The document discusses changes between the proposed rule and final rule for implementing the Medicare and Medicaid EHR Incentive Program under the HITECH Act. Key changes included lowering the thresholds for meaningful use measures, modifying clinical quality measures, and clarifying eligible provider and hospital definitions. The final rule aimed to ease burden and address concerns raised during public comment period.

1. Medicare & Medicaid EHR
Incentive Program Final Rule
Implementing the American
Recovery & Reinvestment Act of 2009

2. The Journey to Meaningful Use
Faith is the bird that sings when the dawn is still
dark. Rabindranath Tagore
2

3. Overview
• American Recovery & Reinvestment Act
(Recovery Act) – February 17, 2009
• Medicare & Medicaid Electronic Health Record
(EHR) Incentive Program Notice of Proposed
Rulemaking (NPRM)
• Display – December 30, 2009
• Publication – January 13, 2010
• Final Rule on Display – July 13, 2010
• Final Rule Published – July 28, 2010
3

4. What did not change
in the final rule
• Adopted statutory provider eligibility and payment
requirements
• Meaningful Use matrix goals remained the same.
• Hospital definition did not change.
• EPs will still be required to demonstrate MU
individually
• Clinical quality measures reporting timeline will stay
the same
• MU reporting period of 90 days for first year and one
year thereafter. 4

5. What Changed from the NPRM
to the Final Rule?
• Meaningful Use Criteria
• Clinical Quality Measures
• Hospital-based EPs
• Medicaid acute care hospitals
• Medicaid patient volume
• Removed reporting period for adopt, implement
or upgrade (Medicaid)
• All programs will start in 2011
• More clarification throughout
5

6. Changes to Provider Eligibility
• Due to recent legislation, hospital-based EPs are only
those who see more than 90% of their patients in a
hospital in-patient or ER setting
• Medicaid included critical access hospitals in its
definition of “acute care hospital” (but incentive is like
other acute care hospitals, not following the Medicare
CAH formula)
6

7. Medicaid Patient Volume
Medicaid EP participation hinges on patient volume
requirements.
• Medicaid patient volume was significantly clarified
• Expanded definition of “encounter” to include any
encounter for which Medicaid had any payment liability
e.g. premiums, co-pays, waivers
• Allows States to define patient volume as just
encounters or encounters plus patient panel (managed
care), both or propose a new methodology
7

8. Meaningful Use: Process of Defining
• National Committee on Vital and Health Statistics
(NCVHS) hearings
• HIT Policy Committee (HITPC) recommendations
• Listening Sessions with providers/organizations
• Public comments on HITPC recommendations
• Comments received from the Department and the
Office of Management and Budget (OMB)
• Revised based on public comments on the NPRM
8

9. Meaningful Use Stage 1 –
Health Outcome Priorities*
• Improve quality, safety, efficiency, and reduce
health disparities
• Engage patients and families in their health care
• Improve care coordination
• Improve population and public health
• Ensure adequate privacy and security protections
for personal health information
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s
Healthcare. Washington, DC: National Quality Forum; 2008.
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10. Meaningful Use: Changes from
the NPRM to the Final Rule
NPRM Final Rule
Meet all MU reporting objectives Must meet “core set”/can defer 5 from
optional “menu set”
25 measures for EPs/23 measures for 25 measures for EPs/24 for eligible
eligible hospitals hospitals
Measure thresholds range from 10% to Measure thresholds range from 10% to
80% of patients or orders (most at higher 80% of patients or orders (most at lower
range) to middle range)
Denominators – To calculate the Denominators – No measures require
threshold, some measures required manual chart review to calculate
manual chart review threshold
Administrative transactions (claims and Administrative transactions removed
eligibility) included
Measures for Patient-Specific Education Measures for Patient-Specific Education
Resources and Advanced Directives Resources and Advanced Directives (for
discussed but not proposed hospitals) included
10

11. Meaningful Use: Changes from
the NPRM to the Final Rule, cont’d
NPRM Final Rule
States could propose requirements States’ flexibility with Stage 1 MU is
above/beyond MU floor, but not with limited to seeking CMS approval to
additional EHR functionality require 4 public health-related
objectives to be core instead of menu
Core clinical quality measures (CQM) Modified Core CQM and removed
and specialty measure groups for EPs specialty measure groups for EPs
90 CQM total for EPs 44 CQM total for EPs – must report
total of 6
35 CQM total for eligible hospitals and 15 CQM total for eligible hospitals
8 alternate Medicaid CQM
5 CQM overlap with CHIPRA initial core 4 CQM overlap with CHIPRA initial core
set set
11

