oversight

Electronic Health Records: First Year of CMS's Incentive Programs Shows Opportunities to Improve Processes to Verify Providers Met Requirements

Published by the Government Accountability Office on 2012-04-30.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States Government Accountability Office

GAO          Report to Congressional Committees




April 2012
             ELECTRONIC
             HEALTH RECORDS
             First Year of CMS’s
             Incentive Programs
             Shows Opportunities
             to Improve Processes
             to Verify Providers
             Met Requirements




GAO-12-481
                                           April 2012

                                           ELECTRONIC HEALTH RECORDS
                                           First Year of CMS’s Incentive Programs Shows
                                           Opportunities to Improve Processes to Verify
                                           Providers Met Requirements
Highlights of GAO-12-481, a report to
congressional committees




Why GAO Did This Study                     What GAO Found
The Health Information Technology for      The Centers for Medicare and Medicaid Services (CMS), an agency within the
Economic and Clinical Health               Department of Health and Human Services (HHS), and the four states GAO
(HITECH) Act established the               reviewed are implementing processes to verify whether providers met the
Medicare and Medicaid electronic           Medicare and Medicaid EHR programs’ requirements and, therefore, qualified to
health records (EHR) programs. CMS         receive incentive payments in the first year of the EHR programs. To receive
and the states administer these            such payments, providers must meet both (1) eligibility requirements that specify
programs which began in 2011 to            the types of providers eligible to participate in the programs and (2) reporting
promote the meaningful use of EHR          requirements that specify the information providers must report to CMS or the
technology through incentive payments
                                           states, including measures that demonstrate meaningful use of an EHR system
paid to certain providers—that is,
                                           and measures of clinical quality. For the Medicare EHR program, CMS has
hospitals and health care
professionals. Spending for the
                                           implemented prepayment processes to verify whether providers have met all of
programs is estimated to total             the eligibility requirements and one of the reporting requirements. Beginning in
$30 billion from 2011 through 2019.        2012, the agency also has plans to implement a risk-based audit strategy to
Consistent with the HITECH Act, GAO        verify on a postpayment basis that a sample of providers met the remaining
(1) examined efforts by CMS and the        reporting requirements. For the Medicaid EHR Program, the four states GAO
states to verify whether providers         reviewed have implemented primarily prepayment processes to verify whether
qualify to receive EHR incentive           providers met all eligibility requirements. To verify the reporting requirement, all
payments and (2) examined                  four states implemented prepayment processes, postpayment processes, or
information reported to CMS by             both. CMS officials stated that the agency intends to evaluate how effectively its
providers to demonstrate meaningful        Medicare EHR program audit strategy reduces the risk of improper EHR
use in the first year of the Medicare      incentive payments, though the agency has not yet established corresponding
EHR program. GAO reviewed                  timelines for doing this work. Such an evaluation could help CMS determine
applicable statutes, regulations, and      whether it should revise its verification processes by, for example, implementing
guidance; interviewed officials from       additional prepayment processes, which GAO has shown may reduce the risk of
CMS; interviewed officials from four       improper payments. In addition, CMS has opportunities to improve the efficiency
states, which were judgmentally            of verification processes by, for example, collecting certain data on states’ behalf.
selected to obtain variation among
multiple factors; and analyzed data        CMS allows providers to exempt themselves from reporting certain measures if
from CMS and other sources.                providers report that the measures are not relevant to their patients or practices.
                                           Measures calculated based on few patients may be statistically unreliable, which
What GAO Recommends                        limits their usefulness as tools for quality improvement. CMS and others
GAO is making four recommendations         acknowledged that the availability of measures that are relevant to providers’
to CMS in order to improve processes       patients and practices and are statistically reliable is important to provide useful
to verify whether providers met            information to providers. Among participants in the first year of the Medicare EHR
program requirements for the Medicare      program, the majority of providers chose to exempt themselves from reporting on
and Medicaid EHR programs, including       at least one meaningful use measure and many providers reported at least one
opportunities for efficiencies. HHS        clinical quality measure based on few—less than seven—patients.
agreed with three of GAO’s
recommendations, but disagreed with        Information on measures reported by first year participants
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.

View GAO-12-481. For more information,
contact Linda Kohn at (202) 512-7114 or
kohnl@gao.gov.

                                                                                         United States Government Accountability Office
Contents


Letter                                                                                     1
               Background                                                                  8
               For the First Program Year, Processes Are Being Implemented to
                 Verify Requirements Were Met, and CMS Has Opportunities to
                 Improve Them                                                            19
               Most Medicare Providers Exempted Themselves from Reporting
                 Certain Measures and Many Reported Others Based on Few
                 Patients                                                                29
               For the First Program Year, Providers Experienced Challenges and
                 Used Strategies and Services to Facilitate Participation                38
               Conclusions                                                               44
               Recommendations for Executive Action                                      45
               Agency Comments and Our Evaluation                                        46

Appendix I     Scope and Methodology                                                     50



Appendix II    How Medicare and Medicaid EHR Program Incentive Payments
               Are Calculated                                                            56



Appendix III   Meaningful Use and Clinical Quality Measures for the Medicare
               EHR Program, 2011                                                         57



Appendix IV    Regional Extension Center Program, Goals, and Progress in
               Helping Providers Demonstrate Meaningful Use                              65



Appendix V     Comments from the Department of Health and Human Services                 72



Appendix VI    GAO Contact and Staff Acknowledgments                                     77




