The recently enacted American Recovery & Reinvestment Act, commonly referred to as the "stimulus plan," includes more than $19 billion in incentives for physicians to adopt EHR technology.
The recently enacted American Recovery & Reinvestment Act (ARRA), commonly referred to as the “stimulus plan,” includes more than $19 billion in incentives for physicians to adopt electronic health record (EHR) technology. This part of the ARRA legislation is known as the Health Information Technology for Economic and Clinical Health Act (HITECH). In essence, HITECH calls for physicians to earn up to $44,000 over five years if they use an EHR in such a way as to comply with yet-to-be-finalized criteria. So, if you are one of the 83% of doctors who have not yet implemented an EHR system, now may seem like the perfect time to do so. But not so fast…
Now, I’m probably the last person you’d expect to be saying this, but as I investigated the actual details of this law, I came to a startling realization: none of the details have been worked out, and running out to get an expensive EHR system in hopes of recouping the cost through the incentive programs is nowhere near a sure thing.
Financial incentives and penalties
Let’s start with what is known. Beginning in 2011, physicians can receive extra Medicare payments for the “meaningful use” of a certified EHR. These payments can total as much as $18,000 in the first year for practitioners who adopt in 2011 or 2012, with slightly lower amounts for those who do so in 2013 and 2014; incentives are gradually reduced and then end in 2016. For physicians with high volumes of Medicaid patients (30% or higher), the law provides subsidies through the Medicaid program as well. Doctors must choose whether to participate in the Medicaid or Medicare bonus program; they cannot receive bonus payments from both.
Thus, eligible professionals demonstrating meaningful use of a certified EHR starting in 2011 could collect $44,000 over five years. Waiting until 2013 would result in a maximum bonus of $27,000 over three years. HITECH also imposes financial penalties to spur adoption. Physicians who are not using EHRs meaningfully by 2015 will lose 1% of their Medicare fees, then 2% in 2016, and 3% in 2017. The bottom line is that 2011 is still 18 months away, so there is plenty of time to wait to make a decision about your EHR, even if you want to collect the maximum $44,000 benefit.
What qualifies as meaningful use of a certified EHR?
The law states that only “eligible professionals” who “meaningfully use” a “certified” EHR will able to collect the stimulus money. Yet none of these terms have been authoritatively or legally defined. There is much analysis and information about this legislation from various sources floating around the Internet, but none of it has the official seal of government approval. Like most new laws, it will probably take years of regulation, test cases, and interpretations by lawyers and courts before we have definitive answers to many of our questions. We can, however, make some logical assumptions based on the goals of the government.
The biggest issue is America’s high level of healthcare expenditures (compared to the rest of the world). Thus, we can assume that meaningful EHR use will promote the functions that can reduce this cost, such as prescribing generics, sharing lab and radiology findings among physicians rather than reordering tests when the results aren’t readily available, and ensuring that standards of care for community health are followed.
Using e-prescribing, computerized ordering/reviewing of tests, and health information exchange networks all seem to be part of what would be defined as meaningful use; unfortunately, it seems unlikely that tort reform will make it into this discussion to any significant degree, and thus we will continue to practice defensive (and expensive) medicine, ordering questionable tests, procedures, and consults just to reduce our risk of lawsuits.
In terms of a “certified” EHR, it seems reasonable—and it is assumed by many observers—that CCHIT (Certification Commission for Health Information Technology) certification will suffice in lieu of a formal government certifying body. So, even though CCHIT charges tens of thousands of dollars to apply—and requires not only the “meaningful” features above, but also hundreds of other “bell and whistle” features that make EHRs less usable—it looks like that is the future of our EHR choices (Amazing Charts is currently going through the onerous process of getting CCHIT-certified, so watch for a future article describing this experience).
How exactly will reimbursement work?
The most important question for physicians is how to get the promised money (before future budget cuts remove it). I reviewed the HITECH legislation and couldn’t find any real details on how the money was to be distributed. I went to the Healthcare Information and Management Systems Society (HIMSS) conference, where everyone was buzzing about the HITECH legislation. I had two basic questions, assuming I used a certified EHR in a meaningful way by 2011:
• Who is an “eligible professional?” An eligible professional appears to be a physician, but does a nurse practitioner or physician assistant count? What if this mid-level practitioner owns his or her own practice?• How does a physician actually get the money? It appears that you are allowed up to 75% of Medicare payments per physician, but will the payments come in a lump sum, or over time, or piecemeal with each Medicare payment?
Amazingly, nobody I spoke with—including a number of EHR vendors who were advertising the $44,000 stimulus funds to entice folks to purchase their overpriced systems—knew the answers. Eventually, I found a booth for the agency tasked with overseeing HITECH, the Office of the National Coordinator for Health Information Technology (ONCHIT). There, I spoke with two representatives (who requested not to be identified). One said they just didn’t know; the other said she “couldn’t answer.” When asked if she couldn’t because she didn’t know, or wouldn’t because she wasn’t allowed, she replied, “A little of both.”
Frankly, I have no idea what that means. It certainly sounds cryptic, but the fact that even an ONCHIT representative couldn’t (or wouldn’t) provide the answers to simple questions is astounding, especially given the way in which this money is being advertised by vendors and agencies with an interest in accelerating EHR adoption.
While it is disappointing that there is, as of yet, no clear interpretation of several fundamental parts of the HITECH legislation, it is unconscionable that vendors and other groups are hyping this money knowing that the details have yet to be defined. I suspect we’ll find, as we did with the promise of P4P, that the actual money delivered is far less than what was implied. A further risk is that the next administration or congress may choose to cut funding for this incentive program due to fiscal constraints. In the end, it is the underpaid and overworked primary care physicians who will be cajoled, enticed, and ultimately forced into spending tens of thousands of dollars for unproven technology.
I will continue to closely follow and report on how these critical issues play out over the coming months. Until then, slow down and try to ignore all the background noise from vendors and other groups with their various agendas, pushing you into an EHR solution before you’re ready.
Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/ Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.