Electronic Health Records: First Year of CMS's Incentive Programs Shows Opportunities to Improve Processes to Verify Providers Met Requirements
Released: 2012-04-30T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: The Health Information Technology for Economic and Clinical Health (HITECH) Act established the Medicare and Medicaid electronic health records (EHR) programs. CMS and the states administer these programs which began in 2011 to promote the meaningful use of EHR technology through incentive payments paid to certain providers—that is, hospitals and health care professionals. Spending for the programs is estimated to total $30 billion from 2011 through 2019. Consistent with the HITECH Act, GAO (1) examined efforts by CMS and the states to verify whether providers qualify to receive EHR incentive payments and (2) examined information reported to CMS by providers to demonstrate meaningful use in the first year of the Medicare EHR program. GAO reviewed applicable statutes, regulations, and guidance; interviewed officials from CMS; interviewed officials from four states, which were judgmentally selected to obtain variation among multiple factors; and analyzed data from CMS and other sources.

section_title: What GAO Found
paragraphs: The Centers for Medicare and Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), and the four states GAO reviewed are implementing processes to verify whether providers met the Medicare and Medicaid EHR programs’ requirements and, therefore, qualified to receive incentive payments in the first year of the EHR programs. To receive such payments, providers must meet both (1) eligibility requirements that specify the types of providers eligible to participate in the programs and (2) reporting requirements that specify the information providers must report to CMS or the states, including measures that demonstrate meaningful use of an EHR system and measures of clinical quality. For the Medicare EHR program, CMS has implemented prepayment processes to verify whether providers have met all of the eligibility requirements and one of the reporting requirements. Beginning in 2012, the agency also has plans to implement a risk-based audit strategy to verify on a postpayment basis that a sample of providers met the remaining reporting requirements. For the Medicaid EHR Program, the four states GAO reviewed have implemented primarily prepayment processes to verify whether providers met all eligibility requirements. To verify the reporting requirement, all four states implemented prepayment processes, postpayment processes, or both. CMS officials stated that the agency intends to evaluate how effectively its Medicare EHR program audit strategy reduces the risk of improper EHR incentive payments, though the agency has not yet established corresponding timelines for doing this work. Such an evaluation could help CMS determine whether it should revise its verification processes by, for example, implementing additional prepayment processes, which GAO has shown may reduce the risk of improper payments. In addition, CMS has opportunities to improve the efficiency of verification processes by, for example, collecting certain data on states’ behalf.

CMS allows providers to exempt themselves from reporting certain measures if providers report that the measures are not relevant to their patients or practices. Measures calculated based on few patients may be statistically unreliable, which limits their usefulness as tools for quality improvement. CMS and others acknowledged that the availability of measures that are relevant to providers’ patients and practices and are statistically reliable is important to provide useful information to providers. Among participants in the first year of the Medicare EHR program, the majority of providers chose to exempt themselves from reporting on at least one meaningful use measure and many providers reported at least one clinical quality measure based on few—less than seven—patients.

section_title: What GAO Recommends
paragraphs: GAO is making four recommendations to CMS in order to improve processes to verify whether providers met program requirements for the Medicare and Medicaid EHR programs, including opportunities for efficiencies. HHS agreed with three of GAO’s recommendations, but disagreed with the fourth recommendation that CMS offer to collect certain information on states’ behalf. GAO continues to believe that this action is an important step to yield potential cost savings.

section_title: Letter
paragraphs: Widespread use of health information technology, such as electronic  health records (EHR), has the potential to improve the quality of care  patients receive and reduce health care costs. Historically, patient health  information has been scattered across paper records kept by many  different providers in many different locations. When this occurs, health  care professionals may lack ready access to critical information needed to  make the most informed decisions on treatment options, potentially  putting the patient’s health at risk or leading to inappropriate or duplicative  tests and procedures that increase health care spending. To help address  these issues, EHRs can be used, for example, to electronically collect,  store, retrieve, and transfer clinical information related to patients’ care,  allowing ready access to this information by multiple providers in different  locations. Despite the potential benefits, studies have estimated that as of  2009, 78 percent of office-based physicians and 91 percent of hospitals  had not adopted EHRs.

The HITECH Act was enacted as title XIII of division A and title IV of division B of the  Recovery Act. Pub. L. No. 111-5, div. A, tit. XIII, 123 Stat. 115, 226-279 and div. B, tit. IV,  123 Stat. 115, 467-497 (Feb. 17, 2009). meaningful use of certified EHR technology. The largest of these  activities, in terms of potential federal expenditures, are the Medicare and  Medicaid EHR programs. These programs aim to increase the  meaningful use of EHR technology by providing incentive payments and,  later, penalties for providers—that is, certain hospitals and professionals,  such as physicians and nurse practitioners, who participate in Medicare  or Medicaid. To receive incentive payments under the EHR programs,  providers must meet two types of requirements: (1) eligibility  requirements that specify the types of providers eligible to participate in  the programs and (2) reporting requirements that specify the information  providers must report to the Centers for Medicare & Medicaid Services  (CMS), an agency within HHS, or the states to demonstrate that they  have adopted or meaningfully used the EHR technology. For example, in  2011, Medicare professionals had to report 20 meaningful use measures  to CMS which encompass a variety of activities related to the delivery of  health care and encourage providers to consistently capture information  in their EHR systems, such as patient demographics and clinical  conditions. In contrast, during the first year professionals participate in the  Medicaid EHR program, they need only report having adopted,  implemented, or upgraded to a certified EHR system. However, in  subsequent years, Medicaid professionals will have to report on  meaningful use measures.

The Congressional Budget Office estimated total spending for the  Medicare and Medicaid EHR programs to be $30 billion from 2011, the  year incentive payments began, through 2019. Partial-year estimates for  the 2011 program year show that 42,897 providers received  approximately $3.1 billion in Medicare and Medicaid EHR incentive  payments. CMS is responsible for administering the Medicare EHR  program. These responsibilities include ensuring providers meet program  eligibility and reporting requirements, issuing payments, and ensuring the  integrity of those payments. The states and U.S. insular areas are  responsible for administering and overseeing the Medicaid EHR program,  with additional oversight from and partial funding provided by CMS.

States are not required to offer the Medicaid EHR program, although  CMS anticipates that the majority of states will eventually participate.

The HITECH Act requires us to report on the effect, among other things,  of its provisions on the adoption of EHRs by providers.  As discussed  with the committees of jurisdiction, our objectives for this report are to   (1) examine efforts by CMS and the states to verify whether providers  meet program requirements and can, therefore, receive incentive  payments under the Medicare and Medicaid EHR programs; (2) examine  information reported to CMS by providers to demonstrate meaningful use  in the first year of the Medicare EHR program; and (3) describe providers’  experiences during the first year of the Medicare and Medicaid EHR  programs.