               Page i                                    GAO-12-481 Electronic Health Records
Tables
         Table 1: Medicare EHR Program’s Eligibility and Reporting
                  Requirements, 2011                                               12
         Table 2: Medicaid EHR Program’s Eligibility and Reporting
                  Requirements, 2011                                               15
         Table 3: CMS’s Processes to Verify Whether Providers Met
                  Medicare EHR Program Eligibility and Reporting
                  Requirements in 2011                                             21
         Table 4: Four States’ Processes to Verify Whether Providers Met
                  Medicaid EHR Program Eligibility and Reporting
                  Requirements in 2011                                             24
         Table 5: Percentage of Professionals Who Participated in the
                  Medicare EHR Program That Claimed an Exemption for at
                  Least One Meaningful Use Measure, through December 8,
                  2011                                                             30
         Table 6: Percentage of Hospitals That Participated in the Medicare
                  EHR Program That Claimed an Exemption for at Least
                  One Meaningful Use Measure, 2011                                 32
         Table 7: Percentage of Professionals Who Participated in the
                  Medicare EHR Program That Reported at Least One
                  Clinical Quality Measure That Was Calculated Based on
                  Few Patients, through December 8, 2011                           35
         Table 8: Percentage of Hospitals That Participated in the Medicare
                  EHR Program That Reported at Least One Clinical Quality
                  Measure That Was Calculated Based on Few Patients, 2011          37
         Table 9: Number of Measures Providers Must Report or Claim
                  Allowed Exemptions from Reporting for the Medicare
                  EHR Program, 2011                                                58
         Table 10: Meaningful Use Measures for Professionals and Hospitals
                  in the Medicare EHR Program, 2011                                59
         Table 11: Clinical Quality Measures for Professionals in the
                  Medicare EHR Program, 2011                                       61
         Table 12: Clinical Quality Measures for Hospitals in the Medicare
                  EHR Program, 2011                                                64
         Table 13: Goals and Number of Professionals Assisted in
                  Progressing Towards Demonstrating Meaningful Use, by
                  Regional Extension Center, through December 19, 2011             66
         Table 14: Goals and Number of Hospitals Assisted in Progressing
                  Towards Demonstrating Meaningful Use, by Regional
                  Extension Center, through December 19, 2011                      69




         Page ii                                   GAO-12-481 Electronic Health Records
Figures
          Figure 1: Permissible Provider Types in the Medicare and Medicaid
                   EHR Programs                                                                      9
          Figure 2: Years in Which Incentive Payments Are Available and
                   When Penalties Will be Assessed in the Medicare and
                   Medicaid EHR Programs                                                            10
          Figure 3: Oversight Process CMS and States May Use to Verify
                   Providers Met Eligibility and Reporting Requirements for
                   the Medicare and Medicaid EHR Programs                                           17
          Figure 4: Practice Settings of Professionals with Signed Technical
                   Assistance Agreements with Regional Extension Centers,
                   through December 19, 2011                                                        41
          Figure 5: Examples of Services Provided by Regional Extension
                   Centers                                                                          43




          Abbreviations

          CMS                        Centers for Medicare & Medicaid Services
          EHR                        electronic health record
          HHS                        Department of Health and Human Services
          HITECH Act                 Health Information Technology for Economic and
                                      Clinical Health
          OIG                        Office of Inspector General
          ONC                        Office of the National Coordinator for Health
                                      Information Technology
          Recovery Act               American Recovery and Reinvestment Act of 2009



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          Page iii                                             GAO-12-481 Electronic Health Records
United States Government Accountability Office
Washington, DC 20548




                                   April 30, 2012

                                   Congressional Committees

                                   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. 1

                                   The Health Information Technology for Economic and Clinical Health
                                   (HITECH) Act, enacted as part of the American Recovery and
                                   Reinvestment Act of 2009 (Recovery Act), 2 among other things, provided
                                   funding for various activities intended to promote the adoption and




                                   1
                                    The following studies surveyed office-based physicians or hospitals’ health information
                                   technology staff to determine the percentage that had adopted EHR systems: C.J. Hsiao,
                                   E. Hing, T.C. Socey, and B. Cai, “Electronic Medical Record/Electronic Health Record
                                   Systems of Office-Based Physicians: United States, 2009 and Preliminary 2010 State
                                   Estimates,” National Center for Health Statistics Health E-stat (2010); and A.K. Jha, C.M.
                                   DesRoches, P.D. Kralovec, and M.S. Joshi, “A Progress Report On Electronic Health
                                   Records In U.S. Hospitals,” Health Affairs, no.10 (2010):1951-1957.
                                   2
                                    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).




                                   Page 1                                                  GAO-12-481 Electronic Health Records
meaningful use of certified EHR technology. 3 The largest of these
activities, in terms of potential federal expenditures, are the Medicare and
Medicaid EHR programs. 4 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. 5 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. 6 For example, in
2011, Medicare professionals had to report 20 meaningful use measures


