ARRA and Beyond: How to Select a Stimulus-ready EHR for the Life of Your Practice and Your Patients

Now that CMS and the Office of the National Coordinator for Health Information Technology (ONC) have released meaningful use criteria, physicians have a checklist for selecting the right EHR to assure they’ll meet the standards.

And there’s still time.

Stated goals of the HITECH (Health Information Technology for Economic and Clinical Health) Act within ARRA (The American Recovery and Reinvestment Act of 2009) mirror those of physician practices: early detection, prevention, and management of chronic diseases, for example.

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Additional goals seek to improve the coordination of care and information among hospitals, laboratories, and physician officesimprove healthcare quality, reduce medical errors, reduce health disparities, and advance the delivery of patient-centered medical care.

Getting there, specifically in terms of qualifying for Medicare or Medicaid, Regional Extension Center (REC), Health Information Exchange (HIE), broadband, and the many related programs together offering approximately $45 billion in incentive funds and grants combines the art of traditional medicine and the science of today’s healthcare delivery capabilities, as well as innovation.

Now that the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have released meaningful use criteria—with the CMS proposed rule defining criteria for eligible professional providers, and the ONC interim final rule setting functionality standards for EHRs—the documents can provide a checklist for selecting the right EHR.

And there’s still time. For both the Medicare and Medicaid incentive pathways, the initial meaningful use year for non hospital-based eligible providers remains 2011, with respective funding continuing for 5- and 6-year cycles. (Medicaid incentives can be subject to individual state plans in regards to timetables and is well worth checking.) The major financial tenets of achieving incentive funds through the use of a certified EHR offering meaningful use functionality are well chronicled and unchanged: up to $44,000 through Medicare and up to $63,750 through Medicaid pathways, paid per eligible professional within a practice of any size.

Whether your practice is seeking a fully integrated, interoperable, and certified EHR/practice management (PM) solution or just searching for a companion certified EHR for an existing PM system, many independent evaluation and analysis tools focus on ARRA-driven meaningful use functionality standards, as well as a wealth of ROI calculators and case studies to draw from.

Throughout the closing months of 2009, tangible ARRA-supporting funding announcements and new legislation brought multiple reasons for confidence in the incentive package. For example, The Small Business Health Information Technology Financing Act (HR 3014) guarantees loans through SBA of up to $350,000 for small practices and $2 million for group practices to bridge EHR implementation costs until ARRA reimbursement kicks in (http://tinyurl.com/yle7x9l). HR 3014 has already passed the House of Representatives, and a companion bill has been introduced in the Senate.

www.gao.gov/new.items/d0784.pdf)

Looking deeper into incentives pathways reveals additional opportunities. Practices within health professional shortage areas can qualify for an additional 10% of incentive funds (. A total of $2.5 billion is available for the aforementioned utilization of broadband and telemedicine capabilities, and the REC program’s $598 million in funding targets practices of 1-10 providers (http://tinyurl.com/my736w).

Demystifying Meaningful Use

The proposed meaningful use criteria for the main ARRA incentive funds for certified EHR adoption is a two-part consideration. On one hand, your certified EHR must have the necessary functionality to support meaningful use. On the other, practices must show they are using the functionality in a meaningful way within proposed criteria to qualify for the appropriate incentives.

The overall meaningful use criteria is proposed in three phases over time, with only phase one required in the first meaningful use year. Phase one includes the ability of providers to collect data in electronic form, share key information with other providers and patients, and the ability to report quality measures. And within the Medicare pathway, for example, the proposals state that eligible professionals must only achieve meaningful use reporting for 90 continuous days to qualify.

For EHR software providers, functionality must allow integration or interoperability via standard exchange language (CCD or CCR) to share data. Electronic prescribing and computerized physician order entry (CPOE) are examples of the basic interoperable and meaningful functionalities to secure.

But of course, it’s smart to look ahead. Phases two and three of meaningful use coming after 2011 expand functionality to include disease management criteria and information exchange with government and public health agencies, when formulary checks, encounter progress notes, and automated lab results come into play. For example, an interoperable EHR should link clinical devices such as ECG or spirometry, or merge automated lab results into flow sheets on a system that maintains the values and integrity of the data for later retrieval.