The HITECH Act created incentive programs for Medicare fee-for-service, Medicare  Advantage, and Medicaid. Under the Medicare Advantage EHR program, Medicare  Advantage Organizations—private companies that provide Medicare health insurance  coverage to beneficiaries for hospital, physician, and other services—receive incentive  payments for certain affiliated professionals and hospitals that meet program  requirements. Pub. L. No. 111-5, § 4101(c), 123 Stat. 473-476. A review of the Medicare  Advantage EHR program is outside the scope of this report. Throughout this report, we  use the term Medicare EHR program to refer to the Medicare fee-for-service EHR  program. and reporting requirements. In addition, we reviewed these states’ State  Medicaid Health Information Technology Plans, which describe how the  states plan to implement and oversee their Medicaid EHR programs and  which CMS is responsible for reviewing. We also reviewed an HHS Office  of Inspector General (OIG) report, issued in July 2011, which describes  the processes used and the challenges that selected states face in  verifying whether providers meet the Medicaid EHR program’s eligibility  requirements. Finally, as part of our review, we assessed the verification  processes used by CMS and the four states in the context of federal  standards for internal controls for risk assessment and control activities.  The internal control for risk assessment refers to an agency’s  identification, analysis, and management of relevant risks associated with  achieving the agency’s objectives, such as risks to program integrity.  Control activities refer to an agency’s ability to ensure that the policies  and procedures that enforce management’s directives—such as the  processes used to verify that providers qualify to receive incentive  payments—are carried out in an effective and efficient manner.

To examine the information reported to CMS by providers in the first year  of the Medicare EHR program, we conducted several analyses of CMS’s  National Level Repository data from 2011. Specifically, we analyzed the meaningful use and clinical quality measures providers reported to CMS  through December 8, 2011, to demonstrate meaningful use under the  Medicare EHR program. We analyzed the CMS data to identify  the extent to which providers claimed an exemption, as allowed under  the program, from reporting certain meaningful use measures if,  according to the providers, those measures were not relevant to their  patient populations or clinical practices. The agency allows providers  to claim exemptions from reporting certain meaningful use measures  in 2011 to help ensure that providers with all types of patient  populations and clinical practices could potentially demonstrate  meaningful use;the frequency with which providers reported meaningful use measures  for which exemptions were allowed; and the extent to which providers had few patients—less than seven—who  could be included in the calculation of at least one clinical quality  measure.

As part of our analysis, we also analyzed data from CMS and HHS’  Health Resources and Services Administration to compare, among  different types of providers, the percentage of providers that (1) reported  an exemption from reporting certain meaningful use measures and   (2) reported clinical quality measures based on few patients. To ensure  the reliability of the various data we analyzed, we interviewed officials  from CMS, reviewed relevant documentation, and conducted electronic  testing to identify missing data and obvious errors. On the basis of these  activities, we determined that the data we analyzed were sufficiently  reliable for our analysis. In addition to conducting data analyses, we  interviewed officials and reviewed documents from the following  organizations to obtain information on measures providers were required  to report to CMS to demonstrate meaningful use in 2011: the American  Medical Association; the American Hospital Association; and the Health  Information Technology Policy Committee and the Health Information  Technology Standards Committee, both of which advise HHS’s Office of  the National Coordinator for Health Information Technology (ONC) on a  variety of health technology issues.

We judgmentally selected these six providers in order to provide variation among the  following: type of provider (hospital or professional), professional specialty (professionals  only), whether the professional belonged to a group practice (professionals only), and  geographic region. We selected these providers based on CMS data on providers that  received incentive payments from the Medicare EHR program as of July 31, 2011. analyzed were sufficiently reliable for our analysis. Appendix I provides  more information on our data analyses.

We conducted this performance audit from April 2011 through April 2012  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Although the Medicare and Medicaid EHR programs are generally similar,  there are some differences related to the types of providers that are  permitted to participate, the duration and amount of incentive payments  and penalties, and information providers must submit to satisfy the  programs’ requirements.
subsections: section_title: Permissible Providers
paragraphs: The types of providers eligible to participate in the Medicare and Medicaid  EHR programs—referred to as permissible providers—differ. See figure 1  below.

Beginning in 2011, the first year of the Medicare and Medicaid EHR  programs, the programs have provided incentive payments to eligible  providers that met program requirements. Beginning in 2015, the  Medicare EHR program is generally required to begin applying a penalty  for hospitals and professionals that do not meet the Medicare EHR  program requirements. Figure 2 below provides information on the years  that incentive payments are available and that penalties, if applicable, will  be assessed for professionals and hospitals under the Medicare and  Medicaid EHR programs.

The amount of incentive payment varies depending on the type of  provider (professionals or hospitals) and the program in which the  provider participates (Medicare EHR program or Medicaid EHR program).  For example, in the Medicare EHR program, professionals cannot earn  more than $18,000 in incentive payments in their first year, and, over a   5-year period, payments cannot exceed a total of $44,000. In contrast, in  the Medicaid EHR program, professionals cannot earn more than  $21,250 in incentive payments in the first year and $8,500 during each of  5 subsequent years for a total of $63,750. (See app. II for more  information on the amounts of incentive payments available under both  programs and how the amounts are calculated.)

To receive incentive payments from either the Medicare or Medicaid EHR   To  programs, providers must meet eligibility and reporting requirements.do so, providers report certain information to CMS, the states, or to  both—a process referred to as “attestation”—by entering certain  information into CMS’s or the states’ EHR program web-based attestation  tools. Providers that, based on information submitted to CMS and the  states, meet the requirements receive incentive payments. Some of the  eligibility and reporting requirements for the Medicare EHR program differ  from those in the Medicaid EHR program.

section_title: Medicare EHR Program Requirements
paragraphs: To receive Medicare EHR incentive payments in 2011, professionals had  to meet three eligibility and three reporting requirements, while hospitals  had to meet two eligibility and two reporting requirements. (See table 1.)

One noteworthy reporting requirement for 2011 was that providers were  required to demonstrate meaningful use of certified EHR technology by  collecting and reporting information to CMS on various measures  established by CMS. Specifically, in 2011, professionals had to report on  a total of 20 meaningful use measures, and hospitals had to report on a  total of 19 meaningful use measures. This information had to be collected  over 90 consecutive days during 2011.

Professionals. Of the 20 meaningful use measures for professionals,  15 are mandatory. Of those 15 mandatory measures, 6 measures  allow professionals to claim exemptions—that is, they may report to  CMS that those measures are not relevant to their patient populations  or clinical practices. measures—“report clinical quality measures to CMS”—requires  professionals to report on at least 6 clinical quality measures identified  by CMS. Professionals have the flexibility to choose the remaining 5  meaningful use measures from a menu of 10 measures.

One of the mandatory meaningful use

Hospitals. Of the 19 meaningful use measures hospitals must report,  14 are mandatory. Of those 14 mandatory measures, 3 measures  allow hospitals to claim exemptions. Similar to professionals, to satisfy  the mandatory meaningful use measure “report clinical quality  measures to CMS,” hospitals must report on 15 clinical quality  measures identified by CMS. Hospitals have the flexibility to choose  the remaining 5 meaningful use measures from a menu of 10  measures.

See appendix III for a listing of the meaningful use measures and clinical  quality measures for 2011.