3
 Congress defined “meaningful use” in this context to mean that the user of health
information technology demonstrates to the satisfaction of the Secretary of the
Department of Health and Human Services (HHS) that the technology is certified and
being used in a meaningful manner, that the technology is connected in a manner that
provides for the electronic exchange of health information to improve the quality of health
care, and that such information is submitted in a form and manner specified by the
Secretary. See Pub. L. No. 111-5, § 4101(a) 123 Stat. 467-472. Certified EHR technology
is technology that meets certain certification criteria established by HHS’s Office of the
National Coordinator for Health Information Technology (ONC). The certification criteria
describe the minimum related standards and implementation specifications.
4
  See Pub. L. No. 111-5, §§ 4101-4201, 123 Stat. 467-494. Medicare is a federal program
financing health care for individuals aged 65 and older, certain disabled individuals, and
individuals with end-stage renal disease. In 2010, Medicare covered 47 million
beneficiaries. Medicaid is a federal-state program financing health care for certain low-
income children, families, and individuals who are aged or disabled. In fiscal year 2009,
Medicaid covered over 65 million beneficiaries.
5
 See Pub. L. No. 111-5, § 4101(a)-(b), 123 Stat. 467-473.Beginning in 2015, the Medicare
EHR program is to begin applying a payment adjustment, referred to in this report as a
penalty, for hospitals and professionals that do not meet the Medicare EHR program
requirements. The Medicaid EHR program does not impose penalties on Medicaid
providers that do not meet the Medicaid EHR program’s requirements by a specific date;
however, if Medicaid providers also treat Medicare patients, they are required to meet the
Medicare EHR program’s requirements from 2015 onward to avoid penalties from the
Medicare EHR program.
6
 In February 2012, CMS announced a proposed rule that would set out the next steps and
criteria for providers participating in the Medicare and Medicaid EHR programs. Among
other things, this proposed rule would revise certain reporting requirements that may take
effect as early as 2013. See CMS, “Medicare and Medicaid Programs; Electronic Health
Record Incentive Program—Stage 2” downloaded from
http://www.ofr.gov/ofrupload/ofrdata/2012-0043_PI.pdf on February 24, 2012.




Page 2                                               GAO-12-481 Electronic Health Records
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. 7 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. 8 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. 9




7
 Congressional Budget Office, “Health Information Technology for Economic and Clinical
Health Act” (Washington, D.C.: Jan. 21, 2009). This estimate includes spending estimates
for bonuses and payment reductions from the penalties.
8
  Due to various reasons, such as the time needed to process providers’ payments, at the
time of our analysis, CMS and the states were still in the process of making payments to
providers for the 2011 program year. Therefore, these totals reflect partial-year data and
are expected to increase. See CMS, “Medicare and Medicaid EHR Incentive Program
Payment and Registration Report, January 2012” downloaded from
https://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp on February 19,
2012. In the comments HHS provided on our draft report in April 2012, HHS reported that
57,765 professionals had attested to meaningful use. CMS projected that between 62,569
and 206,276 providers would receive Medicare or Medicaid EHR program incentive
payments in 2011. See 75 Fed. Reg. 44548 – 44562 (July 28, 2010).
9
 CMS provides states 100 percent of the cost of incentive payments made to Medicaid
providers and 90 percent of the costs related to reasonable administrative expenses and
planning activities related to the Medicaid EHR program. 42 U.S.C. § 1396b(a)(3)(F)(i)
and (ii).




Page 3                                              GAO-12-481 Electronic Health Records
States are not required to offer the Medicaid EHR program, although
CMS anticipates that the majority of states will eventually participate. 10

The HITECH Act requires us to report on the effect, among other things,
of its provisions on the adoption of EHRs by providers. 11 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. 12

To examine efforts by CMS and the states to verify whether providers met
program requirements and qualify to receive incentive payments in 2011,
we identified the eligibility and reporting requirements that providers must
meet in order to receive incentive payments under the Medicare and
Medicaid EHR programs. 13 To do this, we reviewed applicable statutes,
regulations, and guidance. We also interviewed officials from CMS and
four states (Iowa, Kentucky, Pennsylvania, and Texas) that we
judgmentally selected to obtain more information about their specific
efforts or processes used to verify whether providers met these eligibility




10
  According to a monthly report on CMS’s website, through January 2012, 34 states
issued incentive payments to providers that participated in the Medicaid EHR Program.
The agency anticipates that 8 additional states will issue incentive payments for 2011.
11
     Pub.L. No. 111-5, § 13424(e), 123 Stat. 278-279.
12
  We also discussed with the committees of jurisdiction that we would report on, at a later
date, the number and characteristics of providers that received incentive payments from
CMS during the first year of the Medicare and Medicaid EHR programs.
13
  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.




Page 4                                                  GAO-12-481 Electronic Health Records
and reporting requirements. 14 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. 15 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. 16
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. 17 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



14
  From among the states that had started registering providers for their states’ Medicaid
EHR program as of June 6, 2011, we judgmentally selected these four states based on
the variation in the following: geographic region, total state population, Medicaid
enrollment as a percentage of state population, and whether the state had started making
incentive payments as of May 31, 2011.
15
  HHS, OIG, “Early Review of States’ Planned Medicaid Electronic Health Record
Incentive Program Oversight,” OEI-05-10-00080 (Washington, D.C.: July 15, 2011).The
OIG selected 13 states because they had CMS-approved State Medicaid Health
Information Technology Plans as of January 14, 2011, and were available for interviews at
the time of OIG’s review. The 4 states we reviewed were among those included in the OIG
report.
16
 See GAO, Standards for Internal Control in the Federal Government,
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and GAO, Internal Control
Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.: August 2001).
17
  We analyzed data submitted by providers from April 18, 2011, the date CMS began
collecting these data, through December 8, 2011.




