; HITECH is Title IV of Division B and Title XIII of Division A of the ARRA). The HITECH Act creates a series of incentives for providers to use HIT. These include authorizing incentive payments through Medicare and Medicaid to clinicians and hospitals when they use EHRs privately and securely to achieve specified improvements in care delivery.

The act makes available incentive payments totaling about $27 billion over six years. Beginning in 2011, the EHR incentive program will provide incentive payments of as much as $44,000 to providers who see Medicare patients and $63,000 to those who see Medicaid patients if they engage in the “meaningful use” of certified EHR technology. The act did not define “meaningful use;” however, subsequent federal regulations have done so (see below). Eligible providers (called “eligible professionals” under the law) for the incentives include doctors of medicine or osteopathy, dental surgery or medicine, podiatric medicine, optometry, and chiropractic.

The HITECH Act also establishes penalties for providers who do not adopt EHR and related technologies by 2016. At that time, those not using EHR systems will have their Medicare and Medicaid payments cut.

Two agencies within the federal Department of Health and Human Service (HHS) are responsible for the implementation of this legislation - the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS).

MEANINGFUL USE

The goal of HITECH is not just adoption of, but also meaningful use of EHRs, that is, their use by providers to realize significant health care improvement. As noted above, the legislation does not define “meaningful use,” but instead left it to the HHS secretary to develop meaningful use objectives and measures. CMS was primarily responsible for developing regulations addressing the meaningful use issue and published proposed meaningful use rules in January 2010. Their proposal attracted over 2,000 comments.

Final regulations were issued in July 2010 and incorporate significant changes from the initial draft proposal in response to the comments received. Of particular concern, according to the comments, were the pace and scope of implementing meaningful use objectives and measures. As a result, the final regulations reflects a two-track approach concerning the elements that allow physician practices and hospitals to qualify for incentive payments in the first two years. These regulations apply to the first two years (2011, 2012) of the multi-year incentive program. Two more stages of the program will follow in 2013 and beyond. Further regulations will govern later phases of the program as HHS plans to expand the definition of meaningful use by adding IT functions that providers must use to get incentive payments.

The regulations can be found at 42 CFR Parts 412, 413,422, and 495 (see Federal Register, July 28, 2010).

Required Clinical Functions

The most significant part of the meaningful use regulation addresses what providers must do with EHRs to be considered meaningful users in 2011 and 2012. Under the regulation, providers seeking incentive payments during the program's first phase must use a set of core measures—14 for hospitals and 15 for physicians and clinicians. They must also select five other measures from a menu of ten optional elements. One of the five optional measures must address public health.

Generally, the core measures address basic functions that enable EHRs to support improved health care. These include basic data entry such as patients' vital signs and demographics, medications and allergies, up-to-date lists of current and active diagnoses, and smoking status. Other core measures involve use of several software applications that will lead to improvements in health care safety, quality and efficiency.

The optional elements include performing drug formulary checks, incorporating clinical laboratory results into EHRs, reminding patients about needed care, identifying and providing patient-specific health education resources, and using EHRs to support a patient's movement between health care settings.

Providers must use their EHR systems to perform each function over a period of 90 days in the first year and also meet numerical targets. After 2011, they must demonstrate meaningful use for the entire year.

EHR System Certification

In order to meet the meaningful use standard, providers must use EHR systems that comply with technical standards established by the ONC. The systems must be certified as compliant, functional, and secure, with certification performed by HHS-authorized organizations. Providers' existing systems may have to be upgraded in order to meet certification standards. To date, only one organization, the Certification Commission for Health Information Technology (CCHIT) has done all the certification work for HHS programs. The ONC wants to authorize more organizations as official certification bodies to speed up the certification process. HHS has begun a temporary certification program.

Summary Overview of Meaningful Use Objectives

Following is an overview of the meaningful use measures in HHS' final July 2010 regulation, as provided in a recent New England Journal of Medicine article. The actual regulations and filing requirements that must be met to qualify for the incentive payments can be found at www.cms.org.

