HITECH: Everything you need to know about the federal stimulus for HIT

By Kate McCann

When President Barack Obama signed the American Recovery and Reinvestment Act in February 2009, he gave the go-ahead for the most substantial federal investment in health information technology ever. With a $19-billion down payment—$17 billion in financial incentives for physicians to adopt and use electronic health records and an additional $2 billion dedicated to developing a technical support infrastructure—the administration proclaimed American medicine would finally move into the digital age.

Under the catchy acronym HITECH, or the Health Information Technology for Economic and Clinical Health Act, the administration has set an ambitious goal of widespread adoption of health information technology by 2014. Their underlying hope is that implementation of HIT will improve quality of care, enhance coordination of care and improve public health activities: strategies all designed to reduce overall health care expenditures. Considering that 2014 is only five years away, the prospects of such a fundamental, systemic transformation of America’s health care system faces some very real hurdles, not the least of which is expense.

Heeding universal warnings from physicians, health care policy experts and others about the challenges to widespread adoption, including expense outlays for the purchase of equipment and software, staff training and decline in physician productivity, Congress and the administration are showing they are serious by increasing payments through Medicare and Medicaid for physicians willing to take the leap into the digital age.

Disbursement of these physician incentive payments will start in January 2011 and early adopters could be eligible to receive up to $44,000 in bonus Medicare payments over five years. Non-hospital based physicians with a 30-percent Medicaid workload threshold could receive up to $25,000 the first year and up to $10,000 per year for four subsequent years through the Medicaid program for a maximum of $65,000 over the five-year period. Physicians who practice in health professional shortage areas may be eligible to receive an additional 10-percent boost in their payments.

As of now, the bonus payments progressively decrease in the years 2012, 2013 and 2014, and physicians who haven’t adopted and begun using an EHR by 2015 will be penalized 1 percent of their Medicare payments. In 2016, the penalty increases to 2 percent, in 2017, to 3 percent, and in later years, 3-5 percent, though the penalty would not exceed 5 percent overall.

A few key federal agencies bear the brunt of the tasks set forth in the HITECH Act. The largest, of course, is the Department of Health and Human Services, which encompasses the Office of the National Coordinator for Health Information Technology. The appointed National Coordinator, David Blumenthal, M.D., M.P.P., has been given the overarching task of developing a nationwide health information infrastructure that allows for the electronic use and exchange of information.

Additionally, Blumenthal chairs the HIT Policy Committee, a federal advisory committee that will set the basic policy framework and send recommendations to another advisory committee, the HIT Standards Committee. This committee will make recommendations for standards on implementation and certification criteria. With incentives flowing through the two largest government health programs, the Centers for Medicare and Medicaid Services will also play a major role.

With part of the $2 billion set aside for the support infrastructure, HITECH creates a national Health Information Technology Research center to provide technical assistance and identify best practices in adopting, implementing and using HIT. Information from the national center will trickle down through regional extension offices.

Here come the asterisks

In addition to the reality that physicians will not receive up-front money to adopt an EHR system, the whole pot of money hangs on defining two key terms. To receive incentives, physicians must show they are “meaningful users” of “certified EHR technology,” which will require more effort than simply installing any system. As described in HITECH, a certified EHR contains patient demographic information and clinical health information, and has the capacity to provide clinical decision support, support physician order entry, capture and query information for quality purposes, and exchange and integrate electronic health information with other sources.

So far there’s no word on who exactly will determine which EHR systems meet federal standards, but it’s fairly safe to say that a big player will be the Certification Commission for Healthcare Information Technology, or CCHIT, a non-profit group made up largely of vendors who has applied its rubber stamp to products since 2006. This group is currently the only federally recognized certifying body, though the ARRA legislation allows ONC to recognize others in this process.

In preparation, CCHIT overhauled their old process and released a new three-path certification plan that labels products EHR Comprehensive, EHR Module or EHR Site. The first, EHR-C, encompasses all of the previously certified products. It’s the highest tier reserved for systems that go “above and beyond” the minimum federal requirements for meaningful use. The second, EHR-M, is for products that meet one or more of the federal requirements. Physicians would have to combine several EHR-M systems to meet the total requirements for meaningful use. The third, EHR-S, certifies a system for a physician at a site. In this case, if a physician developed his or her own product or had another vendor tailor a product for the practice, CCHIT would perform a unique site certification only applicable to that practice.