Page 5                                              GAO-12-481 Electronic Health Records
•     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; 18

•     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. 19

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




18
    See 75 Fed. Reg. 44328-44329 (July 28, 2010).
19
  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.




Page 6                                              GAO-12-481 Electronic Health Records
the National Coordinator for Health Information Technology (ONC) on a
variety of health technology issues. 20

To describe providers’ experiences during the first year of the Medicare
and Medicaid EHR programs, we interviewed six judgmentally selected
providers (three professionals and three hospitals) about their
experiences adopting and meaningfully using certified EHR technology in
2011. 21 To obtain additional information on providers’ experiences
participating in the Medicare and Medicaid EHR programs in 2011, we
interviewed officials and reviewed documents from the following
organizations: the American Medical Association; the American Hospital
Association; and four judgmentally selected Regional Extension
Centers. 22 The Regional Extension Center program was established by
the HITECH Act and is administered by ONC to help some types of
providers, such as those in rural areas, participate in CMS’s EHR
programs. 23 We also analyzed data reported as part of the Regional
Extension Center program to identify the number of providers they helped
participate in CMS’s EHR programs. 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



20
  Both committees were established under the HITECH Act. The Health Information
Technology Policy Committee is charged with making recommendations to ONC on a
policy framework for the development and adoption of a nationwide health information
infrastructure whereas the Health Information Technology Standards Committee is
charged with making recommendations to ONC on standards, implementation
specifications, and certification criteria for the electronic exchange and use of health
information. Pub. L. No. 111-5, § 13101, 123 Stat. 228-242.
21
  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.
22
  We judgmentally selected these four Regional Extension Centers in order to provide
variation based on the following: total funding levels under the Regional Extension Center
program, progress towards meeting the Regional Extension Center’s goal for the number
of professionals assisted, geographic region, and urban-rural population mixes.
23
  Pub. L. No 111-5 § 13101, 123 Stat. 246-250. We did not review all ONC or CMS efforts
to educate providers about the Medicare and Medicaid EHR programs. For example, CMS
created a website that provides various educational materials that we did not include in
our review.




Page 7                                                 GAO-12-481 Electronic Health Records
                        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.


                        Although the Medicare and Medicaid EHR programs are generally similar,
Background              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.


Permissible Providers   The types of providers eligible to participate in the Medicare and Medicaid
                        EHR programs—referred to as permissible providers—differ. See figure 1
                        below.




                        Page 8                                      GAO-12-481 Electronic Health Records
Figure 1: Permissible Provider Types in the Medicare and Medicaid EHR Programs




                                       a
                                        Physician assistants are one of the permissible provider types if they also work in a federally
                                       qualified health center or rural health center that is led by a physician assistant.
                                       b
                                        Professionals that are eligible to participate in both the Medicare and Medicaid EHR programs may
                                       only receive an incentive payment from one program per year.
                                       c
                                       In contrast to professionals, hospitals that are eligible to participate in both the Medicare and
                                       Medicaid EHR programs may receive an incentive payment from both programs in the same year.
                                       d
                                        For the Medicare EHR program, acute care hospitals refer to hospitals described in Section 1886(d)
                                       of the Social Security Act, which are paid under the inpatient prospective payment system. For the
                                       Medicaid EHR program, acute care hospitals refer to hospitals with an average length of patient stay
                                       of 25 days or fewer with a CMS Certification Number that has the last four digits in the series 0001-
                                       0879 or 1300-1399 and excludes critical access hospitals and cancer hospitals.




                                       Page 9                                                       GAO-12-481 Electronic Health Records
Incentive Payments and                  Beginning in 2011, the first year of the Medicare and Medicaid EHR
Penalties                               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.

Figure 2: Years in Which Incentive Payments Are Available and When Penalties Will be Assessed in the Medicare and
Medicaid EHR Programs




                                        Note: Payment years are determined and awarded on a calendar year basis for professionals and on
                                        a fiscal year basis for hospitals. Professionals may not receive incentive payments under both the
                                        Medicare EHR program and the Medicaid EHR program during the same year; they must choose one
                                        of the two programs under which they will participate. In contrast, hospitals may qualify for incentive
                                        payments under both programs during the same year.
                                        a
                                         The Medicaid EHR program does not impose penalties on Medicaid providers that do not meet the
                                        Medicaid EHR program’s requirements by a specific date; however, if Medicaid providers also treat
                                        Medicare patients, they are required to meet the Medicare EHR program’s requirements from 2015
                                        onward to avoid penalties from the Medicare EHR program.


                                        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


                                        Page 10                                                     GAO-12-481 Electronic Health Records
                       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
                       programs, providers must meet eligibility and reporting requirements. 24 To
                       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.


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




                       24
                         CMS plans to make the requirements that providers must meet more robust over time.
                       According to CMS, the current focus of the EHR programs includes electronically
                       capturing health information in a structured format and tracking key clinical conditions.




                       Page 11                                              GAO-12-481 Electronic Health Records
Table 1: Medicare EHR Program’s Eligibility and Reporting Requirements, 2011

Requirement                                                                                                                            Professional   Hospital
Eligibility requirements
Provider type
    Provider is a permissible provider type.                                                                                                √            √
    Professional is not hospital-based.                                                                                                     √
    Professional cannot have performed 90 percent or more of his/her services in the prior year in
    hospital inpatient or emergency room settings.
Provider qualifications
    Provider is not excluded, sanctioned, or otherwise deemed ineligible to receive payments from                                           √            √
                            a
    the federal government.
Reporting requirements
    Provider uses a certified EHR system.                                                                                                   √            √
    At least 50 percent of a professional’s patient encounters during the reporting period occurred at                                      √
    practice(s) or location(s) equipped with certified EHR technology.
    Provider demonstrates meaningful use.                                                                                                   √            √
    Professionals must report 20 meaningful use measures; hospitals must report 19 such
              b
    measures.
                                               Source: GAO analysis of applicable CMS regulations and interviews with CMS officials.

                                               Note: Providers attest to information submitted to CMS regarding the Medicare EHR program’s
                                               eligibility requirements, which specify the types of providers eligible to participate in the program. To
                                               demonstrate that providers met the Medicare EHR program’s reporting requirements, providers must
                                               report information to CMS to demonstrate that they have meaningfully used the certified EHR
                                               technology.
                                               a
                                                Professionals may not receive incentive payments from both the Medicare and Medicaid EHR
                                               programs in the same year.
                                               b
                                                One of the meaningful use measures requires professionals and hospitals to report clinical quality
                                               measures. 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.


