Transforming and Improving Health Care through Meaningful Use of Health Information Technology

Abstract

Use of electronic health records (EHRs)is becoming more and more common. It is anticipated that their use will improve patient care, decrease practice costs, and increase provider productivity and revenue. The State of Hawai‘i has received funding to assist Hawai‘i and Pacific providers in their selection of qualified EHR products that will meet federal Medicare and Medicaid requirements for “Meaningful Use.” This article describes federal recommendations and resources available to Hawai‘i providers. While it can be fairly overwhelming for small practices to convert to EHRs, there is technical assistance available to support Hawai‘i providers in meeting the Meaningful Use requirements of EHR usage in order to become eligible for financial incentives and to improve positive health outcomes for patients. On October 31st, 2011, there were 138,570 eligible professionals and eligible hospitals registered for the Medicare and Medicaid EHR Incentive Programs nationally. These providers have received $1,238,000,000 in incentives since January 2011. In Hawai‘i there are approximately 400 active registrations for the Medicare program, of which 95 have been successful at meeting Meaningful Use criteria and have received $8.1 million in incentive payments from Medicare. The State of Hawai‘i is preparing to launch its Medicaid EHR incentive program in mid-to-late 2012, which should produce additional payments to Hawai‘i‘s health care providers.

Background

The Institute of Medicine estimated that approximately 98,000 Americans die each year from preventable medical errors.¹ Medical errors are killing more people per year in the United States than breast cancer, AIDS, and motor vehicle accidents combined. Eighty percent of errors were initiated by miscommunication.² A major transformation in the current 2A American health care system is underway, and the demand for more accountable care and better communication is creating the momentum to address the need for improvement in clinical care management, the capture of data for continuity of care, and the definition of measures to monitor costs and quality of care.

The Office of the National Coordinator for Health Information Technology (ONC) was created in 2004 to be a resource for the entire US health care system.³ In 2009, the ONC was mandated through the Health Information Technology for Economic and Clinical Health (HITECH) Act to support and coordinate efforts to improve health care through the adoption of health information technology (HIT) and the development of a nationwide health information exchange (HIE). This is the HIT component of the American Recovery and Reinvestment Act (ARRA) signed into law on February 17, 2009, with provisions of 17.2 billion dollars for EHR use and HIE development. The vision of the HITECH Act is to furnish tools to begin a transformation in our nation's health care system so that each patient can receive optimal care. The adoption of Meaningful Use of electronic patient data and the development of a nationwide exchange of health information over the next several years will serve to optimize and align our combined efforts to improve health outcomes, reduce costs, and increase patient, staff, and provider health care experience and satisfaction.

In 2011, the National Center for Health Statistics estimated that the rate of providers using any EHR was between 40% in Louisiana to 84% in North Dakota, with Hawai‘i having a 70.5% adoption rate.⁴ Any EHR system was defined as an affirmative response to the question, “Does this practice use electronic health records (not including billing records)?”

In comparison, a “basic EHR system” is one that has all of the following functionalities: patient history and demographics, patient problem list, physician clinical notes, comprehensive list of patient's medications and allergies, computerized orders for prescriptions, and ability to view laboratory and imaging results electronically. This may or may not include certified electronic health record technology as specified by ONC Certified Health IT Product List.⁵ Nationally, about 34% of physicians reported having a system that met the criteria for a basic system, up from 25% average in 2010. The lowest state was New Jersey at 16% and the highest was Minnesota at 61%. In Hawai‘i, the EHR adoption rate for a basic system is 46.3%.

Nationwide, approximately 52% of physicians reported intending to apply for Meaningful Use incentives, up from 41% in 2010. While the barriers to the implementation of EHRs include potentially high financial investments, an increase in initial physician and staff training time, workflow redesign efforts, and the need to hire new staff for HIT support, an EHR creates a database of information that will assist in the coordination of patient care and improvement of communication about shared patients among health care providers.

Benefits of using EHRs can include, but are not restricted to, reduced paperwork for patients and doctors, expanded access to affordable care, improved patient quality of care, prevention of medical errors, decrease in health care costs, increase in administrative efficiencies, and engagement of patients/families in their own health care.

An EHR converts a paper medical record into electronic format for faster communication, recall, and clinical decision-making. The goal of clinical decision support is designed to deploy electronic and non-electronic tools to effectively make use of best practices and evidence-based guidelines to help guide care in a more timely manner. Furthermore, the use electronic health records fundamentally changes a practice's communications by redesigning workflows that allow for better access to patient information almost immediately. Transcription costs will be reduced, patients with specific conditions can be more quickly identified and clinical decision support tools will be in place.