The new process is meant to decrease barriers to physicians, says Sue Reber, CCHIT’s marketing director. “Our intent is to provide more choices for providers in getting these certified products,” she says. “A lot of physicians will want assurance that the whole product works together and that we’ve certified that it’s already used in many sites. … There may be some that are developing their own products. We don’t want to be the barrier to either one of those paths.”

Some question whether products currently on the market have the basic capabilities to meet the federal government’s requirements. In a perspective article in the April 2009 New England Journal of Medicine, Blumenthal wrote, “many EHRs are neither user-friendly not designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system.”

This means that EHR vendors must alter or create products to meet evolving criteria in 2011 and beyond, or simply educate their clients on current products and ensure they have the correct upgrades to move forward. Mike Nolte, marketing spokesman for GE, says his company is actively monitoring the discussions in Washington, D.C., to ensure they can react appropriately as the CMS rulemaking process evolves.

“The main short-term effect is that we have built-in capacity to ensure that we have adequate flexibility to respond quickly to the finalized meaningful use requirements later this year,” Nolte says. “Longer term, we see the evolving federal requirements as a validation of the investments in our platforms, building further quality and efficiency capability into software that already has proven ability to support the delivery of higher quality and lower cost care.”

The most elusive term to watch—and one of utmost importance to physicians as well as vendors—is “meaningful use.” Many organizations weighed in on what the term should mean, including AAFP, who joined with the Markle Foundation to publish the “Seven Principles for Meaningful Use and Qualification or Certification of EHRs.” In it, the Academy stated its desired goals for health IT investments: to improve health care quality, reduce growth in costs, stimulate innovation and protect privacy.

AAFP also stressed “effective use of information” to support better decision-making and more effective care processes to remove the focus solely from the technology and put it on the care team who will best be able to coordinate care of their patients and provide the right treatment at the right time.

The first draft of meaningful use criteria arrived on June 16 when the Health IT Policy Committee released the preamble and multi-page matrix. The preamble introduces the framework for the definition as well as the ultimate goal: to enable significant and measurable improvements in population health through a transformed health care delivery system.

The more interesting section is the matrix, which contains goals, objectives and measures for 2011, 2013 and 2015 for five health outcome policy priorities. As early as 2011, when the objective is to electronically capture and report health information to track key clinical conditions, meaningful use mandates using computerized physician order entry for all order types including medications, recording vital signs and lab test results, generating lists of patients by conditions, exchanging key clinical information among different providers, opening access to patients, and reporting quality measures on conditions like diabetes and hypertension, among others.

Steve Waldren, M.D., director of the AAFP Center for Health Information Technology, says he was happy that the definition included quality outcomes and goals and not just the features and functions of an EMR. What’s lacking, however, is clarity of what will be required in 2013 and 2015, he says. “They realize that they still have some work to do. What appears is that the requirements for meaningful use will become more stringent as we move forward through the process.”

“If that’s the case, we understand the standpoint that people get meaningful use of technology in 2011 so they can get the incentive they need to move down the path, but we also want them to be very clear about what will be required in 2013 and 2015 so that practices understand what technology they need and how they can create their roadmaps to move forward.”

Though the committee will make recommendations to ONC on the definition of meaningful use and certified EHR, ultimately it’s up to CMS to publish the final rule, scheduled for December 31, 2009. In addition to the definitions, the final rule will include the criteria for the incentives as they pertain to Medicare. Medicaid programs will set their own requirements.

That brings us to the state. Because of size, urban-rural makeup and sheer number of health care providers and patients, Texas faces a mammoth challenge. Yvonne Sanchez, senior health policy analyst in Medicaid and CHIP for the Texas Health and Human Services Commission, says she expects the federal government to set policies that will establish the infrastructure and the framework, leaving the heavy lifting to be done at the state and local levels.

Even before they begin to discuss distribution of funds, HHSC must conduct an environmental scan to determine physician readiness to adopt HIT. Additionally, the agency has joined a multi-state collaborative with other Medicaid agencies and CMS to exchange ideas and make sure questions are clarified in the published guidance such as which providers will be included in the incentives and how the state will calculate Medicaid patient volume among different practitioners.

“In some ways, we can learn from California because they are further out in the health IT arena than we are, so hopefully that will make it easier for us because they will have learned the lessons and we can avoid other mistakes that other agencies have had to deal with,” Sanchez says.