                                               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




                                               Page 12                                                                      GAO-12-481 Electronic Health Records
total of 19 meaningful use measures. This information had to be collected
over 90 consecutive days during 2011. 25

•    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. 26 One of the mandatory meaningful use
     measures—“report clinical quality measures to CMS”—requires
     professionals to report on at least 6 clinical quality measures identified
     by CMS. 27 Professionals have the flexibility to choose the remaining 5
     meaningful use measures from a menu of 10 measures.

•    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.



25
  To receive incentive payments in 2011, providers must collect data related to the
meaningful use measures and clinical quality measures in any 90 consecutive days during
that year and report those data to CMS. To receive incentive payments in subsequent
years, providers must collect data related to the meaningful use measures over a full year
and report those data to CMS.
26
  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.
27
  A clinical quality measure is a mechanism used for assessing the degree to which a
provider competently and safely delivers clinical services that are appropriate for the
patient in an optimal time frame. Professionals must report on 3 core clinical quality
measures and 3 menu clinical quality measures from a list of 38 such measures. If
professionals have zero patients that could be included in the calculation of any one of the
core measures, they must report on up to 3 alternate core measures. In contrast to
professionals, hospitals do not have the option of choosing which clinical quality measures
they can report.




Page 13                                              GAO-12-481 Electronic Health Records
Medicaid EHR Program   To receive Medicaid EHR incentive payments during 2011, professionals
Requirements           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. 28 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. 29 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. 30

                              •   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. 31




                       28
                            No such patient volume requirement applies to the Medicare EHR program.
                       29
                        Needy patients are defined by CMS as patients who are enrolled in Medicaid or the
                       Children’s Health Insurance Program, receive uncompensated care, or receive care at no
                       cost or on a sliding scale determined by ability to pay.
                       30
                         Pediatricians must have a Medicaid patient volume of at least 20 percent. Professionals
                       who practice predominantly in a federally qualified health center or rural health center
                       must have a needy patient volume of at least 30 percent. To be considered as practicing
                       predominantly in a federally qualified health center or rural health center, a professional
                       must treat over 50 percent of his or her total patient volume over a period of 6 months in a
                       federally qualified health center or rural health center. Hospitals must have a Medicaid
                       patient volume of at least 10 percent, except for children’s hospitals, which do not have a
                       patient volume requirement.
                       31
                         In general, the meaningful use criteria for the Medicare and Medicaid EHR programs are
                       identical. CMS is allowing states to require Medicaid providers to report additional
                       information related to public health and data registries as a condition for receiving
                       incentive payments.




                       Page 14                                               GAO-12-481 Electronic Health Records
Table 2: Medicaid EHR Program’s Eligibility and Reporting Requirements, 2011

Requirement                                                                                                              Professional      Hospital
Eligibility requirements
Provider type
    Provider is a permissible provider type.                                                                                   √               √
    Professional is not hospital-based.                                                                                        √
    Professional cannot have performed 90 percent or more of his/her services in the prior year in
    hospital inpatient or emergency room settings.
                                                                       a                                                                        a
    Hospital has an average length of stay of 25 days or less.                                                                                 √
    If professional is a physician assistant, s/he works in a physician assistant-led federally qualified                      √
    health center or rural health center.
Provider qualifications
    Provider is licensed to practice in the state.                                                                             √               √
    Provider is a Medicaid provider in the state.                                                                              √               √
    Provider is not excluded, sanctioned, or otherwise deemed ineligible to receive payments from                              √               √
                                 b
    the state/federal government.
    Provider meets patient volume requirements.                                                                                √               √
    Professionals must have a Medicaid patient volume of at least 30 percent unless they are
                                                                                                           c
    pediatricians or practice predominantly in a federally qualified health center or rural health center.
                                                                             d
    Hospitals must have a Medicaid patient volume of at least 10 percent.
Reporting requirements
                                                                                                 e
    Provider has adopted, implemented, or upgraded to a certified EHR system.                                                  √               √
                                               Source: GAO analysis of applicable CMS regulations and guidance.

                                               Note: Providers attest to information submitted to CMS and/or the states regarding the Medicaid EHR
                                               program’s eligibility requirements, which specify the types of providers eligible to participate in the
                                               program. To demonstrate that providers met the Medicaid EHR program’s reporting requirement,
                                               providers must report information to the states to demonstrate that they have adopted, implemented,
                                               or upgraded to the certified EHR technology.
                                               a
                                                   Children’s hospitals are not subject to this requirement.
                                               b
                                                Professionals may not receive incentive payments from both the Medicare and Medicaid EHR
                                               programs in the same year. In addition, Medicaid professionals and hospitals cannot receive incentive
                                               payments from more than one state in the same year.
                                               c
                                                Pediatricians must have a Medicaid patient volume of at least 20 percent. Professionals who practice
                                               predominantly in a federally qualified health center or rural health center must have a needy patient
                                               volume of at least 30 percent. A needy individual is defined as someone who is enrolled in Medicaid
                                               or the Children’s Health Insurance Program, receives uncompensated care, or receives care at no
                                               cost or on a sliding scale determined by ability to pay. To practice predominantly in a federally
                                               qualified health center or rural health center means that a professional treats over 50 percent of his or
                                               her total patient volume over a period of 6 months in a federally qualified health center or rural health
                                               center.
                                               d
                                               Hospitals must have a Medicaid patient volume of at least 10 percent, except for children’s hospitals,
                                               which do not have a patient volume requirement.
                                               e
                                                During the first year providers participate in the Medicaid EHR program, they need only adopt,
                                               implement, or upgrade to a certified EHR system. In subsequent years, they must meet two other
                                               reporting requirements—demonstrate meaningful use and at least 50 percent of the professional’s
                                               patient encounters during the reporting period occurred at practices or locations equipped with
                                               certified EHR technology.