In order to meet the definition of meaningful use, eligible professionals and hospitals  must report on measures specified by CMS. An exclusion for a nonapplicable measure is  permitted if the provider meets certain requirements specified in the regulation. 42 C.F.R.  § 495.6. In this report we use the term “exemption” to refer to the exclusion of a  nonapplicable measure.

section_title: Medicaid EHR Program Requirements
paragraphs: To receive Medicaid EHR incentive payments during 2011, professionals  had to meet seven eligibility requirements, hospitals had to meet six  eligibility requirements, and both hospitals and professionals had to meet  one reporting requirement. (See table 2.) Compared to the Medicare EHR  program, the Medicaid EHR program requirements had two noteworthy  differences in 2011.

Providers had to meet a patient volume requirement. This  requirement was established to ensure that providers that receive  incentive payments from the Medicaid EHR program serve a  minimum volume of Medicaid patients, or, for certain  professionals, a minimum volume of needy patients. Specifically,  professionals must have a Medicaid patient volume of at least   30 percent unless they are pediatricians or practice predominantly  in a federally qualified health center or rural health center;  hospitals generally must have a Medicaid patient volume of at  least 10 percent.

Providers only had to adopt, implement, or upgrade to a certified  EHR system in 2011 and did not have to demonstrate meaningful  use during the first year they participate in the Medicaid EHR  program. However, in subsequent years, they must demonstrate  meaningful use.  individual or group primary care practices with 10 or fewer  professionals; public, rural, and critical access hospitals;  community health centers and rural health clinics; collaborative networks of small practices; and other settings that predominantly serve medically underserved populations, as defined by each Regional Extension Center.

ONC also provides funding for Regional Extension Centers to provide  assistance to certain hospitals—critical access and rural hospitals—to  ensure that centers’ services are available in those settings.

ONC’s overall goal for the Regional Extension Center program is to help  100,000 professionals meet the EHR programs’ requirements for  meaningful use by 2014 and to help a total of 1,777 critical access and  rural hospitals meet the EHR programs’ requirements for meaningful use  by 2014. In its agreement with ONC, each Regional Extension Center  established its own goal for the number of providers it would assist to help  the program meet its overall goal.

section_title: For the First Program Year, Processes Are Being Implemented to Verify Requirements Were Met, and CMS Has Opportunities to Improve Them
paragraphs: CMS and the four states we reviewed are implementing processes to  verify whether providers met the Medicare or Medicaid EHR programs’  eligibility and reporting requirements and, therefore, qualified to receive  incentive payments in the programs’ first year. Although CMS is taking  some steps to improve the processes CMS and states use to verify  whether providers have met Medicare and Medicaid EHR program  requirements, we found that CMS has additional opportunities to assess  and improve these processes.
subsections: section_title: CMS and Selected States Are Implementing Processes to Verify Whether Providers Met Requirements to Receive Incentive Payments
paragraphs: For the first program year, CMS is implementing a combination of pre-  and postpayment processes to verify whether providers have met all of  the Medicare EHR program eligibility and reporting requirements. In  addition, the four states we reviewed have implemented or plan to  implement a combination of pre- and postpayment processes to verify  whether providers have met Medicaid EHR program eligibility and  reporting requirements.

CMS has developed and begun to implement processes to verify whether  providers participating in the Medicare EHR program have met all of the  program’s eligibility and reporting requirements and thereby qualify to  receive incentive payments. In 2011, CMS implemented prepayment  processes to verify whether providers have met all three of the Medicare  EHR program’s eligibility requirements. These processes consist of  automatic checks that are built into CMS’s databases to verify the  information submitted by providers when they register for the program.

CMS also implemented a process to verify, on a prepayment basis,  whether providers have met one of the Medicare EHR program’s  reporting requirements—to use a certified EHR system. Specifically,  CMS built an automatic check to compare the EHR certification numbers  for the systems providers reported using during attestation against a list  of EHR systems that have been certified by ONC.

In 2012, according to CMS officials, the agency plans to implement  additional processes to verify, on a postpayment basis, whether a sample  of providers has met all three of the Medicare EHR program’s reporting  requirements. To conduct these verifications, CMS has developed a risk- based approach that will be used to identify a sample of about 10 percent  of professionals and 5 percent of hospitals for audits. planned audit strategy, the agency may request that providers selected  for postpayment audits submit documentation, such as patient rosters,  EHR screenshots, and reports generated by the EHR system to support  data the providers reported to CMS during attestation. If CMS determines  during the audits that a provider has failed to meet any one of the  reporting requirements, it plans to take steps to recoup incentive  payments. CMS officials said that they decided to wait until 2012 to begin  conducting audits of providers that received incentive payments in 2011,  the first payment year, to ensure that the agency does not unfairly target  a disproportionate number of early participants in the Medicare EHR  program. For an overview of CMS’s processes to verify whether  providers met the Medicare EHR program’s eligibility and reporting  requirements, see table 3.

In addition, according to CMS officials, the agency plans to conduct a separate audit,  beginning in 2012, to verify that providers had the certified EHR systems they attested to  using. For these audits, CMS anticipates sampling roughly 20 percent of professionals  and 10 percent of hospitals, identified through random sampling as well as some targeted  selection.
subsections: section_title: Verification under the Medicaid EHR Program
paragraphs: Three of the states we reviewed—Iowa, Kentucky, and Pennsylvania— have implemented processes to verify whether providers have met all the  Medicaid EHR program’s eligibility and reporting requirements and  thereby qualify to receive incentive payments. The fourth state, Texas,  has implemented processes to verify whether providers met most of the  program’s eligibility and reporting requirements and is in the process of  developing additional verification processes as part of its postpayment  audit strategy. Because CMS allows states flexibility in determining how  they verify compliance with these requirements, the states vary in terms  of whether they use prepayment or postpayment verification processes.

In order to verify whether providers have met the Medicaid EHR  program’s eligibility requirements, all four states have primarily  implemented prepayment processes, some of which are automated  checks built into their databases. Iowa, Kentucky, and Pennsylvania also  conduct postpayment audits of samples of providers to verify whether  they have met requirements that were not checked on a prepayment  basis. These states identify samples of providers to be audited using  various risk-based approaches. Texas intends to conduct postpayment  audits as well, but has not finalized its audit strategy.

Three states—Iowa, Kentucky, and Pennsylvania—use a combination of  pre- and postpayment processes to verify whether providers have met the  eligibility requirement regarding the Medicaid patient volume threshold,  which is determined by dividing a professional’s number of Medicaid  patient visits by their total number of patient visits. For example, they use  Medicaid claims data to verify, on a prepayment basis, the professionals’  number of Medicaid patient visits over the reporting period. Then, on a  postpayment basis for a sample of professionals, the states use  documentation submitted by professionals, such as patient billing reports,  to verify their total number of patient visits. Most states, including these  three, must rely on provider self-reported information to verify compliance  with this requirement, because states typically do not collect data on  some of the professionals’ patient visits, such as visits paid for by private  insurance.