“We have our HIT experts here at HHSC doing a lot of work with other states,” says Kay Ghahremani, deputy director for Medicaid and CHIP Policy Development. “There’s a lot of communication with the other states on what’s worked and what hasn’t worked, and that’s going to be really helpful for us given that we are behind in terms of creating our plan.”

For Texas and the Medicaid program, Sanchez sees HIT as a tool that will enable hospitals and physician practices to provide more efficient care. “Health care is a very information-intensive industry, so it will be a better way to capture that information and really to know the health history of that person, what’s been tried and what hasn’t. If you know what’s been happening with your patients, you can provide better health care and you can reduce duplication of services.”

HIT or miss

Putting the logistical questions aside, the success of HITECH will largely depend on physician adoption. Purchasing software and hardware, changing office procedures and bringing the entire health care team online can be challenging, to say the least. For Brett Johnson, M.D., program director for the Methodist Health System Family Medicine Residency, his experience has been both “exciting and horrible.” Methodist began the process of selecting their EHR two years ago, implemented the chosen system one year ago, and has since brought on different parts of the hospital including the clinic connected to the residency program.

“There was a time span of a few months where it was horrible,” Johnson says. “It’s exciting because you see the birth of something and the potential that something has to make your residency better.”

Even after vetting vendors, prep work by the IT team and hiring an extra staff person to enter data, they encountered unexpected speed bumps. “You really don’t know what type of product you have until you start the implementation process,” Johnson says. “It’s like a car. You go to a car dealer, they’re going to show you the interior, take you for a test drive, show you how it runs, but you really don’t know the specifics. With EHRs, no matter how good you are with regards to sitting down and asking questions, it’s not until the rubber meets the road that you have a good idea of what you’re dealing with.”

The residency program brought the EHR into their clinic in phases, starting with the billing and scheduling aspects. Johnson became the designated “super user” and trained the faculty so they could turn around and teach the residents. It turns out that the residents adopted the system quickly because of early exposure to EHRs in medical school, while the faculty who had never seen this technology before had the toughest time, he says.

Despite the hectic months, Johnson says their EHR has made daily tasks easier. “You’re not running around the office trying to track down charts anymore.”

For physicians without an EHR, AAFP Senior Technology Adviser David Kibbe, M.D., M.B.A., recommends waiting a few months before purchasing a system to assess personal practice needs and until some of the unanswered questions are resolved. “If you have gone through the due diligence and have your heart set on buying an electronic health record from one of the certified vendors, I would probably go ahead with that implementation. But if that’s not the case, I think it’s prudent to wait and see what actually will be required.”

Options are not limited for physicians who already have an EHR. Kibbe has heard some physicians say, “This is a great time to switch. We were never happy with this vendor, so we’re going to think about de-installing this product and going to another product or even downsizing in the sense that we’ve been using this product that has 450 features and we only need 200 of them. Should we actually find a system that’s Web-based that gives us those 200 features?”

Either way, when choosing or updating a system, physicians must comply with HITECH’s changes to the information privacy and security rules established under the Health Insurance Portability and Accountability Act, HIPAA. Starting Jan. 1, 2014, a patient will have the right to request his or her electronic personal health information dating back three years. In the case of a small-scale privacy breach, the physician must notify individuals that their health information has been compromised. In large cases involving more than 500 patients, the physician must immediately notify the individuals, prominent media outlets and Health and Human Services. Additionally, HITECH creates a new tiered penalty system for HIPAA violations, which range from $100 to $50,000 per violation depending on whether the violation is due to willful neglect and the haste by which it is corrected, and that allows for state attorneys general to seek damages on behalf of state residents.

While Waldren believes that an investment in HIT can improve quality, “I think it has to be thought of as a stethoscope. A stethoscope doesn’t make a doctor a great doctor; it’s the use of the stethoscope and understanding how to use that tool. I think the same is very true of an EHR and health IT. Just putting it in doesn’t increase quality; it’s really changing your processes and leveraging the technology to drive a quality process that will increase quality.”

In the end, expanding health information technology holds great potential to significantly improve an expensive and inefficient health care system. “The best thing that could happen is that it lays the foundation to get true health care reform that allows us to get the payment reform that rewards us for quality, efficiency and safety as opposed to volume of procedures, and sets forth the ability for primary care to take the lead again in health care,” Waldren says.

“The risk is that we spend all this money and get docs to implement a lot of technology and it doesn’t get linked with quality, efficiency and safety, and we spend a lot of time and energy putting in technology that ends up not working.”