                                               Page 15                                                            GAO-12-481 Electronic Health Records
Oversight Responsibilities   To help ensure the integrity of incentive payments, CMS and the states
for the EHR Programs         are responsible for developing oversight strategies, which may include
                             conducting verifications of provider-submitted information before
                             payments are made (prepayment) or after payments are made
                             (postpayment). The latter consists of verifying provider-submitted
                             information by auditing a sample of providers. See figure 3 for information
                             on the sequence of pre- and postpayment verification.




                             Page 16                                     GAO-12-481 Electronic Health Records
Figure 3: Oversight Process CMS and States May Use to Verify Providers Met
Eligibility and Reporting Requirements for the Medicare and Medicaid EHR
Programs




Page 17                                        GAO-12-481 Electronic Health Records
Regional Extension Center   The HITECH Act established the Regional Extension Center program and
Program                     approximately $721 million in grants were awarded to Regional Extension
                            Centers. Administered by HHS’s ONC, the primary mission of the
                            Regional Extension Center program is to assist providers with adopting,
                            implementing, and meaningfully using EHRs, particularly those providers
                            that may face challenges due to, for example, limited financial and staff
                            resources. 32 This assistance is intended to facilitate providers’
                            participation in the Medicare and Medicaid EHR programs. There are
                            62 Regional Extension Centers, covering all 50 states, the District of
                            Columbia, and all U.S. insular areas.

                            The Regional Extension Center program targets professionals who work
                            in certain settings for assistance:

                            •    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; 33 and

                            •    other settings that predominantly serve medically underserved
                                 populations, as defined by each Regional Extension Center. 34

                            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.




                            32
                              Regional Extension Centers offer assistance to providers irrespective of whether they
                            are eligible to receive incentive payments under the EHR programs.
                            33
                              ONC defines collaborative networks of small practices as practices of 10 or fewer
                            professionals who share services, purchasing arrangements, and/or patient coverage.
                            34
                              In some of these categories, such as the category of “other settings that predominantly
                            serve medically underserved populations,” ONC required each Regional Extension Center
                            to define the types of professionals they would assist by addressing local concerns, such
                            as professionals in practices with a high percentage of uninsured patients.




                            Page 18                                             GAO-12-481 Electronic Health Records
                                  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.


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

Verification under the Medicare   CMS has developed and begun to implement processes to verify whether
EHR Program                       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. 35



                                  35
                                    According to CMS officials, because a provider’s status may change, CMS has also
                                  implemented processes to recheck whether the provider has met some of the Medicare
                                  EHR program’s eligibility requirements before payments are issued to providers.




                                  Page 19                                          GAO-12-481 Electronic Health Records
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. 36 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. 37 Under CMS’s
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. 38 For an overview of CMS’s processes to verify whether
providers met the Medicare EHR program’s eligibility and reporting
requirements, see table 3.




36
  CMS also plans to verify whether providers have met this requirement on a postpayment
basis by reviewing documentation that supports that providers have the EHR technology
they attested to using.
37
  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.
38
  These officials also explained that, because this is a new program, the agency will
continue to reevaluate and improve its audit process using the best information that is
currently available.




Page 20                                              GAO-12-481 Electronic Health Records
Table 3: CMS’s Processes to Verify Whether Providers Met Medicare EHR Program Eligibility and Reporting Requirements in
2011

                                                                                             Verification through     Verification through
                                                                                                 prepayment       postpayment audit processes
Requirement                                                                                   processes in 2011         planned for 2012
Eligibility requirements
Provider is a permissible provider type.                                                                    √
Professional is not hospital-based.                                                                         √
Provider is not excluded, sanctioned, or otherwise deemed ineligible to                                     √
receive payments from the federal government.
Reporting requirements
                                        a
Provider uses a certified EHR system.                                                                       √                               √
                                                                                                                                            b
Provider demonstrates meaningful use.                                                                                                      √
At least 50 percent of a professional’s patient encounters during the                                                                       √
reporting period occurred at practice(s) or location(s) equipped with certified
EHR technology.
                                              Source: GAO analysis of CMS documents and interviews with CMS officials.

                                              Note: Providers attest to information submitted to CMS regarding the Medicare EHR program’s
                                              eligibility requirements, which specify the types of providers eligible to participate in the program. To
                                              demonstrate that providers met the Medicare EHR program’s reporting requirements, providers must
                                              report information to CMS to demonstrate that they have meaningfully used certified EHR technology.
                                              a
                                               CMS implemented a process to verify, on a prepayment basis, whether providers have met the
                                              requirement to use a certified EHR system. Specifically, CMS built an automatic check to compare
                                              the EHR certification numbers providers reported during attestation against a list of EHR systems
                                              certified by the Office of the National Coordinator for Health Information Technology. CMS also plans
                                              to implement a process to verify this requirement on a postpayment basis by reviewing
                                              documentation that supports that providers have the EHR system they claimed to use.
                                              b
                                               CMS checks, after providers attest, that the information they submitted met the thresholds for the
                                              meaningful use measures, where applicable. However, the agency does not verify the accuracy of the
                                              information submitted until after payments are issued. For example, for the meaningful use measure
                                              that providers record demographic information for 50 percent or more of their patients, CMS checks
                                              that the information providers submitted met that threshold. However, the agency does not verify that
                                              all demographic information for at least 50 percent of the providers’ patients has been populated in
                                              their EHR system until after payments are issued.


