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Government EHR Incentive Program Starts to Take Shape

President Obama has been touting health information technology as an essential element of healthcare reform since he entered office. The American Recovery and Reinvestment Act of 2009 (ARRA) promotes adoption of electronic health records (EHRs) by offering providers incentives for the "meaningful use" of qualified EHRs. Yesterday the Department of Health and Human Services (HHS) published in the Federal Register a notice of proposed rulemaking (NPRM) that defines meaningful use, along with an interim final rule that proposes health IT standards and criteria for EHR certification. Both sets of regulations will be finalized next spring, following a 60-day comment period.

Healthcare providers are very interested in these regulations. Eligible physicians stand to gain from $44,000 to $64,000 each by demonstrating meaningful use to Medicare or Medicaid over a five-year period, and hospitals may be able to net millions. Starting in 2015, the Centers for Medicare and Medicaid Services (CMS) will financially penalize providers who don't show meaningful use of EHRs.

For physicians who have EHRs, the bar for establishing meaningful use in 2011, the first year of the incentive payments, is relatively low in some respects. For example, HHS decided-against the recommendations of its own Health IT Policy Committee-not to require physicians to document their progress notes electronically. At a press conference to announce the proposed rules, David Blumenthal, MD, the National Coordinator for Health IT, explained that this type of documentation was not necessary to meet the goals of meaningful use, which include improvements in quality, safety, and efficiency.

What this means is that physicians could dictate or type their notes, allowing staff members to enter other required data, such as vital signs. This would help promote EHR adoption, because many physicians have a problem with the "point-and-click" method of documenting visits on EHR note templates.

However, the current definition of meaningful use raises other issues. For one thing, physicians must incorporate at least half of lab results in their EHRs as structured data. That requires interfaces with their major labs, but such interfaces may be unavailable or may be too expensive for some practices. Also, physicians are supposed to prove they can send clinical summaries from their EHRs to the EHRs of the specialists they refer patients to, but the exchange of the required summary documents-while available in a growing number of EHRs--has not been adequately field-tested.

The Medical Group Management Association (MGMA) says the new rules are "overly complex" and present some daunting challenges to physician groups. MGMA objects to "unreasonable thresholds for some of the meaningful use criteria", as well as the requirement that physician offices provide patients with electronic copies of their medical records.

Meanwhile, a new study in the Journal of General Internal Medicine points to the relatively poor track record of EHRs in the coordination of care, partly because the records are designed more for justifying billing than for improving quality. For instance, few EHRs enable doctors to track referrals. The authors suggest that much more development work needs to be done on EHRs before the government's goals can be met.

Despite the many uncertainties surrounding adoption, CMS has made a relatively robust forecast on the percentage of physicians who will show meaningful use of EHRs. Based on an estimate that there will be 404,000 eligible professionals in 2011, CMS predicts that between 10 percent and 36 percent will do so in 2011, 15 percent to 44 percent in 2013, and 21 percent to 53 percent in 2015.

The wide range of estimates reflects the current healthcare environment, including the remote possibility that Congress will allow Medicare to cut physician pay by 21 percent in 2010. In addition, as CMS officials made clear at the press conference, many providers will be put off by the formidable challenges of meaningful use. The Administration has taken on a giant challenge itself; but it is one that, like reform itself, must be overcome to transform our healthcare system.

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