The What and Why of Meaningful Use

The term “Meaningful Use” applies to the extent to which a health care provider or organization utilizes electronic health records. The American Recovery and Reinvestment Act (ARRA) defines Meaningful Use as the following:

Use of certified EHR in a meaningful manner (eg, E-prescribing);
Use of certified EHR technology for electronic exchange of health information to improve quality of health care; and,
Use of certified EHR technology to submit clinical quality reporting and other measures.

The government has identified three stages toward meeting their definition of Meaningful Use. The Stage 1 goal is to capture data electronically. The Stage 2 goal is to expand upon Stage 1 criteria and to report health information and track key clinical conditions. The Stage 3 goal is to improve quality, safety, effi ciency, and performance and health outcomes. Meaningful Use includes both a core set and a menu set of objectives that are specific to eligible professionals or eligible hospitals and critical access hospitals. All of the metrics are described in detail at the Centers for Medicare and Medicaid Services (CMS) website.⁶

An example of a core objective is for an eligible professional to “generate and transmit permissible prescriptions electronically (eRx).” The definition of e-prescribing is a prescriber's ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point-of-care. This is an important element in improving the quality of patient care. In Stage 1, this requirement is successfully measured when more than 40% of all permissible prescriptions written by the eligible professional are transmitted electronically using certified EHR technology. In Stage 2, the suggestion is for the percentage requirement to increase to 50% of orders transmitted as eRx. In Stage 3, the suggested threshold for this measure is to increase to 80% of orders transmitted as eRx. See Table 1.

Table 1

Stages of ePrescribing

This HIT-enabled health reform approach aims to capture data in a coded format and expand exchange of information in the most structured format possible in order to advance clinical processes and improve health outcomes by placing emphasis on high priority clinical conditions, patient self-management, and access to comprehensive data. Therefore, the focus is not just about technology, but about improving health and transforming health care through Meaningful Use of HIT.

Financial Incentives for Achieving Meaningful Use

Through the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Programs, Medicare and Medicaid are providing financial incentives for “eligible professionals” (EPs) who have adopted a certified EHR and can demonstrate “Meaningful Use.” Participating eligible professionals must choose to be reimbursed either through Medicare or Medicaid and cannot receive incentive payments from both programs at the same time. Below is a description of each program.

Medicare EHR Incentive Program

The Medicare eligibility criteria for EPs include doctors of medicine, osteopathy, dental surgery, podiatry, optometry or chiropractic care. Excluded from this list are EPs who furnish 90% or more of their services in either the inpatient or emergency department of a hospital. (Eligible hospitals include subsection (d) hospitals and Critical Access Hospitals).

Beginning January 2011, EPs who adopt and demonstrate Meaningful Use of an EHR may be eligible for up to $44,000 in Medicare incentive payments spread out over five years. (This amount is increased by 10% for EPs who predominantly furnish services in a health professional shortage area.) The last year to initiate the Medicare program is 2014 with the last payment in 2016. It is important to note that from 2013, the incentive payments start to decrease every year thereafter. Medicare payment reductions begin in 2015 for providers that do not demonstrate Meaningful Use. The reporting period for meeting Meaningful Use the first year is 90 continuous days within the calendar year and for subsequent years it is the full calendar year.

Medicaid EHR Incentive Program

The Medicaid eligibility criteria for EPs are inclusive of physicians, dentists, certified nurse-midwives, nurse practitioners, and also for physician assistants working in a federally qualified health center / rural health center that is physician-assistant led. Under Medicaid, EPs must practice in a setting where 30% of patient encounters are attributed to Medicaid patients, with the exception of pediatricians who must have a minimum volume of 20% Medicaid patients. However, their incentive payments are limited to two-thirds of the maximum amount or $42,500. Pediatricians with 30% Medicaid population are eligible for the maximum payout of $63,750. (Eligible hospitals include acute care hospitals and critical access hospitals with at least 10% Medicaid patient volume, as well as children's hospitals with no Medicaid volume requirement.) As with Medicare eligibility, Medicaid EPs who furnish 90% or more of their services in either the inpatient or emergency department of a hospital are excluded from the list.

In some states, eligible professionals have begun receiving Medicaid payments as early as January 2011. Unlike Medicare, EPs can participate in the Medicaid program and receive the maximum payment through 2016. This means that the last year for eligible professionals to both initiate and register for the Medicaid EHR incentive program is 2016. EPs may receive up to a maximum of $63,750, with the first year payment being $21,250 for providers who are engaged in efforts to “adopt, implement or upgrade” (AIU) to certified EHR technology. The Medicaid program payments are made over a six-year time period. The last Medicaid EHR payment year is 2021.