                                              According to CMS officials, the agency is also developing processes to
                                              verify the accuracy of the incentive payment amounts made to hospitals
                                              in the first year of the Medicare EHR program. The Medicare EHR
                                              incentive payment amount is calculated based on information from
                                              Medicare cost reports. According to CMS officials, by mid-2012, the
                                              agency plans to audit this information to verify that the information is
                                              accurate. In contrast, CMS is not developing processes to verify the
                                              accuracy of incentive payment amounts made to professionals in the first




                                              Page 21                                                                    GAO-12-481 Electronic Health Records
                                  year of the program because those amounts are based on information
                                  from Medicare Part B claims that it has already audited. 39

Verification under the Medicaid   Three of the states we reviewed—Iowa, Kentucky, and Pennsylvania—
EHR Program                       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. 40 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



                                  39
                                    Medicare Part B covers physician, outpatient hospital, home health care, and certain
                                  other services.
                                  40
                                    These states also reverify, on a postpayment basis, whether providers have met some
                                  eligibility requirements that were checked prepayment. In addition, CMS officials told us
                                  that the agency checks some eligibility information submitted by Medicaid providers. For
                                  example, after a provider registers at the CMS EHR program website, CMS automatically
                                  validates that the provider has not been excluded from participating in federal health care
                                  programs.




                                  Page 22                                              GAO-12-481 Electronic Health Records
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. 41

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. 42 Further, Kentucky takes additional
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.




41
  CMS officials recognize that verifying whether professionals met the patient volume
requirement is challenging for states, and the OIG report also found that states had
difficulty verifying that professionals met this requirement. CMS plans to continue to
provide additional guidance to states on how they can ensure professionals complied with
this requirement.
42
  CMS expects states to check the certification number providers submitted against a list
of such numbers maintained by ONC prior to issuing payments to providers. CMS State
Medicaid Director Letter, Aug. 17, 2010 (SMD# 10-016), Enclosure B. Accessed at
www.cms.gov on April 13, 2011.




Page 23                                             GAO-12-481 Electronic Health Records
Table 4: Four States’ Processes to Verify Whether Providers Met Medicaid EHR Program Eligibility and Reporting
Requirements in 2011

                                  Iowa                            Kentucky                               Pennsylvania                                     Texas
                           Verified   Verified          Verified           Verified                 Verified           Verified               Verified              Verified
                             pre-      post-              pre-              post-                     pre-              post-                   pre-                 post-
                                                                                                                                                                             a
Requirement                payment    payment           payment            payment                  payment            payment                payment              payment
Eligibility requirements
Provider type
                                                                                                                                                                        a
Provider is a                 √                               √                  √                        √                                         √
permissible provider
type.
                                                                                                                                                                        a
Professional is not           √          √                    √                  √                        √                  √                      √
hospital-based.
                                                                                                                                                                        a
Hospital has an                          √                    √                                           √                                         √
average length of stay
of 25 days or less.
                                                                                                                                                                        a
If professional is a                     √                                       √                        √
physician assistant,
s/he works in a
physician assistant-led
federally qualified
health center or rural
health center.
Provider qualifications
                                                                                                                                                                        a
Provider is licensed to       √                               √                                           √                  √                      √
practice in the state.
                                                                                                                                                                        a
Provider is a Medicaid        √                               √                                           √                                         √
provider in the state.
                                                                                                                                                                        a
Provider is not               √                               √                                           √                                         √
excluded, sanctioned,
or otherwise deemed
ineligible to receive
payments from the
state/federal
government.
                                                                                                                                                                        a
Provider meets patient        √          √                    √                  √                        √                  √                      √
                     b
volume requirements.
                          c
Reporting requirement
                                                                                                                                                                        a
Provider has adopted,         √          √                    √                                           √                  √                      √
implemented, or
upgraded to a certified
             d
EHR system.
                                             Source: GAO analysis of State Medicaid Health Plans and other state documents, and interviews with state officials.




                                             Page 24                                                                       GAO-12-481 Electronic Health Records
Note: Providers attest to information submitted to CMS and/or the states regarding the Medicaid EHR
program’s eligibility requirements, which specify the types of providers eligible to participate in the
program. To demonstrate that providers met the Medicaid EHR program’s reporting requirement,
providers must report information to the states to demonstrate that they have adopted, implemented,
or upgraded to certified EHR technology.
a
    As of December 2011, Texas had not finalized its postpayment audit strategy.
b
 Iowa, Kentucky, and Pennsylvania use a combination of pre- and postpayment processes to verify
whether providers have met this requirement. For example, these states use processes to verify
whether certain professionals have met the Medicaid patient volume requirement, on a prepayment
basis, using Medicaid claims data to check the professionals’ number of Medicaid patient visits. Then,
they use processes to verify whether a sample of professionals have met this requirement, on a
postpayment basis, using documentation submitted by providers, such as patient billing reports, to
confirm their total number of patient visits.
c
 During the first year providers participate in the Medicaid EHR program, they need only adopt,
implement, or upgrade to a certified EHR system. In subsequent years, they must meet two other
reporting requirements—demonstrate meaningful use and at least 50 percent of the professional’s
patient encounters during the reporting period occurred at practices or locations equipped with
certified EHR technology.
d
 Iowa, Pennsylvania, and Kentucky use two verification processes to check whether providers have
met the reporting requirement to adopt, implement, or upgrade to a certified EHR system. Consistent
with CMS guidance, these states as well as Texas implemented processes to verify, on a prepayment
basis, whether providers have met this requirement by checking the EHR certification numbers
providers reported during attestation against a list of EHR systems certified by the Office of the
National Coordinator for Health Information Technology. CMS State Medicaid Director Letter,
August 17, 2010 (SMD# 10-016), Enclosure B. Accessed at www.cms.gov on April 13, 2011. These
states also verify whether providers have met this requirement by reviewing documentation that
supports that providers have the EHR system they claimed to have. Kentucky conducts this additional
verification prior to issuing payments to providers, and Iowa and Pennsylvania conduct it after
payments are issued.