To verify whether providers have met the Medicaid EHR program’s  reporting requirement to adopt, implement, or upgrade to a certified EHR  system, the four states we reviewed use prepayment processes,  postpayment processes, or both. The four states we reviewed have  implemented processes, on a prepayment basis, that check the EHR  certification numbers reported by providers against a list of EHR systems  that have been certified by ONC.steps to verify, on a prepayment basis, compliance with this requirement  by reviewing documentation, such as EHR invoices. Iowa and  Pennsylvania include a similar verification process as part of their  postpayment audits. Texas has not yet determined whether it will conduct  additional postpayment verifications. For an overview of the four selected  states’ processes to verify whether providers met the Medicaid EHR  program’s eligibility and reporting requirements, see table 4.

section_title: Most Medicare Providers Exempted Themselves from Reporting Certain Measures and Many Reported Others Based on Few Patients
paragraphs: Most providers participating in the first year of the Medicare EHR program  through December 8, 2011, exercised program flexibility to exempt  themselves from reporting on at least one mandatory meaningful use  measure. In addition, many providers also reported at least one clinical  quality measure based on few patients.
subsections: section_title: Most Providers Exercised Program Flexibility to Exempt Themselves from Reporting on Certain Mandatory Measures
paragraphs: During the first year of the Medicare EHR program through December 8,  2011, most participating providers exercised flexibility allowed under the  program to claim an exemption from reporting at least one mandatory  meaningful use measure. Specifically, 72.4 percent of professionals and  79.6 percent of hospitals claimed such an exemption. Providers may  exempt themselves from reporting certain mandatory meaningful use  measures—up to six measures for professionals and up to three  measures for hospitals—if they report to CMS that those measures are  not relevant to their patient populations or clinical practices.

We found that a greater percentage of some professionals reported at  least one exemption than other professionals. Specifically, we found that a greater percentage of chiropractors, dentists, optometrists,  specialists, and other eligible physicians reported at least one  exemption compared to generalists; and a greater percentage of professionals with 2010 Medicare Part B  charges at or below the 75th percentile reported at least one  exemption compared to those with charges above the 75th percentile.

We also found that among specialists, the largest specialty group of  participating professionals, over three-quarters claimed at least one  exemption. (See table 5.)

We found that a greater percentage of some hospitals reported at least  one exemption than other hospitals. Specifically, we found that a greater percentage of critical access hospitals reported at least one  exemption compared to acute care hospitals, and a greater percentage of hospitals with less than 200 beds reported at  least one exemption compared to hospitals with 200 beds or more.

We also found that among acute care hospitals, the largest type of  participating hospital, slightly over three-quarters claimed at least one  exemption. (See table 6.)

Of the mandatory meaningful use measures for which providers may  claim exemptions, we found that the majority of providers claimed an  exemption from the mandatory measure “provide patients with an  electronic copy of their health information.” Providers may claim an  exemption from this measure if they receive no requests from patients for  an electronic copy of their health information. This measure was the   least frequently reported mandatory measure for both professionals   (32.7 percent) and hospitals (30.3 percent). In contrast, the most  frequently reported mandatory measure for which exemptions were  permitted was “record smoking status for patients 13 years old or older”  for both professionals (99.4 percent) and hospitals (99.5 percent).

Our finding that a majority of providers claimed exemptions from reporting  at least one mandatory meaningful use measure is consistent with  comments made by stakeholders in response to CMS’s Rule on the  Electronic Health Record Incentive Program. Specifically, those  stakeholders stated that certain providers, including specialists and small  hospitals, would not be able to report all mandatory meaningful use  measures, since some measures would be outside the scope of their  practice. While CMS currently allows providers the flexibility to claim  exemptions from reporting certain mandatory meaningful use measures,  in future years of the EHR programs, CMS stated that it may not allow  providers the same flexibility. It is unclear what effect, if any, such a  change would have on participation levels in future program years.

section_title: Many Providers Reported Clinical Quality Measures Based on Few Patients
paragraphs: Our analysis of clinical quality measures found that many providers  reported at least one such measure based on few patients—less than  seven—during the first year of the Medicare EHR program through  December 8, 2011. Providers were required to report these measures to  satisfy one of the mandatory meaningful use measures—”report clinical  quality measures to CMS.” Specifically, 41.3 percent of professionals and  86.9 percent of hospitals reported at least one clinical quality measure  based on few patients. Clinical quality measures calculated using few  patients may be statistically unreliable, which, according to the American  Hospital Association and others, could detract from providers’ abilities to  use those measures as meaningful tools for quality improvement.

We found that a greater percentage of some professionals reported  measures based on few patients than other professionals. Specifically,  we found that a greater percentage of chiropractors, dentists, optometrists,  specialists, podiatrists, and other eligible professionals reported at  least one clinical quality measure that was calculated using few  patients compared to generalists; a greater percentage of professionals practicing in urban locations  reported at least one clinical quality measure that was calculated  using few patients compared to those practicing in rural locations; and a greater percentage of professionals with 2010 Medicare Part B  charges at or below the 50th percentile or above the 75th percentile  reported at least one clinical quality measure that was calculated  using few patients compared to those with charges above the 50th  percentile, but at or below the 75th percentile.

We also found that about half of specialists, the largest specialty group of  participating professionals, reported at least one clinical quality measure  based on few patients. (See table 7.)

We found that a greater percentage of some hospitals reported measures  based on few patients than other hospitals. Specifically, we found that a greater percentage of critical access hospitals reported at least one  clinical quality measure that was calculated using few patients  compared to acute care hospitals, a greater percentage of government-owned and proprietary hospitals  reported at least one clinical quality measure that was calculated  using few patients compared to nonprofit hospitals, a greater percentage of hospitals with less than 200 beds reported at  least one clinical quality measure that was calculated using few  patients compared to hospitals with 200 beds or more, and a greater percentage of hospitals located in rural areas reported at  least one clinical quality measure that was calculated using few  patients compared to hospitals located in urban areas.

We also found that among acute care hospitals, the largest type of  participating hospital, more than 80 percent reported at least one clinical  quality measure based on few patients. (See table 8.)

The American Medical Association and others stated that some providers  may experience challenges selecting clinical quality measures to report.  CMS has acknowledged that the availability of clinical quality measures  that are relevant to providers’ patient populations and clinical practices is  important to inform providers’ efforts to improve quality of care and to  measure potential impacts of the EHR programs. In an effort to increase  the availability of such measures, officials from the Health Information  Technology Policy Committee and the Health Information Technology  Standards Committee, which advise ONC on the development of  meaningful use reporting requirements, noted that additional clinical  quality measures may be added to the EHR programs over time. This  action would help to ensure that there are a sufficient number of  measures that providers can report on.

section_title: For the First Program Year, Providers Experienced Challenges and Used Strategies and Services to Facilitate Participation
paragraphs: Providers identified challenges to participating in the first year of the  Medicare and Medicaid EHR programs and strategies used to help  providers participate. Numerous professionals and hospitals have signed  agreements with Regional Extension Centers for technical assistance,  which includes services to facilitate providers’ participation in the  Medicare and Medicaid EHR programs.
subsections: section_title: Providers Identified Challenges and Used Strategies to Facilitate First Year Participation
paragraphs: Acquiring and implementing a certified EHR system are among the first  challenges providers face as they take steps to qualify for a Medicare or  Medicaid EHR incentive payment. Challenges to acquiring EHR systems  described by providers and officials from the American Medical  Association and American Hospital Association we interviewed included  the following: the cost of purchasing or upgrading to a certified EHR  system; obtaining sufficient broadband access, which can affect  providers’ abilities to exchange health information; and obtaining buy-in  from professionals. Challenges to implementing EHR systems described  by providers we interviewed included needing to train staff on how to use  the EHR systems and getting professionals to use the systems.