The demystification comes into play when practices selecting an EHR find that 1) EHR software providers have been developing functionality and interoperability that adheres to previously known meaningful use criteria, and 2) that current certification has also been shaped to meaningful use standards. (The ONC has also proposed that a specific meaningful use certification process be added in 2010. This, along with all content in the proposals, is subject to a 60-day comment period, which began January 13.

Throughout your selection process, keep in mind that the CMS and ONC proposals do state that meaningful use is, “based on currently available technological capabilities and providers’ practice experience,” and that, “the standards adopted in the rules are consistent with current industry standards.”

Selecting an EHR

It is

important for practices to select an internal search committee that is well represented by physician, nurse, administrative, and IT personnel. Next, spend time evaluating the goals and workflows of the practice. Are you adopting a certified EHR for just ARRA incentive reasons? Are you looking for improved efficiency within your practice? Are you seeking to improve quality or improve patient satisfaction? Maybe you would like to participate in clinical research? Community leadership? All of the above?

Other areas to think about and discuss with companies that offer certified EHRs (and hopefully ones you have heard great things about) include:

• Your specific requirements in accordance with your practice’s workflow, growth, and revenue targets, as well as future meaningful use requirements
• Your infrastructure. Does your existing PM system have the ability to interoperate with a separate certified her, or should you invest in just a combined EHR/PM system?
• Your practice size and scope. Do they call for implementing a client-server EHR, or an offsite (Internet-dependent), SaaS (Software as a Service) EHR
• EHR product demonstrations, site visits, and references from similar practices of your size and specialty. Other independent evaluations that speak more to usability should be considered. Two large studies by the AAFP and Medscape were recently released and represent the feeling of thousands of EHR users on the actual usability of their system (http://tinyurl.com/y8rntb6). Another good reference of EHR solutions is found at www.klasresearch.com, where products are listed by practice size. KLAS ratings are based on a set of 25 key questions in the areas of sales and contracting, implementation and training, functionality and upgrades, service and support, and general scoring.

Other national organizations such as the Medical Group Management Association (

the HIMSS EHR Association (

offer EHR implementation tips, as do such compatible websites as

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When it comes to cost, don’t be afraid to negotiate with EHR software providers; discuss monthly payment and lease options, as well as IRS Code section 179 tax incentives, with them.

www.mgma.com) and www.himssehra.org)www.ehrdecisions.com

Finding Confidence in ARRA

It’s important to realize that the stimulus EHR adoption incentives are grounded in law, and not just regulation. ARRA funding and other recent developments, such as HR 3014, that support and fund EHR adoption beyond ARRA have inherent flexibility meant to ensure that practices do not fall outside of the guidelines. For example, Medicare reimbursement is not a fixed appropriation, but a fluid formula that keeps pace with the number of practices that are adopting EHRs and achieving meaningful use.

In late 2009, CMS notified all state Medicaid directors that CMS will reimburse at a 100% level the incentive payments that providers who achieve EHR meaningful use are due by state. Also, on December 9, CMS notified its first group of states (TX, GA, NY, ID, CA, and MT) that funds were also being deployed for statewide analysis and infrastructure needs for the planning of activities to administer incentive funds. Texas, for example, received $3.86 million toward that effort.

And earlier, on November 24, ONC announced an $80 million grants program to train a healthcare IT workforce in community colleges and other realms, with all of these steps pointing to concrete support of the ARRA program.

Practices can keep up with the details of ARRA and ongoing events through HHS websites (www.recovery.gov, www.hhs.gov/recovery) and via a new ONC blog titled Health IT Buzz (http://healthit.hhs.gov/blog/onc).

Many components of the HITECH Act were directly supported by the current presidential administration’s transition team when ARRA was created. That support is further encouragement that the legislation is being successfully implemented, and in a bit of serendipity, the incentive funding in its current language will begin arriving at practices the year of this administration’s re-election campaign, meaning national healthcare organizations invested in ARRA will be letting themselves be heard.

The certified EHR adoption and implementation process for your practice should be as time-consuming as it needs to be for you and your practice to achieve meaningful EHR use, but not intimidating. On your side is a wealth of EHR adoption precedent, evaluation and certification resources, ROI examinations, and growing oversight by federal institutions. Making the right selection can provide ROI far beyond the ARRA incentives and can include your practice in the blueprint for a national health information network (NHIN).

Justin T. Barnes is chairman of the Electronic Health Records Association, and is vice president of Marketing, Corporate Development and Government Affairs at Greenway Medical Technologies, Inc.