What you need to know about the current state of EHR software and reimbursement under the HITECH Act.

By Daniel Sosnoski

At this time last year, we gave you our view of where things stand with electronic health records (EHR) and reimbursement through the Health Information Technology for Economic and Clinical Health (HITECH) Act.1 In this article, we update that report.

shutterstock_55604203As you are probably aware, the act provides that chiropractors who establish “meaningful use” of EHR software within a certain timeframe are eligible for up to $44,000 in incentive payments from the Centers for Medicare and Medicaid Services (CMS). At the time of our initial report, a number of questions were unresolved, but developments since then have clarified how the act may apply to DCs who wish to participate.

A framework taking shape

The first thing to know about EHR software is that not all software is created equal. The government, however, would like it to be and so it established a certification system for software vendors.

Certification helps providers and patients to be confident that the EHR and systems they use are secure, can keep data confidential, and share patient data with other EHR systems. As a result, software vendors who want to have their products certified have been submitting applications to Authorized Testing and Certification Bodies (ATCB) accredited by the Office of the National Coordinator (ONC) for Health Information Technology of the U.S. Department of Health and Human Services (HHS).

The vendor-selected ONC-ATCB then inspects the software according to criteria and standards developed by ONC and test procedures developed by the National Institute of Standards and Technology (NIST), an agency of the U.S. Department of Commerce. Following a successful inspection by an ONC-ATCB,  a vendor’s software will be certified as a “modular” or as a “complete” EHR. There are some important distinctions between these two levels of certification, so be sure you understand the difference.

A software package certified as modular will not be eligible for reimbursement under the federal government’s EHR incentive program.

A collection of modules meeting all of ONC’s criteria is required to qualify a provider for incentives.

This program was set up to provide cash incentives for every chiropractor who uses EHR software in the manner required by the government. Software certified as a complete EHR is eligible for reimbursement, up to $44,000 in total if you can prove meaningful use.

Of course, there is no mandatory requirement to participate in the program. It is likely that CMS in future years will be reducing payments to non-participants (possibly as early as 2015). So your choice is to participate early and get the carrot, participate later for reduced incentives, or opt-out altogether and get the stick.

Because of trends in managed care and programs like “physician quality incentives” and “pay for performance” plans, it is highly likely that private insurers will also be urging their in- network providers to use EHRs, too. That’s because EHRs provide insurers with tools to measure both quality of care and outcomes.

The hope is that EHR technology will improve quality of care by reducing medical errors and redundant tests, and curtailing prescribing mistakes, all while gaining efficiencies.

The net result should be better care at lower cost.

So what is meaningful use?

You won’t be eligible for government reimbursement payments just because you purchase a certified software system. Your EHR software must be certified as a complete EHR or as a collection of certified EHR modules meeting all of the criteria, and you have to demonstrate meaningful use of it.

For now, there are three overriding components of meaningful use:

  1. You must be using a certified EHR system in a meaningful manner.
  2. You are using certified EHR technology for the electronic exchange of health information to improve the quality of your healthcare service.
  3. You are using certified EHR technology to submit clinical quality and other measures.

In other words, meaningful use means that you need to show you’re using certified EHR technology in ways that can be measured significantly in both quality and quantity. That is why the incentive payment program isn’t designed to reimburse you for the cost of your EHR software; it’s intended to encourage your use of the software in the manner prescribed by the government.

For eligible professionals, there are a total of 25 meaningful use objectives developed by CMS. To qualify for an incentive payment, 20 of these 25 objectives must be met. There are 15 required core objectives. The remaining five objectives may be chosen from the list of 10 menu-set objectives.

As long as your system is certified by an ONC-ATCB and you attest to CMS that you are using it for the intended purpose, you should qualify for payment.

The clock is running

As you evaluate your options, be aware that the maximum incentive payment is $44,000, and this is tied to your date of EHR system implementation. If you want to be eligible for the full amount, your current deadline is Dec. 31, 2012.

There is an advantage, however, to participating by Dec. 31, 2011. If you have installed, or plan to install, a certified EHR system during calendar year 2011 and can demonstrate meaningful use during a 90-day reporting period before Dec. 31, you only have to “attest” — not prove — that you used the software as required.2

Your first incentive payment for the Medicare EHR Incentive Program can be made by CMS approximately four to eight weeks after you meet the program requirements and successfully attest you have demonstrated meaningful use of certified EHR technology. Note that payments will be held for eligible professionals until the eligible professional meets the $24,000 threshold in allowed charges.Feature1

On the other hand, if you wait until 2012 to implement your system, and make meaningful use of it for 90 days, you will have to prove you have used the software as required. This will be determined by the electronic records your software produces and sends to CMS. (See chart, “Incentive payment schedule.”)

Getting up to speed

Those with experience in this area caution that installing and using EHR software is no simple matter. First, you’ll have to decide on a system from among the many available. You may wish to involve your staff in the selection process, as they’ll be using the software, too.