Officials we interviewed from hospitals described strategies providers  used to overcome some of the challenges related to acquiring and  implementing EHR systems. For example, one hospital official stated that,  in order to implement a certified EHR system, hospital officials designated  “super users” as a strategy to help their professionals transition to the  EHR system. For instance, one hospital appointed a nurse as a “super  user” who assisted others in learning how to use the EHR system.  Additionally, the chief information officer of another hospital stated her  organization obtained buy-in from professionals and encouraged them to  use the system by presenting the EHR system as a way to improve  patient safety and quality of care rather than as only an information  technology project.

Once a certified EHR system is acquired and implemented, ensuring the  system is effectively used to meet the Medicare meaningful use reporting  requirements can also be challenging for some providers. Specifically,  providers and others we interviewed identified challenges related to  capturing data needed to demonstrate meaningful use, such as lacking a  workflow that allowed the needed data to be collected electronically at the  right time by the right staff member.

Providers we interviewed noted several strategies they used to capture  data in ways which helped them demonstrate meaningful use, including  the following: understanding which fields of the EHR system must be completed and  collecting additional data, as necessary; revising forms, retraining staff so they knew how to complete the  forms, and conducting quality assurance training to ensure that the  appropriate data were being captured consistently; and analyzing workflow, including understanding which staff members are  to enter information into the EHR system and when data entry must  occur.

One provider we interviewed elaborated on the strategy she used to  change the workflow in her practice so that she could satisfy the  meaningful use measure—”provide patients with clinical summaries for  each office visit.” She decided that to meet this meaningful use measure  she would provide the clinical summary to her patients before they left her  office. To do so, she changed her workflow by spending an additional 45  minutes each morning preparing parts of her patient notes in advance of  the patient visit and by scheduling additional time in between patient visits  in order to complete the clinical summaries.

section_title: Numerous Providers Have Signed Agreements with Regional Extension Centers for Services to Facilitate Participation
paragraphs: As of December 2011, about 115,000 professionals and about 1,000  hospitals have signed agreements to receive technical assistance from  one of the 62 Regional Extension Centers. This assistance includes  services to facilitate providers’ participation in the Medicare and Medicaid  EHR programs. Of these professionals, 54,241 had implemented an  EHR system, of which 4,072 had demonstrated meaningful use. The  professionals assisted by the Regional Extension Center program work in  targeted settings, such as individual primary care practices or rural health  clinics. See figure 4, which illustrates the practice settings of  professionals who have agreements with the Regional Extension Centers.

In addition, 1,001 rural hospitals and critical access hospitals have signed  agreements with a Regional Extension Center for technical assistance,  through December 19, 2011. Of these hospitals, 243 had implemented an  EHR system and of those, 41 had demonstrated meaningful use. For  more information on each Regional Extension Center’s progress in  assisting providers to demonstrate meaningful use, see appendix IV.

Regional Extension Centers offer various services to providers with whom  they have agreements to facilitate the providers’ participation in the EHR  programs by helping them meaningfully use EHR systems. Providers  trying to demonstrate meaningful use generally follow a four-step  process, throughout which Regional Extension Centers may provide  assistance to providers. These steps are: (1) prepare to participate in the  CMS EHR programs, (2) select a certified EHR system, (3) implement the  selected EHR system, and (4) demonstrate meaningful use. Examples  of the services offered by the Regional Extension Centers during each of  these steps are described in figure 5.

During the first step, Regional Extension Center officials can help  providers prepare to participate in the EHR programs by explaining those  programs’ requirements and helping providers identify how their workflow  and processes may change with the introduction of an EHR system. For  example, officials from one Regional Extension Center told us they  helped providers determine whether they would qualify for the Medicare  or Medicaid EHR programs. During the second step, the Regional  Extension Centers can help providers select a certified EHR system. For  example, officials from one Regional Extension Center told us they  shared a vendor evaluation tool with providers, which helped providers  evaluate factors such as EHR systems’ capabilities and cost. During the  third step, Regional Extension Center officials can help providers  implement an EHR system by, for example, suggesting best practices for  securing and protecting the privacy of personal health information stored  and processed by the EHR system. During the fourth step, the Regional  Extension Centers provide services that help providers to meet the EHR  programs’ meaningful use criteria. For example, the Regional Extension  Centers may help their clients identify approaches for satisfying certain  program reporting requirements by helping providers capture and  exchange health data.

section_title: Conclusions
paragraphs: The aim of the Medicare and Medicaid EHR programs is not just to  increase EHR adoption, but to support the meaningful use of EHR  technology to improve quality and reduce the cost of care. As a result, the  programs have the potential to affect the millions of people who receive  care through Medicare or Medicaid. Since the programs began in 2011,  CMS has issued $3.1 billion in incentive payments to providers. As a new  program with particular complexities—such as the number and types of  measures providers must report—there are risks to program integrity, and  CMS could take steps, beyond those already taken, to assess and  mitigate the risk of improper payments and to improve program efficiency.  It is encouraging that CMS has awarded contracts to evaluate states’  implementation of the Medicaid EHR program, including their efforts to  prevent improper payments. However, CMS, while planning to assess its  audit strategy for the Medicare EHR program, has not yet specified time  frames for implementing this assessment. As CMS moves forward, it is  important that the agency assess whether verifying additional reporting  requirements on a prepayment basis could improve the integrity of the  Medicare EHR program. Conducting prepayment verifications may be  more effective in minimizing improper payments because CMS’s planned  postpayment audits will be conducted for only a small sample of  providers, whereas CMS’s prepayment verification processes are  conducted for all providers that apply for incentive payments. In addition,  prepayment verifications help to avoid the difficulties associated with the  “pay and chase” aspects of recovering improper payments.

We identified two opportunities for CMS to improve the efficiencies of the  Medicare and Medicaid EHR programs. First, CMS identified and took  action to improve the efficiency of audits under the Medicaid EHR  program but did not take a similar action in the Medicare EHR program.  Specifically, although CMS suggested that states collect additional  information from providers at the time of attestation to improve the  efficiency of the postpayment audit process, CMS has not done so for the  Medicare EHR program, but acknowledged that this action would be  beneficial. Doing so would improve the efficiency of the postpayment  audit process for the Medicare EHR program. Second, CMS could offer  states the option of having CMS collect Medicaid providers’ meaningful  use attestations on their behalf rather than requiring states to collect this  information on their own. CMS, by offering to collect this information from  all Medicaid providers on behalf of states, as the agency currently does  for some Medicaid providers, could alleviate the need for many states to  create and maintain similar web-based attestation tools and could  potentially yield cost savings at both the federal and state levels.

section_title: Recommendations for Executive Action
paragraphs: In order to improve the efficiency and effectiveness of processes to verify  whether providers meet program requirements for the Medicare and  Medicaid EHR programs, we recommend that the Administrator of CMS  take the following four actions:

Establish time frames for expeditiously implementing an evaluation of  the effectiveness of the agency’s audit strategy for the Medicare EHR  program.

