DEP-\RTi\lE1\T OF H tALTH A...ND HlTlVLAl'\T SERVICES' ()FFICE <)F INSPE CT{)R GENE.RAL JUN 21 20ll TO: Farzad Mostashari, M.D., Sc.M. National Coordinator for Health Information Technology Office of the National Coordinator for Health Information Technology Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services FROM: Stuart Wright Deputy Inspector General for Evaluation and Inspections SUBJECT: Memorandum Report: Use ofElectronic Health Record Systems in 2011 Among Medicare Physicians Providing Evaluation and Management Services, OEI -04-10-00184 This memorandum report responds to a request from officials of the Office of the National Coordinator for Health Information Technology (ONC), who expressed interest in information about physicians' reported use of electronic health record (EHR) systems. ONC officials made this request in connection with an ongoing evaluation on the extent ofdocumentation vulnerabilities of evaluation and management (ElM) services using EHR systems (OEI-04-10-00182), which will be issued separately. ONC officials also wanted to know how many and which EHR systems were being used and whether the Medicare physicians in our study were using certified EHR systems to document ElM services. We are also sending this report to the Centers for Medicare & Medicaid Services (CMS), which may find this information helpful as it continues administering its EHR incentive program. SUMMARY We found that 57 percent ofMedicare physicians used an EHR system at their primary practice location in 2011. Overall, 95 percent ofphysicians who used an EHR system to document EIl\1 services first began using it between 2001 and 2011. Ofthese physicians, the largest percentage (22 percent) began using EHR systems in 2011, the year that eMS commenced its incentive program. Additionally, three of every four Medicare physicians with an EHR system used a certified system to document ElM services. Finally, although Page 2 – Farzad Mostashari, M.D., Sc.M.; Marilyn Tavenner many EHR systems can assist physicians in assigning codes for E/M services, we found that most Medicare physicians manually assigned E/M codes. BACKGROUND Meaningful Use of Certified EHR Technology The HITECH Act of 2009 established the goal of achieving meaningful use of EHR technology in Medicare.1, 2 Meaningful use means that Medicare physicians use certified EHR technology in ways (e.g., electronic prescribing) that can be measured to improve the quality of health care for patients and adhere to the standards and criteria of the EHR incentive program.3, 4 Starting in 2015, physicians will be subject to Medicare payment reductions if they do not demonstrate meaningful use of certified EHR systems.5 An EHR system is a computerized recordkeeping approach that allows physicians to record patient information electronically instead of using paper records.6 ONC is responsible for coordinating nationwide efforts to use health information technology, such as certified EHR systems, and for the electronic exchange of health information.7 ONC has promulgated regulations pertaining to the initial set of standards and certification criteria and to the temporary and permanent certification programs.8 For instance, ONC’s rules contain security provisions, such as requiring that an EHR system be capable of maintaining audit logs, have automatic logoff, have access control, and permit emergency access.9 Additionally, ONC has coordinated with CMS to promulgate 1 Title XIII of the American Recovery and Reinvestment Act of 2009, P.L. 111-5. See also, Department of Health and Human Services (HHS) News Release, Accelerating Electronic Health Records Adoption and Meaningful Use, August 2010. 2 EHR technology includes both certified EHR systems and add-on modules. 3 Social Security Act (SSA) § 1848(o)(2). CMS issued regulation that defines “meaningful use” for its EHR incentive program. CMS, EHR Incentive Program Regulations and Notices, May 2012. 4 To participate in the EHR incentive program, Medicare physicians must attest that their certified EHR system is secure, can maintain data confidentiality, can work with other EHR systems to share information, and can perform a set of well-defined functions. ONC, Standards & Certification Criteria Final Rule, March 2011. 5 SSA § 1848(a)(7). Regardless of whether physicians participate in the Medicare EHR incentive program, they will be subject to Medicare payment reductions beginning in 2015 if they do not demonstrate meaningful use of certified EHR systems. See also CMS, Medicare and Medicaid EHR Incentive Program Basics, October 2011. 6 EHRs can include information about patient demographics, progress notes, medications, medical history, and clinical test results from any health care encounter. CMS, Electronic Health Records Overview, October 2011. 7 Public Health Service Act § 3001, as enacted in the HITECH Act. See also ONC, About ONC, October 2011. Accessed at http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc/1200 on February 7, 2012. 