12. How were MU Core Objectives
Selected?
• Overarching considerations
• Statutory requirements-e.g.- e-prescribing, CQM, health information
exchange
• Foundational objectives-e.g. privacy and security and those that provide
foundational data needed for other measures, like demographics,
medication lists, etc.
• Patient-centered
• Patient access- e.g. clinical summaries
• Patient safety-e.g.-drug-drug and drug-allergy features)
• Part of providers’ “normal” practice
• Looked at how the objectives aligned
• Feedback received from HIT Policy Committee and commenters
12

13. Meaningful Use: Denominators
• Two types of percentage based measures are
included to address the burden of demonstrating
MU
1. Denominator is all patients seen or admitted during
the EHR reporting period
• The denominator is all patients regardless of whether their
records are kept using certified EHR technology
1. Denominator is actions or subsets of patients seen or
admitted during the EHR reporting period
13

14. Meaningful Use: Applicability of
Objectives and Measures
• Some MU objectives are not applicable to every
provider’s clinical practice, thus they would not
have any eligible patients or actions for the
measure denominator.
• In these cases, the EP, eligible hospital or CAH
would be excluded from having to meet that
measure
• Ex: Dentists who do not perform immunizations;
Chiropractors do not e-prescribe
• The denominator only includes patients, or actions taken on
behalf of those patients, whose records are kept using
certified EHR technology
14

15. How were the Thresholds Selected
• 80%-Objective part of standard practice-e.g.-
maintain active medication list
• Others-defined on a case-by-case basis based on
commenter or clearance feedback
• Example-e-prescribing set at 40% lowered from
75% to address concerns by commenters
regarding non-participation by pharmacies and
patient preference.
15

16. Meaningful Use – Stage 1 Core Set
Health Stage 1 Objective Stage 1 Measure
Outcomes
Policy
Priority
Improving Use CPOE for medication orders directly entered by More than 30% of unique patients with at least one
quality, any licensed healthcare professional who can enter medication in their medication list seen by the EP or
safety, orders into the medical record per state, local, and admitted to the eligible hospital or CAH have at least
efficiency, professional guidelines one medication entered using CPOE
and Implement drug-drug and drug-allergy interaction The EP/eligible hospital/CAH has enabled this
reducing checks functionality for the entire EHR reporting period
health
disparities EP Only: Generate and transmit permissible More than 40% of all permissible prescriptions written
prescriptions electronically (eRx) by the EP are transmitted electronically using certified
EHR technology
Record demographics: preferred language, gender, More than 50% of all unique patients seen by the EP or
race, ethnicity, date of birth, and date and admitted to the eligible hospital or CAH have
preliminary cause of death in the event of mortality demographics as recorded structured data
in the eligible hospital or CAH
Maintain up-to-date problem list of current and More than 80% of all unique patients seen by the EP or
active diagnoses admitted to the eligible hospital or CAH have at least
one entry or an indication that no problems are known
for the patient recorded as structured data

17. Meaningful Use – Stage 1 Core Set, cont’d
Health Stage 1 Objective Stage 1 Measure
Outcomes
Policy
Priority
Improving Maintain active medication list More than 80% of all unique patents seen by the EP or
quality, admitted to the eligible hospital or CAH have at least
safety, one entry (or an indication that the patient is not
efficiency, currently prescribed any medication) recorded as
and structured data
reducing Maintain active medication allergy list More than 80% of all unique patents seen by the EP or
health admitted to the eligible hospital or CAH have at least
disparities one entry (or an indication that the patient has no
known medication allergies) recorded as structured data
Record and chart vital signs: height, weight, blood For more than 50% of all unique patients age 2 and over
pressure, calculate and display BMI, plot and display seen by the EP or admitted to the eligible hospital or
growth charts for children 2-20 years, including BMI CAH, height, weight, and blood pressure are recorded as
structured data
Record smoking status for patients 13 years old or More than 50% of all unique patients 13 years or older
older seen by the EP or admitted to the eligible hospital or
CAH have smoking status recorded as structured data
Implement one clinical decision support rule and the Implement one clinical decision support rule
ability to track compliance with the rule
Report clinical quality measures to CMS or the States For 2011, provide aggregate numerator, denominator,
and exclusions through attestation; For 2012,
electronically submit clinical quality measures