While some software vendors will only sell to hospitals or large practices, there are some packages designed specifically for chiropractors and these deserve your consideration. You’ll want a system that is highly usable and suits your office and the needs of your staff. While the installation of the software is generally not a time-consuming process, the training required to use it can be a different matter. If you and your staff are already “wired,” comfortable with email, navigating the CMS and managed care websites, paying bills online, and so forth, then you should find it easier to master your new system.

There will be a transition period where you un-learn your old way of doing things and adopt new procedures. Depending on the complexity of your software and hardware, there may be consultation with tech support. All of these things will impact the amount of time it takes you to fully implement your EHR system and begin demonstrating meaningful use.Feature2

Christopher Johnson, DC, is one of the first in the profession to achieve the meaningful use standard. “Installation was easy. Once you get it [your EHR system] installed, that’s when the fun starts.” He credits his EHR vendor’s training program and ongoing guidance as being components of his success. He also recommends shopping for a chiropractor-specific EHR, as opposed to one more geared for MDs.

Remember: You have to successfully demonstrate meaningful use for a consecutive 90-day period in your first year of participation (and for a full year in each subsequent year) to receive EHR incentive payments. If you already use EHR in your practice, check with your vendor to see if a certified version of your software is available and whether you can upgrade to it. That’s what Johnson did.

What to expect from EHR

In short: You can expect a lot. Electronic records will ultimately help streamline your recordkeeping, reduce your documentation storage burden, and increase your efficiency.

To get a closer look, consider what software vendors have had to do in order to achieve certification. The government required software packages to meet what it calls “Stage 1” standards,3 which came into effect this year. These focus on electronically capturing key health information that can be coordinated among care providers. Some clinical quality measures are included, such as the requirement to record all of the following demographics:

  • Preferred language
  • Gender
  • Race
  • Ethnicity
  • Date of birth

In addition, you would also record and chart changes in height, weight, blood pressure, and body mass index (BMI).

The government recognizes that not all healthcare providers offer the same kinds of services. So chiropractors, for example, are exempt from a number of the requirements, but they must still have complete certified systems to ensure that they can comply with changes to be made in future years.

Feature3The Stage 2 standards, scheduled to take effect in 2013, aim at ICD-10 and ANSI 837 5010 claims. They will expand on Stage 1 requirements and facilitate test result reporting (such as blood tests, microbiology, urinalysis, pathology tests, radiology, and more). As you can imagine, this will make it much easier to access test data and share your findings with other professionals.

These health information technology tools are designed to improve health outcomes and promote continuous quality improvement.

Later, the Stage 3 standards scheduled for 2015 will focus on safety and efficiency, and may allow additional patient access to self- management tools and comprehensive patient data, with the overall goal of improving population health.

As will all things governmental, delays, changes, and new requirements can be expected along the way. Your software vendor will need to meet the standards for each stage and upgrade your system to keep you certified (and eligible for reimbursement).

Due diligence

It may be that you do not see Medicare or Medicaid patients and do not plan to seek the incentive payments offered.

Still, you should be thinking about EHR systems anyway because they are likely to become the industry standard and will facilitate your working with other DCs and MDs as well as managed care organizations and insurers.

For example: You are looking at two systems called ABCsystem and XYZnotes. Your first step would be to verify their certification status with the Certified HIT Product List (CHPL) at http://onc-chpl.force.com/ehrcert.Feature4

After selecting “Practice Type: Ambulatory,” you would be able to search for both systems and in using the example above you’d see this:

This would tell you at a glance that of these two, only XYZnotes is a complete EHR eligible for incentive payments. All certified software will have an identification number and vendors usually display it prominently in their ads and brochures. They have worked very hard to obtain this recognition and will want you to know it.

The bottom line

You’ve done your research, marshaled your resources, and installed a certified EHR system. How do you go about getting the incentive payments?

According to the schedule, you are eligible for 75 percent of the reimbursement you received for covered Medicare Part B services up to the maximum allowed for each of the five years in the incentive payment cycle. If you received $24,000 for services from Medicare, you would qualify for the maximum payment.

This assumes that you have demonstrated meaningful use of the system. You’ll probably want to work with a consultant and your software vendor so you fully understand what steps are required and the various nuances involved. This is where early adopters of EHR report having the most difficulty.

The total amount of incentive payments possible begins to decline after 2012. See the schedule chart in this article for more detail.

Going forward, plan on occasional upgrades and concomitant training for you and your staff to remain compliant in your reporting.

Chiropractors using certified EHR to the level mandated by Stage 1 requirements will be highly active members of the wellness framework supporting their patients.

Daniel_SosnoskiDaniel Sosnoski is the editor of Chiropractic Economics. He can be reached at 904-567-1539, dsosnoski@chiroeco.com, or through www.ChiroEco.com.

Russ Leonard, executive director of the Wisconsin Chiropractic Association, contributed to this article.



1Heyboer M. (2010, August 27). The $44,000 Question. Chiropractic Economics, 56, 58-64.

2http://www.cms.gov/EHRIncentivePrograms/20 _RegistrationandAttestation.asp