Evaluate the extent to which the agency should conduct more  verifications on a prepayment basis when determining whether  providers meet Medicare EHR program’s reporting requirements.

Collect the additional information from Medicare providers during  attestation that CMS suggested states collect from Medicaid providers  during attestation.

Offer states the option of having CMS collect meaningful use  attestations from Medicaid providers on their behalf.

section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS for comment. In its written  comments (reproduced in app. V), HHS concurred with three of our  recommendations to CMS. Specifically, we are encouraged that HHS said  that to help implement these recommendations, CMS will evaluate the  effectiveness of the audit strategy for the Medicare EHR program on an  ongoing basis and document results quarterly, beginning approximately   3 months after the audits begin. In addition, CMS will evaluate the  feasibility of conducting additional prepayment verifications under the  Medicare EHR program. Further, CMS will explore collecting additional  information from Medicare providers during attestation that CMS has  suggested that states collect under the Medicaid EHR program.

HHS disagreed with our fourth recommendation that CMS offer to collect  meaningful use attestations data from Medicaid providers on behalf of the  states, citing two reasons. First, HHS does not believe there are  significant barriers to states implementing attestation tools. It stated that  the 43 states participating in the Medicaid EHR program have established  a means for providers to attest to eligibility requirements and the  adoption, implementation, or upgrade of their EHR. In HHS’s view,  incorporating the meaningful use attestations tools into the states’ existing  systems does not pose a barrier in part because HHS says CMS has  taken steps to help the states design their attestation tools and has  approved designs developed by vendors that the states can use. Second,  HHS does not believe that implementing this recommendation would  create a streamlined attestation process for Medicaid providers. It states  that Medicaid providers would have to provide certain information to CMS  and other information to the states, requiring providers to submit data to  multiple sites. HHS believes this change could result in confusion and  payment delays. In addition, HHS believes a more compelling challenge  is designing a way for providers to report clinical quality measures  electronically from their EHRs to the states and CMS. HHS stated that  CMS established pilots that are intended to help providers leverage  existing infrastructure to electronically exchange data on clinical quality  measures directly from their EHRs to CMS.

Despite HHS’s objections, we continue to believe that our  recommendation should be implemented. In response to HHS’s first  reason, we believe that while some states have created tools to collect  Medicaid attestation data, over the long run implementing our  recommendation could improve the efficiency of the Medicaid EHR  program and thereby minimize additional administrative costs, especially  in the program’s future years. Currently, both CMS and states create and  maintain meaningful use attestation tools. The Medicaid EHR program  requirements in the second year of the program and through the rest of  the decade will become increasingly similar to the requirements for the  Medicare EHR program as will the information collected from providers by  the states and CMS. Having both CMS and states design and maintain  systems to collect much of the same information is inefficient. Further, it is  expected that in future years, to demonstrate meaningful use, Medicare  and Medicaid providers will be required to report additional information,  and both CMS and the states will need to expend resources to update the  attestation tools used to collect this information, a point we clarified in our  report. By collecting meaningful use attestations on behalf of some states  and U.S. insular areas, CMS could help ensure effective use of the   $300 million that Congress provided for administrative costs of the  Medicaid EHR program from 2009-2016.

In response to HHS’s second reason, the report notes that under the  current process for registering for the Medicaid EHR program, providers  must already submit information on eligibility to both CMS and the states.  Therefore, providers are familiar with submitting information to multiple  sites. Furthermore, CMS currently collects meaningful use attestations for  some Medicaid providers and has not reported that the transfer of this  information to the states has delayed payments.

We agree with CMS that designing a means to electronically transmit  meaningful use information, including clinical quality measures, directly  from providers’ EHRs to CMS and the states may present challenges. It is  encouraging that the agency is attentive to electronic data exchange  issues and is working with providers in the Medicare program to identify  ways to leverage existing infrastructure to accomplish this goal. However,  it is important for CMS to consider all approaches, including collecting  meaningful use data on behalf of states, to ensure the Medicare and  Medicaid EHR programs are administered as efficiently as possible.

As part of HHS’s written response, the department also provided other  general comments, which we incorporated as appropriate.

We are sending copies of this report to the Secretary of Health and  Human Services, the Administrator of CMS, the National Coordinator for  Health Information Technology, and other interested parties. In addition,  the report will be available at no charge on GAO’s website at  http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at kohnl@gao.gov. Contact points for our Office  of Congressional Relations and Office of Public Affairs can be found on  the last page of this report. Other major contributors to this report are  listed in appendix V.

section_title: Appendix I: Scope and Methodology
paragraphs: This appendix provides additional details regarding our analysis of   (1) measures providers reported to the Centers for Medicare and  Medicaid Services (CMS) to demonstrate meaningful use and   (2) Regional Extension Center data.

Analysis of measures providers reported to CMS to demonstrate  meaningful use. We conducted several analyses of data from CMS’s  National Level Repository that providers reported to CMS to demonstrate  meaningful use under the Medicare electronic health records (EHR)  program in 2011. We analyzed data submitted by providers from April  18, 2011, the date CMS began collecting these data, through December  8, 2011.information because they were required to report these data by  November 30, 2011, to receive a Medicare EHR incentive payment for  2011. In contrast, the data we analyzed for professionals did not include  full-year information because CMS permitted them to submit these data  through February 29, 2012, to receive a Medicare EHR incentive payment  for 2011. We included all hospitals and professionals that, according to  data from CMS’s National Level Repository, had successfully  demonstrated meaningful use even though some of those providers had  not received Medicare EHR program incentive payments from CMS as of  December 8, 2011.

As a result, the data we analyzed for hospitals included full-year  Specifically, we analyzed meaningful use and clinical quality measures  providers reported to CMS and which we obtained from CMS’s National  Level Repository to identify the following:

Frequency of measures reported. We identified the frequency with  which providers reported the mandatory meaningful use measures for  which providers may claim exemptions. Six measures allow  professionals to claim exemptions and three measures allow hospitals  to claim exemptions if, according to the providers, those measures are  not relevant to their patient populations or clinical practices.

Extent to which providers claimed allowable exemptions from  reporting certain mandatory measures. We determined the  percentage of providers that claimed an exemption from reporting at  least one mandatory meaningful use measure. As part of this  analysis, we examined whether a greater percentage of certain types  of providers reported at least one exemption compared to other types  of providers.