18. Meaningful Use – Stage 1 Core Set, cont’d
Health Stage 1 Objective Stage 1 Measure
Outcomes
Policy
Priority
Engage Provide patients with an electronic copy of their More than 50% of all unique patients of the EP, eligible
patients and health information (including diagnostic test results, hospital or CAH who request an electronic copy of their
families in problem list, medication lists, medication allergies, health information are provided it within 3 business
their discharge summary, procedures), upon request days
healthcare Hospitals Only: Provide patients with an electronic More than 50% of all patients who are discharged from
copy of their discharge instructions at time of an eligible hospital or CAH who request an electronic
discharge, upon request copy of their discharge instructions are provided it
EPs Only: Provide clinical summaries for each office Clinical summaries provided to patients for more than
visit 50% of all office visits within 3 business days
Improve care Capability to exchange key clinical information (ex: Performed at least one test of the certified EHR
coordination problem list, medication list, medication allergies, technology’s capacity to electronically exchange key
diagnostic test results), among providers of care and clinical information
patient authorized entities electronically
Ensure Protect electronic health information created or Conduct or review a security risk analysis per 45 CFR
adequate maintained by certified EHR technology through the 164.308(a)(1) and implement updates as necessary and
privacy and implementation of appropriate technical capabilities correct identified security deficiencies as part of the
security EP’s, eligible hospital’s or CAH’s risk management
protections process
for personal
health
information

19. Meaningful Use – Stage 1 Menu Set
Health Stage 1 Objective Stage 1 Measure
Outcomes
Policy
Priority
Improving Implement drug-formulary checks The EP/eligible hospital/CAH has enabled this
quality, functionality and has access to at least one internal or
safety, external drug formulary for the entire EHR reporting
efficiency, period
and reducing Hospitals Only: Record advance directives for More than 50% of all unique patients 65 years old or
health patients 65 years old or older older admitted to the eligible hospital or CAH have an
disparities indication of an advance directive status recorded
Incorporate clinical lab-test results into certified EHR More than 40% of all clinical lab test results ordered by
technology as structured data the EP, or an authorized provider of the eligible hospital
or CAH, for patients admitted during the EHR reporting
period whose results are either in a positive/negative or
numerical format are incorporated in certified EHR
technology as structured data
Generate lists of patients by specific conditions to Generate at least one report listing patients of the EP,
use for quality improvement, reduction of disparities, eligible hospital or CAH with a specific condition
research or outreach
EPs Only: Send reminders to patients per patient More than 20% of all unique patients 65 years or older
preference for preventive/follow-up care or 5 years old or younger were sent an appropriate
reminder during the EHR reporting period

20. Meaningful Use – Stage 1 Menu Set, cont’d
Health Stage 1 Objective Stage 1 Measure
Outcomes
Policy
Priority
Engage EPs Only: Provide patients with timely electronic More than 10% of all unique patients seen by the EP are
patients and access to their health information (including lab provided timely (available to the patient within 4
families in results, problem list, medication lists, medication business days of being updated in the certified EHR
their health allergies) within 4 business days of the information technology) electronic access to their health
care being available to the EP information subject to the EP’s discretion to withhold
certain information
Use certified EHR technology to identify patient- More than 10% of all unique patients seen by the EP or
specific education resources and provide those admitted to the eligible hospital or CAH are provided
resources to the patient, if appropriate patient-specific education resources
Improve care The EP, eligible hospital or CAH who receives a The EP, eligible hospital or CAH performs medication
coordination patient from another setting of care or provider of reconciliation for more than 50% of transitions of care in
care or believes an encounter is relevant should which the patient is transitioned into the care of the EP
perform medication reconciliation or admitted to the eligible hospital or CAH
The EP, eligible hospital or CAH who receives a The EP, eligible hospital or CAH who transitions or refers
patient from another setting of care or provider of their patient to another setting of care or provider of
care or refers their patient to another provider of care provides a summary of care record for more than
care should provide a summary of care record for 50% of transitions of care and referrals
each transition of care or referral