An eligible professional has “adopted” a certified EHR when they have evidence of acquiring and installing the technology. When the EP has “implemented” a certified EHR, then he/she has commenced utilization of the technology, eg, staff training and data entry of patient demographic information into the EHR. The EP has “upgraded” the existing EHR by expanding its current technology or adding new functionality to meet the definition of certified EHR technology. In their first year, the eligible professional will not have to demonstrate Meaningful Use in order to receive the payment; he/she just needs to adopt, implement, or upgrade certified EHR technology. In the second year, he/she will have to demonstrate Meaningful Use for a 90-day period only. An EP who has already achieved Meaningful Use will need to demonstrate Meaningful Use of their certified EHR for a 90-day period the first year, and then in subsequent years, he/she will need to demonstrate Meaningful Use of their certified EHR for the full calendar year.

Medicaid Meaningful Use requirements are reported through a means that is developed by each individual state that chooses to participate. The final Meaningful Use rule mandates that the objectives of Meaningful Use for Medicare be the minimum for Medicaid. The State of Hawai‘i Medicaid Program (Department of Human Services, Med-QUEST Division) received funds to begin development of the advanced implementation plan and reporting process for Hawai‘i's eligible professionals to submit documentation to CMS, with the intent of administering the Medicaid EHR incentives in the fall of 2012. The purpose of the advance planning document is to describe the Hawai‘i Department of Human Services, Med-QUEST Division's (DHS-MQD) implementation activities for the development of a State Medicaid Health Information Technology Plan (SMHP) for Hawai‘i. The SMHP will serve as a strategic vision to enable the DHS-MQD to achieve its future vision by moving from the current “As-Is” HIT landscape to the desired “To-Be” HIT landscape, including a comprehensive HIT road map and strategic plan over the next five years. The plan will also describe the processes, procedures and resources required to implement and oversee the incentive payments to be paid to eligible Hawai‘i Medicaid providers for the Meaningful Use of certified EHRs. It is encouraged that Hawai‘i EPs begin preparing now to achieve Meaningful Use, regardless of the program chosen, in order to prepare for future financial incentive opportunities.

Differences in Medicare and Medicaid EHR Incentive Programs

Eligible professionals (EPs) must select only one method to receive the financial incentives, and are allowed to switch programs one time prior to 2015 after they have completed their attestation. Providers practicing in multiple states can only participate in one state's program. Table 2 below shows the notable differences between the Medicare and Medicaid EHR Incentive programs.

Table 2

Notable Differences Between the Medicare and Medicaid EHR Incentive Programs

Demonstrating and Reporting Meaningful Use

For 2011, results for all objectives and measures, including clinical quality measures, is reported via attestation to the Centers for Medicare and Medicaid Services (CMS). For 2012, measures must be submitted via certified EHR technology. In the provider's first year of participation, the reporting period will be any 90-day period that occurs within the calendar year. For subsequent years of participation, the reporting period will be the entire calendar year.

Penalties for Non-Adopters of Meaningful Use

To receive the maximum EHR incentive payment, Medicare eligible professionals must begin participation by 2012. For 2015 and later, Medicare eligible professionals who do not successfully demonstrate Meaningful Use will have a payment adjustment to their Medicare reimbursement. The payment reduction starts at 1% and increases 1% each year that a Medicare eligible professional does not demonstrate Meaningful Use, to a maximum of 5%.

There are no penalties for EPs who choose the Medicaid method, which means that there is no payment adjustment imposed if an eligible provider that qualifies for Medicaid and subsequently chooses NOT to adopt, implement, or upgrade to certified EHR. If an eligible professional adopts, implements or upgrades to certified EHR in the first year, the EP will not have to demonstrate Meaningful Use in order to receive the first year's payment.

What Can Your Practice Do Now to Achieve Meaningful Use?

For practices with no EHR, develop an EHR implementation strategy by focusing on the following:

begin pre-work by performing a financial assessment and return on investment calculation, assigning a physician as a champion and selecting staff for an EHR implementation team;
determine where you are now in the process by performing a readiness assessment, evaluate staff computer skills, analyze your current workflow, and review hardware and software needs;
start planning by deciding where you want to be in the future and how to get there, by defining EHR goals and measurements and drafting an internal project plan for implementation;
evaluate the certified vendors to see which system meets your needs by scheduling demonstrations and negotiating contracts;
begin the EHR implementation process and effectively install the EHR by working with your vendor on implementation planning, system customization/testing/practicing/backup and establishing down time procedures; and,
prepare a post go-live evaluation by reviewing goals, Meaningful Use status, clinical measure reports, and subsequent phase planning.