SUMMARY OF MEANINGFUL USE OBJECTIVES AND MEASURES

Objective

Measure

Core set of objectives to be achieved by all eligible professionals, hospitals, and critical access hospitals to qualify for incentive payments

Record patient demographics (sex, race, ethnicity, date of birth, preferred language, and in the case of hospitals, date and preliminary cause in the event of death)

● Over 50% of patients' demographic data recorded as structured data

● Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children)

● Over 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data

● Maintain up-to-date problem list of current and active diagnoses

● Over 80% of patients have at least one entry recorded as structured data

● Maintain active medication list

● Over 80% of patients have at least one entry recorded as structured data

● Maintain active medication allergy list

● Over 80% of patients have at least one entry recorded as structured data

● Record smoking status for patients 13 years of age or older

● Over 50% of patients 13 years of age or older have smoking status recorded as structured data

● For individual professionals, provide patients with clinical summaries for each office visit; for hospitals, provide an electronic copy of hospital discharge instructions on request

● Clinical summaries provided to patients for over 50% of all office visits within 3 business days; over 50% of all patients who are discharged from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it

● On request, provide patients with an electronic copy of their health information (including diagnostic-test results, problem list, medication lists, medication allergies, and for hospitals, discharge summary and procedures)

● Over 50% of requesting patients receive electronic copy within 3 business days

● Generate and transmit permissible prescriptions electronically(does not apply to hospitals)

● Over 40% are transmitted electronically using certified EHR technology

● Computer provider order entry (CPOE) for medication orders

● Over 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE

● Implement drug–drug and drug–allergy interaction checks

● Checks can be conducted for the entire reporting period

-Continued-

Objective

Measure

● Implement capability to electronically exchange key clinical information among providers and patient-authorized entities

● Perform at least one test of EHR's capacity to electronically exchange information

● Implement one clinical decision support rule and ability to track compliance with the rule

● One clinical decision support rule implemented

● Implement systems to protect privacy and security of patient data in the EHR

● Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies

● Report clinical quality measures to CMS or states

● For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures

Eligible professionals, hospitals, and critical access hospitals may select any five choices from the menu set

Implement drug formulary checks

● Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period

● Incorporate clinical laboratory test results into EHRs as structured data

● Over 40% of clinical laboratory test results whose results are reported in positive/negative or numerical format are incorporated into EHRs as structured data

● Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach

● Generate at least one listing of patients with a specific condition

● Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate

● Over 10% of patients are provided patient-specific education resources

● Perform medication reconciliation between care settings

● Medication reconciliation is performed for over 50% of transitions of care

● Provide summary of care record for patients referred or transitioned to another provider or setting

● Summary of care record is provided for over 50% of patient transitions or referrals

● Submit electronic immunization data to immunization registries or immunization information systems

● Perform at least one test of data submission and follow-up submission(where registries can accept electronic submissions)

● Submit electronic syndromic surveillance data to public health agencies

● Perform at least one test of data submission and follow-up submission(where public health agencies can accept electronic data)

Additional choices for hospitals and critical access hospitals

Record advance directives for patients 65 years of age or older

● Over 50% of patients 65 years of age or older have an indication of an advance-directive status recorded

● Submit electronic data on reportable laboratory results to public health agencies

● Perform at least one test of data submission and follow-up submission(where public health agencies can accept electronic data)

Continued-

Objective

Measure

Additional choices for eligible professionals

Send reminders to patients (per patient preference) for preventive and follow-up care

● Over 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders

● Provide patients with timely electronic access to their health information(including laboratory results, problem list, medication lists, medication allergies)

● Over 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

Source: “The Meaningful Use Regulation for Electronic Health Records,” The New England Journal of Medicine, August 5, 2010, pp. 502-503.

ADDITIONAL SOURCES

For more information see:

David Blumenthal, M.D., M.P.P. and Marilyn Tavenner, R.N., M.H.A., “The Meaningful Use Regulation for Electronic Health Records,” The New England Journal of Medicine, August 5, 2010; NEJM.ORG.

Nancy Ferris, “Meaningful Use of Electronic Health Records,” Health Policy Brief, Health Affairs, August 24, 2010; http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=24

EHR Incentive Programs, Centers for Medicare and Medicaid Services; https://www.cms.gov/EHRIncentivePrograms/

Electronic Health Records and Meaningful Use, Department of Health and Human Services; http://healthit.hhs.gov

JK:ts