21. Meaningful Use – Stage 1 Menu Set, cont’d
Health Stage 1 Objective Stage 1 Measure
Outcomes
Policy
Priority
Improve Capability to submit electronic data to immunization Performed at least one test of the certified EHR
population registries or Immunization Information Systems and technology’s capacity to submit electronic data to
and public actual submission in accordance with applicable law immunization registries and follow-up submission if the
health1 and practice test is successful (unless none of the immunization
registries to which the EP, eligible hospital or CAH
submits such information have the capacity to receive
such information electronically)
Hospitals Only: Capability to submit electronic data Performed at least one test of certified EHR
on reportable (as required by state or local law) lab technology’s capacity to provide submission of
results to public health agencies and actual reportable lab results to public health agencies and
submission in accordance with applicable law and follow-up submission if the test is successful (unless
practice none of the public health agencies to which the EP,
eligible hospital or CAH submits such information have
the capacity to receive such information electronically)
Capability to submit electronic syndromic Performed at least one test of certified EHR
surveillance data to public health agencies and actual technology’s capacity to provide electronic syndromic
submission in accordance with applicable law and surveillance data to public health agencies and follow-
practice up submission if the test is successful (unless none of
the public health agencies to which the EP, eligible
hospital or CAH submits such information have the
capacity to receive such information electronically)
1
Unless an EP, eligible hospital or CAH has an exception for all of these objectives and measures they must complete at least one as part of their
demonstration of the menu set in order to be a meaningful EHR user.

22. Future Stages
• Intend to propose 2 additional Stages through
future rulemaking. Future Stages will expand upon
Stage 1 criteria.
• Stage 1 menu set will be transitioned into core
set for Stage 2
• Administrative transactions will be added
• CPOE measurement will go to 60%
• Will reevaluate other measures – possibly higher
thresholds
• Stage 3 will be further defined in next rulemaking
22

23. States’ Flexibility to Revise
Meaningful Use
• States can seek CMS prior approval to require 4
MU objectives be core for their Medicaid
providers:
• Generate lists of patients by specific conditions for
quality improvement, reduction of disparities, research
or outreach (can specify particular conditions)
• Reporting to immunization registries, reportable lab
results and syndromic surveillance (can specify for
their providers how to test the data submission and to
which specific destination)
23

24. MU for Hospitals that Qualify for
Both Medicare & Medicaid Payments
• Applies to sub-section (d) and acute care
hospitals
• Attest/Report on Meaningful Use to CMS for the
Medicare EHR Incentive Program
• Will be deemed meaningful users for Medicaid
(even if the State has CMS approval for the MU
flexibility around public health objectives)
24

25. Clinical Quality Measures (CQM)
Overview
• 2011 – EPs, eligible hospitals and CAHs seeking
to demonstrate Meaningful Use are required to
submit aggregate CQM numerator, denominator,
and exclusion data to CMS or the States by
attestation.
25

26. Meaningful Use for EPs who Work at
Multiple Sites
• An EP who works at multiple locations, but does
not have certified EHR technology available at all
of them would:
• Have to have 50% of their total patient encounters at
locations where certified EHR technology is available
• Would base all meaningful use measures only on
encounters that occurred at locations where certified
EHR technology is available
• 2012 – EPs, eligible hospitals and CAHs seeking to demonstrate
Meaningful Use are required to electronically submit aggregate CQM
numerator, denominator, and exclusion data to CMS or the States.
26

27. CQM: Eligible Professionals
• Core, Alternate Core, and Additional CQM sets for
EPs
• EPs must report on 3 required core CQM, and if the
denominator of 1or more of the required core measures is
0, then EPs are required to report results for up to 3
alternate core measures
• EPs also must select 3 additional CQM from a set of 38
CQM (other than the core/alternate core measures)
• In sum, EPs must report on 6 total measures: 3 required
core measures (substituting alternate core measures where
necessary) and 3 additional measures
27

28. CQM: Core Set for EPs
NQF Measure Number & PQRI Clinical Quality Measure Title
Implementation Number
NQF 0013 Hypertension: Blood Pressure
Measurement
NQF 0028 Preventive Care and Screening
Measure Pair: a) Tobacco Use
Assessment b) Tobacco Cessation
Intervention
NQF 0421 Adult Weight Screening and Follow-up
PQRI 128
28

29. CQM: Alternate Core Set for EPs
NQF Measure Number & PQRI Clinical Quality Measure Title
Implementation Number
NQF 0024 Weight Assessment and Counseling for
Children and Adolescents
NQF 0041 Preventive Care and Screening:
PQRI 110 Influenza Immunization for Patients 50
Years Old or Older
NQF 0038 Childhood Immunization Status
29