For practices with an EHR, start now by focusing on the following:

inquire on EHR vendor status of ARRA certification and find out when upgrades will be available;
review reporting requirements and work backwards to ensure that documentation supports required reports;
if possible, implement a lab interface and eRx with interaction checking;
begin using computerized physician order entry (CPOE);
perform gap analysis of documentation: medications, problem, and allergy lists, vitals, etc;
create lists of patients within the EHR using clinical decision support rules and send patient reminders;
implement a patient portal;
implement a medication reconciliation process;
develop a source of statewide information on community HIE and test one exchange of key health data to other providers, health department, or immunization registry; and,
conduct a HIPAA security analysis and address issues.

Overview of the Regional Extension Center Program

The HITECH Act⁷ has established 62 nationwide regional extension centers, including the Hawai‘i Pacific Regional Extension Center (HPREC), in order to offer technical assistance, guidance and information on best practices to support and accelerate health care providers' efforts to become “meaningful users” of EHRs. The coordinated adoption and use of secure EHRs will ultimately enhance the quality and value of health care across the country.

Regional Extension Centers focus their most intensive technical assistance on priority primary care providers (PPCPs), including MDs, DOs, nurse practitioners, physician assistants, and certified nurse mid-wives furnishing primary-care services (ie, adolescent medicine, family practice, general practice, internal medicine, OB, GYN, geriatrics, or pediatrics), with a particular emphasis on individual and small group practices (fewer than ten providers with prescriptive privileges). PPCPs in such practices deliver the majority of primary care services, but have the lowest rates of adoption of EHR systems and the least access to resources to help them implement, use, and maintain such systems. Regional Extension Centers also focus rigorous technical assistance on providers providing primary care in public and critical access hospitals, community health centers, and in other settings that predominantly serve uninsured, underinsured, and medically underserved populations.

As of December 2011, over half of the individual and small group practices in Hawai‘i have not yet implemented basic EHR systems. The HPREC is prepared to assist practices in Hawai‘i with or without EHR systems currently in place and can support health care providers with direct, individualized, and on-site technical assistance in: (1) selecting a certified EHR product that offers the best value for the providers' needs; (2) achieving effective implementation of a certified EHR product; (3) enhancing clinical and administrative workflows to optimally leverage an EHR system's potential to improve quality and value of care; (4) observing and complying with applicable legal, regulatory, professional, and ethical requirements to protect the integrity, privacy, and security of patients' health information; and (5) preparing the required reports to become eligible to receive EHR incentive payments.

The HPREC was established to serve all of the Hawaiian Islands, as well as Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands. The HPREC is a program that is managed by the Hawai‘i Health Information Exchange (Hawai‘i HIE).⁸ The Hawai‘i HIE partners with health care providers to improve patient care, improve operational efficiency, reduce operating costs, receive financial incentives, and become part of a statewide information network for the exchange of electronic health records.

EHR Vendor Identification and Selection Process

Eligible professionals will need to implement an EHR technology that is certified for meeting Meaningful Use and is listed on the ONC certified health IT product list. Certification will promote EHR adoption by giving providers assurance that products and systems will help them achieve Meaningful Use. The choice of the specific, certified technology used should be driven by clinical goals and operations rather than by restrictive certification requirements.

The HPREC is open to working with any certified EHR vendor who meets the selection criteria and who is preferred by the health care provider. Notably, the vendor selection criteria developed by the HPREC goes beyond the national EHR vendor certification requirements and accounts for other requirements, including reliable on-island support needed for Hawai‘i and Pacific island providers.

The HPREC has developed an analytical process utilizing vendor milestone reviews and due diligence in order to determine a list of qualified electronic health record vendors, which included the following steps:

Identifying EHR vendors with installations in Hawai‘i;
Identifying other national vendors to participate in process;
Creating pre-screening list of questions;
Creating survey for interested vendors to complete which helps to profile their business in Hawai‘i;
Holding meetings or sent out correspondence explaining our process and asked all interested vendors to respond by completing pre-screening questions and survey;
Reviewing detailed Request for Proposal (RFP) and provided input regarding any Hawai‘i specific requirements;
Identifying short list of vendors to receive detailed RFI;
Selecting pre-qualified vendors,

Furthermore, the selection process consisted of meeting the following milestones:

Reviewing and analyzing EHR vendor pre-screen responses;
RReviewing and analyzing EHR vendor survey data;
Reviewing and analyzing EHR vendor Request for Information responses;
Vendor reference checking;
Vendor price negotiating and structuring;
Vendor contract negotiating and structuring.