Extent to which providers had patients who could be included in the  calculation of clinical quality measures. We examined the extent to  which providers had few patients who could be included in the  calculation of at least one clinical quality measure. Measures that  capture a small number of patients may be unreliable measures of  quality because relatively small changes in the number of patients  who experienced the care processes or outcomes targeted by the  measure can generate large shifts in the calculated percentage for the  measure. CMS has recognized in other programs that including a  small number of patients in the calculation of a measure is a reliability  issue. For example, on the agency’s Hospital Compare website, which  publicly reports clinical quality measures by hospital, CMS indicates  whether the number of patients included in a particular measure  calculation was based on less than 25 patients and thus too small to  reliably tell how well the hospital was performing. For our analysis, we  identified clinical quality measures as unreliable if fewer than   seven patients met inclusion criteria for the calculation. The reporting  period for the first year a provider demonstrates meaningful use is any   90 consecutive days during the year; for subsequent years, the  reporting period is the full year. Assuming a steady patient population,  providers that had fewer than seven patients meet inclusion criteria for  calculating clinical quality measures during the 90-day reporting  period would have fewer than 25 patients meet these criteria during  the full-year reporting period. As part of this analysis, we examined  whether a greater percentage of certain types of providers reported at  least one clinical quality measure based on few patients compared to  other types of providers.

We also analyzed other data sources to determine whether the reporting  of meaningful use and clinical quality measures varied based on  providers’ characteristics, such as whether critical access hospitals were  more likely than acute care hospitals to claim an exemption from reporting  at least one mandatory meaningful use measure. We used Chi-square  likelihood tests to determine whether differences in provider  characteristics were statistically significant. In particular, we analyzed  data from the following sources: CMS’s Online Survey, Certification, and  Reporting System (downloaded May 2011); CMS’s National Plan and  Provider Enumeration System Downloadable File (downloaded October  2011); the Health Resources and Services Administration’s 2009-2010  Area Resource File (released August 2010); and CMS’s 2010 Medicare  Part B claims (downloaded February 2012). Using these data, we  examined the following provider characteristics:

Hospital type. We obtained data on hospital type—acute care or  critical access hospital—from CMS’s Online Survey, Certification, and  Reporting System.

Hospital ownership type. We obtained data on hospital ownership  type from CMS’s Online Survey, Certification, and Reporting System.  We created the ownership type of proprietary by selecting proprietary;  the ownership type of nonprofit by combining voluntary nonprofit –  church, voluntary nonprofit – private, and voluntary nonprofit – other;  and the ownership type of government-owned by combining the four  government designations (federal, state, local, and hospital district or  authority).

Hospital number of beds. We obtained data on the number of beds in  hospitals, which includes beds that are certified for payment for  Medicare and/or Medicaid, from CMS’s Online Survey, Certification,  and Reporting System. Using those data, we created four categories  for the number of beds: (a) 1 to 49 beds, (b) 50 to 99 beds, (c) 100 to  199 beds, and (d) 200 or more beds.

Professional specialty. We obtained data on professionals’ primary  specialty from CMS’s National Plan and Provider Enumeration  System Downloadable File. Then, with the assistance of a crosswalk  that we obtained from CMS that aggregates specialty taxonomy codes  into a smaller number of specialties, we created the following seven  professional specialty categories: (a) chiropractor, (b) dentist,   (c) generalist, (d) optometrist, (e) podiatrist, (f) specialist, and (g) other  eligible physician. Of those professionals who demonstrated  meaningful use in the Medicare EHR program in 2011, we were  unable to identify a primary specialty for 164 professionals (less than  0.7 percent) using the CMS downloadable file. The 900 professionals  that were classified as “other eligible physicians” (about 3.8 percent)  includes physicians for whom the information on professional  specialty needed to classify them into one of the other professional  specialty categories was not available in CMS’s National Plan and  Provider Enumeration System; however, we determined that those  professionals had specialty types that were eligible to receive  incentive payments using other CMS databases.

Professionals’ Medicare Part B charges. We obtained all 2010  Medicare Part B charges from CMS.

For each professional (identified  by National Provider Identifier), we summed the amount of Medicare  Part B charges over the year. Subsequently, we created four  categories by aggregating total charges by professional: (a) less than  or equal to the 25th percentile, (b) greater than the 25th percentile  and less than or equal to the 50th percentile, (c) greater than the 50th  percentile and less than or equal to the 75th percentile, and (d)  greater than the 75th percentile. Of those professionals who  demonstrated meaningful use in the Medicare EHR program in 2011,  information on the amount of Part B charges was missing for 359  professionals (about 1.5 percent).

Provider location. We obtained zip codes for facility or practice  locations for hospitals and professionals from CMS’s Online Survey,  Certification, and Reporting System and CMS’s National Plan and  Provider Enumeration System, respectively. Then, with the  assistance of a zip code to Federal Information Processing Standard  code crosswalk file we obtained from CMS, we used the Health  Resources and Services Administration’s Area Resource File to  identify whether providers were located in a metropolitan area—an  area that has at least one urbanized area of 50,000 people. We then  categorized providers located in metropolitan areas as being located  in urban areas and providers that were not as being located in rural  areas. We were unable to match 20 providers’ zip codes to the Area  Resource File (which is less than 0.1 percent of participating  professionals).

To ensure the reliability of the data we analyzed, we interviewed officials  from CMS, reviewed relevant documentation, and conducted electronic  testing to identify missing data and obvious errors. On the basis of these  activities, we determined that the data we analyzed were sufficiently  reliable for our analysis.

Analysis of Regional Extension Center data. We analyzed data we  obtained from the Office of the National Coordinator for Health  Information Technology (ONC) in December 2011. The data, which the  agency collects from Regional Extension Centers, contains information  about the providers to whom the centers provided technical assistance.  We determined the number of providers assisted by the Regional  Extension Center program as well as the percentage of those providers  overall and for each center that had (1) signed an agreement with a  center, (2) implemented an EHR, and (3) demonstrated meaningful use.  In addition, we determined the types of professionals who had signed an  agreement for technical assistance with a center.

We made some adjustments to the data we obtained for professionals  based on information obtained from officials at ONC. Specifically, we  limited our analysis to professionals identified by a Regional Extension  Center as being priority primary care providers, which are types of  professionals for which ONC reimburses centers for providing technical  assistance. This excluded 7,019 professionals (about 5.7 percent) from  our analysis. We also excluded from our analysis professionals whose  data we determined were unreliable based on information obtained from  ONC officials. Specifically, we excluded any professionals who were  missing or had anomalous entries for both an individual national provider  identifier and an organizational national provider identifier. This excluded  355 professionals (about 0.3 percent) from the analysis. We also  excluded another 2 professionals (less than 0.1 percent) who were  identified in the data as being a type of professional that was not  considered to be a priority primary care provider even though the  professional was designated as such in the ONC data.

We also made some adjustments to the data we obtained for hospitals  based on information obtained from officials at ONC. Specifically, we  limited our analysis to hospitals identified by a Regional Extension Center  as being a type of hospital targeted for outreach—that is, a critical access  hospital or rural hospital. This excluded four organizations (about 0.4  percent) from the analysis.