30. CQM: Additional Set for EPs
1. Diabetes: Hemoglobin A1c Poor Control
2. Diabetes: Low Density Lipoprotein (LDL) Management and Control
3. Diabetes: Blood Pressure Management
4. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB)
Therapy for Left Ventricular Systolic Dysfunction (LVSD)
5. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)
6. Pneumonia Vaccination Status for Older Adults
7. Breast Cancer Screening
8. Colorectal Cancer Screening
9. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD
10. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
11. Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase
Treatment
12. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
13. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of
Retinopathy
14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
15. Asthma Pharmacologic Therapy
16. Asthma Assessment
17. Appropriate Testing for Children with Pharyngitis
18. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR)
Positive Breast Cancer
19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
30

31. CQM: Additional Set for EPs, cont’d
20. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
21. Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco Users to
Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and
Tobacco Use Cessation Strategies
22. Diabetes: Eye Exam
23. Diabetes: Urine Screening
24. Diabetes: Foot Exam
25. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol
26. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation
27. Ischemic Vascular Disease (IVD): Blood Pressure Management
28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
29. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b)
Engagement
30. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)
31. Prenatal Care: Anti-D Immune Globulin
32. Controlling High Blood Pressure
33. Cervical Cancer Screening
34. Chlamydia Screening for Women
35. Use of Appropriate Medications for Asthma
36. Low Back Pain: Use of Imaging Studies
37. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
38. Diabetes: Hemoglobin A1c Control (<8.0%)
31

32. CQM: Eligible Hospitals and CAHs
1. Emergency Department Throughput – admitted patients Median time from ED arrival to
ED departure for admitted patients
2. Emergency Department Throughput – admitted patients – Admission decision time to ED
departure time for admitted patients
3. Ischemic stroke – Discharge on anti-thrombotics
4. Ischemic stroke – Anticoagulation for A-fib/flutter
5. Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom
onset
6. Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2
7. Ischemic stroke – Discharge on statins
8. Ischemic or hemorrhagic stroke – Stroke education
9. Ischemic or hemorrhagic stroke – Rehabilitation assessment
10. VTE prophylaxis within 24 hours of arrival
11. Intensive Care Unit VTE prophylaxis
12. Anticoagulation overlap therapy
13. Platelet monitoring on unfractionated heparin
14. VTE discharge instructions
15. Incidence of potentially preventable VTE
32

33. Participation in HITECH and other
Medicare Incentive Programs for EPs
Other Medicare Incentive Eligible for HITECH EHR Incentive Program?
Program
Medicare Physician Quality Yes, if the EP is eligible.
Reporting Initiative (PQRI)
Medicare Electronic Health Yes, if the EP is eligible.
Record Demonstration (EHR
Demo)
Medicare Care Management Yes, if the practice is eligible. The MCMP demo will end
Performance Demonstration before EHR incentive payments are available.
(MCMP)
Electronic Prescribing (eRx) If the EP chooses to practice in the Medicare EHR Incentive
Incentive Program Program, they cannot participate in the Medicare eRx
Incentive Program simultaneously in the same program
year. If the EP chooses to participate in the Medicaid EHR
Incentive Program, they can participate in the Medicare
eRx Incentive Program simultaneously.
33

34. EHR Incentive Program Timeline
• Registration for the EHR Incentive Programs will begin in January 2011
• For Medicare providers, attestation for the EHR Incentive Programs will begin in
April 2011
• EHR incentive payments will be made 11 months after the rule is published*
• For Medicaid providers, States may launch their programs in January 2011 and
thereafter
• November 30, 2011 – Last day for eligible hospitals and CAHs to register and
attest to receive an incentive payment for FFY 2011 (Medicare providers)
• February 29, 2012 – Last day for EPs to register and attest to receive an incentive
payment for CY 2011 (Medicare providers)
• 2015 – Medicare payment adjustments begin for EPs and eligible hospitals that are
not meaningful users of EHR technology**
• 2016 – Last year to receive a Medicare EHR incentive payment; Last year to
initiate participation in Medicaid EHR Incentive Program**
• 2021 – Last year to receive Medicaid EHR incentive payment**
**Statutory
34

35. More Information
• http://www.cms.gov/EHRIncentivePrograms
35