8 See ONC’s initial set of standards and certification criteria at 75 Fed. Reg. 44590 (July 28, 2010). ONC promulgated the rules for its Temporary Certification Program and its Permanent Certification Program at, respectively, 75 Fed. Reg. 36158 (June 24, 2010) and 76 Fed. Reg. 1262 (Jan. 7, 2011). 9 45 CFR §§ 170.302(o)-(r). Use of EHR Systems in 2011 Among Medicare Physicians Providing E/M Services OEI-04-10-00184 Page 3 – Farzad Mostashari, M.D., Sc.M.; Marilyn Tavenner the meaningful use criteria for the first stage of the EHR incentive program.10 Physicians must demonstrate the meaningful use of certified EHR systems to avoid payment reductions beginning in 2015.11 EHR systems are certified by an Authorized Testing and Certification Body (ONC-ACTB) according to certification processes defined by ONC.12, 13 As of March 2012, approximately 1,200 EHR products were certified by ONC-ACTB. Certification criteria require that EHR systems have the necessary technological capability, functionality, and security to meet the applicable meaningful use criteria. These criteria can include the capability to maintain active medication allergy lists and provide clinical summaries for patients for each office visit, as defined in CMS regulation.14 However, companies (i.e., vendors) that develop and market EHR systems can include additional capabilities that are not required for the purposes of certification. In 2011, CMS began a three-stage, 5-year EHR incentive program with objectives that physicians must meet to demonstrate their meaningful use of certified EHR technology.15 Each stage requires increasing use of EHR technology and electronic information exchange. For Stage 1, physicians must meet 15 core objectives (e.g., maintain active medication list) and 5 of 10 menu objectives (e.g., submit electronic data to immunization registries) to receive an EHR incentive payment.16 In March 2012, CMS issued a notice of proposed rulemaking to delineate the Stage 2 meaningful use requirements for certified EHR technology. Stage 3 meaningful use requirements are expected to be proposed in early 2014. E/M Services Physicians and nonphysician practitioners can use EHR systems to document E/M services, which are visits to assess and manage a patient’s health. Hereinafter, we refer to physicians and nonphysician practitioners as physicians.17 In 2010, approximately 65 percent of all Medicare physicians billed for E/M services, accounting for $33.5 billion of $110 billion (30 percent) in total payments for Medicare Part B goods 10 See CMS’s meaningful use regulations at 75 Fed. Reg. 44314 (July 28, 2010). 11 Social Security Act § 1848(a)(7). 12 See 75 Fed. Reg. 36158 (June 24, 2010) and 76 Fed. Reg. 1262 (Jan. 7, 2011). 13 ONC selected six organizations as ATCBs. ONC, ONC-Authorized Testing and Certification Bodies, March 2012. 14 45 CFR §§ 170.302, 170.304, and 170.306. 15 See 75 Fed. Reg. 44314 (July 28, 2010). Starting in 2011, physicians can receive up to $44,000 over 5 years under the Medicare EHR incentive program. See 75 Fed. Reg. 44314, 44551 (July 28, 2010). See also CMS, EHR Incentive Programs: Overview, April 2011. 16 42 CFR § 495.6. 17 Nonphysician practitioners are health care providers (i.e., nurse practitioners, clinical nurse specialists, and physician assistants) who practice either in collaboration with or under the supervision of a physician. Use of EHR Systems in 2011 Among Medicare Physicians Providing E/M Services OEI-04-10-00184 Page 4 – Farzad Mostashari, M.D., Sc.M.; Marilyn Tavenner and services.18, 19 E/M services also represented 45 percent of the top 20 procedure codes billed to Medicare in 2010.20 E/M services are grouped into visit types. Each visit type reflects the type of service, the place of service, and the patient’s status. For example, there are two types of office visits (new patient and established patient). Similarly, there are two types of hospital visits (initial and subsequent). Most E/M services are billed using codes that reflect the complexity of the service, ranging from lower level (i.e., less complex and less expensive) to higher level (i.e., more complex and more expensive) codes.21 Within each visit type, Medicare payment for the E/M service depends on the complexity of the visit. EHR Systems and E/M Coding Numerous EHR systems with various capabilities and features are available for purchase from vendors. For example, some EHR systems have add-on modules that automatically assign E/M codes based on the information provided by the physician.22 However, ONC has not established standards for how physicians should use EHR systems to create medical records that meet CMS documentation requirements for E/M services.23, 24 Vendors can market these additional capabilities to physicians as tools to enhance E/M coding accuracy and efficiency, as well as to ensure that the highest E/M code is used to optimize revenue.25 Depending on the vendor, add-on modules may include broader applications of the coding software, such as generating diagnosis and complexity levels associated with an E/M code.