To ensure the reliability of the data we analyzed, we interviewed officials  from ONC, reviewed relevant documentation, and conducted electronic  testing to identify obvious errors. On the basis of these activities, we  determined that the data we analyzed were sufficiently reliable for our  analysis.

section_title: Appendix II: How Medicare and Medicaid EHR Program Incentive Payments Are Calculated
paragraphs: Appendix II: How Medicare and Medicaid EHR  Program Incentive Payments Are Calculated Provider type  EHR program  Professionals  Medicare EHR program  The amount of incentive payment in any given year is equal to 75 percent of the  professional’s Medicare Part B charges for the year, subject to an annual limit which  varies by year. The amount of the incentive payment in the first year cannot exceed  $18,000 and the total over a 5-year period cannot exceed $44,000.

Medicaid EHR program  The amount of incentive payment that a professional receives in any given year is, in  general, a fixed amount; $21,250 in the first year and $8,500 in up to 5 subsequent years  and the total amount over a 6-year period cannot exceed $63,750. Professionals must  receive an incentive payment by calendar year 2016 in order to receive incentive  payments in subsequent years.

Medicare EHR program  For acute care hospitals, the amount of incentive payment in any given year is generally  based on the hospital’s annual discharges and Medicare share (i.e., percentage of  inpatient days at the hospital in a given year attributable to Medicare patients). Incentive  payments are awarded over periods of up to 4 years. To earn the maximum amount,  acute care hospitals must first demonstrate meaningful use in fiscal year 2011, 2012,   or 2013.  For critical access hospitals, the incentive payment amount is generally based on the  hospital’s Medicare share and the reasonable costs incurred for the purchase of  depreciable assets necessary to administer certified EHR technology, such as computers  and associated hardware and software. Critical access hospitals can earn payments for  up to 4 years. To earn the maximum amount, critical access hospitals must first  demonstrate meaningful use in fiscal year 2011 or 2012.

Medicaid EHR program  The amount of incentive payment that a hospital receives in any given year is generally  based on the hospital’s annual discharges and Medicaid share. The number of years over  which incentive payments are awarded (between 3 to 6 years) is at the discretion of the  state.

CMS will increase the incentive payments that would otherwise apply by 10 percent each year for  Medicare professionals that predominantly furnish services in geographic areas designated as health  professional shortage areas, such as areas that have a shortage of primary medical care.

section_title: Appendix III: Meaningful Use and Clinical Quality Measures for the Medicare EHR Program, 2011
paragraphs: To demonstrate meaningful use in the first year of the Medicare EHR  program, professionals must report on a total of 20, and hospitals must  report on a total of 19, meaningful use measures. For certain meaningful  use measures, providers may report to CMS that the measures are not  relevant to them; this is referred to as claiming an exemption.  Furthermore, to satisfy the requirement for one of the meaningful use  measures “report clinical quality measures to CMS,” providers must report  on clinical quality measures identified by CMS.the number of meaningful use measures and clinical quality measures  providers must report for the first year of the Medicare EHR program.  Table 10 describes the meaningful use measures, and table 11 and table  12 describe the clinical quality measures for professionals and hospitals,  respectively.

section_title: Appendix IV: Regional Extension Center Program, Goals, and Progress in Helping Providers Demonstrate Meaningful Use
paragraphs: Regional Extension Centers report to the Office of the National  Coordinator for Health Information Technology (ONC) data that describes  the progress they have made in providing technical assistance to  professionals or hospitals to help those providers meaningfully use EHRs.  The data the Regional Extension Centers report to ONC describe the  following three milestones in the technical assistance provided:

The professional or hospital signs an agreement with a Regional  Extension Center to receive technical assistance.

The professional or hospital implemented an EHR which has  electronic prescribing and measure reporting functionality.

The professional or hospital demonstrated meaningful use, consistent  with the Medicare and Medicaid EHR programs’ requirements.

When the program was established, ONC also required each of the 62  Regional Extension Centers to set a targeted numbers of professionals  and hospitals each center would assist—that is, the center’s goal for the  number of providers it would help meaningfully use EHRs. ONC uses the  data the Regional Extension Centers report for each of the three  milestones in the technical assistance process as well as the goals each  center established to evaluate the effectiveness of individual Regional  Extension Centers and of the program as a whole. Tables 13 and 14 list  the goals and number of professionals and hospitals, respectively,  assisted towards meaningful use by each center.

section_title: Appendix V: Comments from the Department of Health and Human Services

section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, E. Anne Laffoon, Assistant  Director; Julianne Flowers; Krister Friday; Melanie Krause; Shannon  Legeer; Monica Perez-Nelson; Amanda Pusey; and Stephen Ulrich made  key contributions to this report.


Question-summary annotations: questions: question: In what circumstance does CMS allow providers to exempt themselves from reporting certain measures?
answer: CMS allows providers to exempt themselves from reporting certain measures if providers report that the measures are not relevant to their patients or practices.

question: How might unreliable measures impact CMS?
answer: Measures calculated based on few patients may be statistically unreliable, which limits their usefulness as tools for quality improvement.

question: Why might the CMS acknowledge the relevance of the measures?
answer: CMS and others acknowledged that the availability of measures that are relevant to providers’ patients and practices and are statistically reliable is important to provide useful information to providers.

question: How have the providers responded to the Medicare EHR program?
answer: Among participants in the first year of the Medicare EHR program, the majority of providers chose to exempt themselves from reporting on at least one meaningful use measure and many providers reported at least one clinical quality measure based on few—less than seven—patients.

questions: question: What did the HITECH create?
answer: The Health Information Technology for Economic and Clinical Health (HITECH) Act established the Medicare and Medicaid electronic health records (EHR) programs.

question: Why does the CMS administer these programs?
answer: CMS and the states administer these programs which began in 2011 to promote the meaningful use of EHR technology through incentive payments paid to certain providers—that is, hospitals and health care professionals.
child_questions: question: What are the projected costs of these programs?
answer: Spending for the programs is estimated to total $30 billion from 2011 through 2019.

question: How has the GAO examined the HITECH Act?
answer: Consistent with the HITECH Act, GAO (1) examined efforts by CMS and the states to verify whether providers qualify to receive EHR incentive payments and (2) examined information reported to CMS by providers to demonstrate meaningful use in the first year of the Medicare EHR program.

question: How did the GAO create its report?
answer: GAO reviewed applicable statutes, regulations, and guidance; interviewed officials from CMS; interviewed officials from four states, which were judgmentally selected to obtain variation among multiple factors; and analyzed data from CMS and other sources.

questions: question: Why is the GAO in contact with the CMS?
answer: GAO is making four recommendations to CMS in order to improve processes to verify whether providers met program requirements for the Medicare and Medicaid EHR programs, including opportunities for efficiencies.
child_questions: question: How has the HHS responded to these four recommendations?
answer: HHS agreed with three of GAO’s recommendations, but disagreed with the fourth recommendation that CMS offer to collect certain information on states’ behalf.
child_questions: question: Why does the GAO believe that the fourth recommendation is still important?
answer: GAO continues to believe that this action is an important step to yield potential cost savings.