Health Information Technology: Meaningful Use AMA Comments and OIG Report

One of the central pieces to the Affordable Care Act (PPACA), along with the American Reinvestment and Recovery Act (ARRA) was the implementation and “meaningful use” of electronic health records (EHRs)—through the HITECH provision.  Consequently, the Office of the National Coordinator for Health IT’s (ONC) HIT Policy Committee has released a copy of its proposed recommendations for public comment. 

Under the 2009 federal economic stimulus package, health care providers who demonstrate “meaningful use” of certified electronic health record systems can qualify for Medicaid and Medicare incentive payments.  To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services. 

CMS expects to pay about $6.6 billion in incentive payments to providers who use certified HER technology between 2011 and 2016.  So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals.  By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. 

The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) reported that the percentage of doctors adopting electronic health records has increased from 48 percent in 2009 to 72 percent in 2012.  The ONC report shows that since 2009, the percent of physicians with computerized capabilities to e-prescribe has more than doubled, from 33 percent to 73 percent.  

While HHS and the Obama Administration have been busy issuing rules and regulations, as well as various guidance, and holding numerous forums and educational opportunities for individual providers and institutions, a recent report from HHS’ Office of Inspector General (OIG) found that the Centers for Medicare & Medicaid Services (CMS) is falling down on the job when it comes to verifying if providers receiving incentive payments are entitled to them.   We previously noted that the government is already concerned that doctors and providers may be using EHRs to upcode medical bills.  

In addition to OIG’s report, the American Medical Association (AMA) sent comments to ONC, expressing its extreme concern that ONC is moving full speed ahead with Stage 3 of the meaningful use EHR program “without a comprehensive evaluation of the program and resolving existing barriers, including HIT infrastructure flaws.”  The 20-page letter outlined the following top five concerns and recommendations to improve the meaningful use program: 

1. An evaluation process is lacking. An external, independent evaluation is necessary to improve and inform the future of the program.
2. 100 percent pass rate is not the right approach. The pass rate should be reasonable and achievable. Failing to meet just one measure by one percent would make a physician ineligible for incentives and subject to financial penalties
3. One size does not fit all. Under the current program, every physician regardless of their specialty must meet the same measures (i.e., core measures), and there are few exceptions. The program requirements should be appropriately flexible and better structured to accommodate various practice patterns and specialties. Also, additional resources and time to develop and test e-specified electronic measures focused on outcomes must be allotted to ensure successful implementation of the meaningful use program.
4. Usability of certified EHRs should be addressed. The EHR certification process should address physician usability concerns.
5. Health IT infrastructure barriers should be resolved. The health IT infrastructure does not enable physicians to readily electronically share patient data with other health care providers; infrastructure improvement to allow an efficient and secure electronic information exchange must be a priority. Improving the Health IT infrastructure to allow physicians to readily and securely exchange patient data with other health care providers should be made a top priority and take precedence over the development of future stages of the meaningful use program. 

The American Hospital Association (AHA) and The College of Healthcare Information Management Executives (CHIME) echoed AMA’s concerns in their own comment letters.   

OIG Report 

The OIG report found that the EHR system is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, reported the New York Times.  The report mirrors a report earlier this year from the Government Accountability Office, which also expressed concern that CMS was not verifying provider attestation information before distributing payments to them. 

According to the New York Times, the report states that “Medicare has not audited any of the $3.6 billion payments it has made to date, which faults the agency for its lack of prepayment review and reliance on self-reporting after money has been spent.” 

The OIG report blasts CMS for not verifying the accuracy of providers’ attestation information both before and after paying the incentive, leaving the program “vulnerable,” reported FierceHealthcare.  “Currently, CMS has not implemented strong prepayment safeguards,” the report states.  “CMS does not verify the accuracy of professionals’ and hospitals’ self-reported information prior to payment because data necessary for verifications are not readily available.  CMS also does not direct high-risk professionals and hospitals to submit supporting documentation for prepayment review.” 

OIG also found that ONC’s requirements for EHR reports in certified EHR technology may be contributing to CMS’ oversight obstacles, since those reports are not sufficient for CMS to verify providers’ reports.  “Absent changes to the definition of Meaningful Use, CMS should consider ways to strengthen its program oversight to protect the $4 billion in Medicare EHR incentive payments that it has paid, as well as billions of dollars in future incentive payments,” OIG said. 

OIG recommended that CMS obtain and review supporting documentation prior to payment to verify the accuracy of self reported information and issue guidance with specific examples of documentation that providers should maintain to support the compliance.  OIG also recommended that ONC require that certified EHR technology be capable of producing reports for yes/no meaningful use measures where possible and improve the certification process for EHR technology to ensure accurate EHR reports. 

Previously, a group of Republicans from the House of Representatives, including the Chairs of the Ways and Means and Energy and Commerce Committees, sent a letter to HHS Secretary Kathleen Sebelius expressed their concern that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.  They asserted that the State 2 Meaningful use program rules are “in some respects, weaker than the proposed Stage 1 regulations released in 2009,” which will result in a “less efficient system that squanders taxpayer dollars and does little if anything, to improve outcomes for Medicare.”  Due to their concerns, they urged the Secretary to: 

• Immediately suspend the distribution of incentive payments until HHS promulgates universal interoperable standards, which would also require a commensurate delay of penalties for providers who choose not to integrate HIT into their practice
• Significantly increase what’s expected of Meaningful users (e.g., requiring a summary transfer when a  patient moves to a different care setting in electronic format only 10% of the time is insufficient; requiring radiology and laboratory orders to be electronic 30% of the time and medication reconciliation and e-prescribing to occur just 50% is woefully inadequate, they wrote.
• Take steps to eliminate the subsidization of business practices that block the exchange of information between providers.   

The NY Times reported that Sebelius responded in an unpublished by dismissing the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.”  She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate. 

While CMS agreed with some of OIG’s comments and recommendations, Marilyn Tavenner, the acting administrator for Medicare, strongly disagreed with the idea that the agency should do more to ensure payments are appropriate before writing a check.  Requiring an audit before paying hospitals and doctors “could significantly delay payments to providers,” she said, and these reviews “would also impose an increased upfront burden on providers,” Ms. Tavenner said. Medicare took some steps to make sure providers were eligible for the payments but “does not believe prepayment audit is necessary at this juncture.”  Medicare maintains that it has systems in place to verify the information being submitted.