These milestones encompass analysis of Hawai‘i specific functionality and requirements, clinical features and functionality, vendor business and organizational profiles, implementation and training models, support and maintenance models, and technology platform, framework, and scalability of systems.

The Hawai‘i Health Information Exchange

In September 2009, the Hawai‘i HIE was recognized as the State Designated Entity (SDE) through a cooperative agreement from the State Health Information Exchange Cooperative Agreement Program funded by the ONC. The mission of the Hawai‘i HIE is to facilitate the exchange of health information that enables quality health care statewide and to provide reliable health information when and where it is needed.

This will be accomplished by:

Achieving widespread and sustainable HIE within and among states through the Meaningful Use of electronic health records (EHRs);
Establishing and implementing appropriate governance, policies, and network services within the national frame work to build connectivity between and among health care providers;
Improving the capability of providers to actively exchange health care data focusing specifically on electronic orders and receipt of labs and test results as well as e-prescribing;
Developing and implementing up-to-date privacy and security requirements for HIE;
Organizing directories and technical services to enable interoperability within and across states and remove barriers that may hinder effective HIE;
Coordinating with Medicaid and state public health programs to enable information exchange and support monitoring of provider participation in the HIE;
Convening health care stakeholders who can provide support for a statewide approach to HIE.

Implications and Conclusion

According to a press release on November 30, 2011 by the US Department of Health and Human Services (HHS),⁹ Secretary Kathleen Sebelius released a new report revealing that doctors' adoption of health information technology has doubled in two years. Doctors who responded quickly will qualify for CMS EHR incentive payments in 2011 as well as 2012 for meeting Stage 1 of Meaningful Use of certified EHR technology. To encourage acceleration in EHR adoption, the Secretary announced that HHS intends to continue to allow doctors and hospitals to adopt HIT in 2012 and 2013 without meeting the new Stage 2 Meaningful Use requirements until 2014.

There are many benefits for early adopters of Stage 1 Meaningful Use. Providers are given additional time to implement new software and meet the new requirements of Stage 2 and vendors are given added time to develop certified EHR technologies for Stage 2. Maintaining the current expectations for those first attesting to Meaningful Use in 2012 will mean that all providers attesting in 2011 and 2012 will not need to begin Stage 2 until 2014. There is added incentive for providers to attest as soon as possible and receive the rewards of being an early participant. Those providers attesting in 2012 will have two payment years under the less stringent Stage 1 criteria, rather than one year. The Stage 2 and Stage 3 criteria are expected to be more robust in coming years.

As EPs and health care organizations reach Meaningful Use of EHRs that ultimately enable the exchange of critical information across a health care system, the health care system will realize improvements in individual and population health outcomes, increased transparency and efficiency, and improved ability to study and improve care delivery.

With advances in recent HIT, workforce development roles across the nation are being created and new skill sets are being developed for health care professionals to support the implementation of EHRs, practice workflow redesign, and information management training.

Meaningful Use of EHRs is an initiative to expand as well as standardize, streamline, and improve the use of health information technology in our country. The target for nationwide health care reform is to improve the quality of health of our patient population which leads to more patient-centered as well as transparent and accountable care. This can be accomplished effectively through the wide-spread use of EHRs and exchange of health information.

Health care providers in Hawai‘i will benefit from HIT because they will have accurate and complete information about a patient's health, thus enabling the provider to give the best possible care, whether during a routine visit or a medical emergency. Providers will also have the ability to better coordinate the care they give, which is especially important if a patient has a serious medical condition. They will have a way to share information with patients and their family caregivers through secure information technology network communication. This means patients and their families can more fully participate in decisions about their own health care. In addition, health care providers will have information and data necessary to diagnose health problems sooner, reduce medical errors, and provide safer care at lower costs. Communication between health professionals and health entities will become more efficient and effective.

Acknowledgements

The authors wish to acknowledge the assistance of Alan Ito, Hawai‘i Pacific Regional Extension Center Project Director, Gregory Suenaga, Health Information Exchange Project Director, and Beth Siegfried, Hawai‘i Health Information Exchange Communications and Marketing Manager, for their contribution to the preparation of this manuscript.

Conflict of Interest

None of the authors identify any conflict of interest.

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