The four states we reviewed are also implementing processes to verify
the accuracy of the incentive payment amounts made to hospitals under
the Medicaid EHR program. CMS allows states flexibility in how they
ensure the accuracy of these payments, and, according to CMS officials,
states are implementing different approaches to verify the accuracy of this
information. CMS officials told us that, for example, some states with
Medicaid EHR programs use cost reports to verify the accuracy of
hospital incentive payments and recheck the information using data from
the state’s Medicaid claims database and other sources. In contrast, for
professionals, the amount of incentive payments received 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. Therefore, states do not need to implement
processes to ensure the amount of incentive payments professionals
receive is accurate.




Page 25                                                      GAO-12-481 Electronic Health Records
CMS Has Opportunities to   CMS has taken some steps, consistent with federal internal control
Assess and Improve         standards, to assess how states have implemented the Medicaid EHR
Processes to Verify        program, including their efforts to prevent improper payments by verifying
                           whether providers have met the program’s requirements. 43 According to
Whether Requirements
                           CMS officials, the agency has entered into two contracts to conduct an
Have Been Met              assessment and to identify tools and resources states could use to
                           improve their implementation and oversight of the Medicaid EHR
                           programs. In the case of the Medicare EHR program, CMS officials
                           recognize that because the program is also in the early stages of
                           implementation, it is important to continually assess the extent to which
                           CMS’s audit strategy mitigates the risk of improper payments. These
                           officials told us that the agency intends to evaluate whether its Medicare
                           EHR program audit strategy is effective in reducing the risk of improper
                           payments. However, the agency has not yet determined what this
                           evaluation will entail or established corresponding timelines for initiating
                           this evaluation. 44

                           If completed, this evaluation provides an opportunity for CMS to assess
                           whether or to what extent the agency should revise its verification
                           processes to further mitigate the risk of making improper payments by, for
                           example, implementing additional prepayment processes as appropriate
                           to verify whether providers have met the Medicare EHR program’s
                           reporting requirements. As we have noted in our prior work, it is more
                           effective and efficient to prevent improper payments than to detect and
                           recoup them later. 45 Verifying that providers qualify for incentive
                           payments on a prepayment basis—that is, before disbursing an incentive
                           payment—is one way to prevent improper payments. Furthermore,
                           conducting this evaluation is important because we have designated the




                           43
                            See GAO, Standards for Internal Control in the Federal Government,
                           GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and GAO, Internal Control
                           Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.: August 2001).
                           44
                             CMS officials told us that the agency plans to determine what its evaluation of the
                           Medicare EHR program audit strategy will entail and develop a corresponding timeline for
                           beginning this work after it begins conducting Medicare EHR program postpayment audits.
                           45
                             GAO, Improper Payments: Status of Agencies’ Efforts to Address Improper Payment
                           and Recovery Auditing Requirements, GAO-08-438T (Washington, D.C.: Jan. 31, 2008).




                           Page 26                                            GAO-12-481 Electronic Health Records
Medicare program as being vulnerable to making improper payments. 46
The EHR programs may be at greater risk of improper payments than
other, more established CMS programs because they are new programs
with complex requirements that providers must meet to qualify for
incentive payments.

In addition, CMS has two opportunities to improve the efficiency of
processes to verify whether providers met requirements for the Medicare
and Medicaid EHR programs. Ensuring program efficiency is consistent
with federal internal control standards.

•    First, while CMS took steps to improve the efficiency of postpayment
     audits under the Medicaid EHR program, it has not done so for the
     Medicare EHR program. For example, in the case of the Medicaid
     EHR program, CMS asked states to obtain additional information,
     when they begin collecting meaningful use attestations from providers
     in 2012, in order to ensure that providers satisfied the meaningful use
     reporting requirement to submit electronic data to immunization
     registries or immunization information systems. 47 CMS officials
     explained that collecting this information at the time of attestation
     would increase the amount of information available to the states when
     they conduct postpayment audits. However, while CMS officials
     recognized that the Medicare EHR program could benefit from taking
     steps to collect similar information from Medicare providers, the
     agency has not yet done so.

•    Second, although states were directed by CMS to develop tools to
     collect information reported by providers when they attest that they
     have met the meaningful use requirements, according to a senior
     CMS official, CMS could potentially collect this information for
     Medicaid providers on the states’ behalf. All states with an EHR
     program will have to begin collecting meaningful use attestations in


46
  High-Risk Series: An Update, GAO-11-278 (Washington, D.C.: February 2011). GAO
has designated Medicare as a high-risk program since 1990 recognizing that the size of
the program, its rapid growth, and its complexity continue to present vulnerabilities that
challenge CMS’s ability to safeguard against improper payments. GAO has designated
Medicaid as a high-risk program since 2003 because of concerns about the program’s
size, growth, diversity, and fiscal management.
47
  CMS suggests states ask providers to indicate during attestation (a) the name of the
immunization registry they submitted their information to and (b) if they did so
successfully.




Page 27                                               GAO-12-481 Electronic Health Records
     the second year of their program as the Medicaid reporting
     requirements are increased to be more like Medicare’s. Several states
     have already developed web-based meaningful use attestation tools,
     while other states have not yet done so. Were CMS to collect this
     information on states’ behalf, federal and state cost savings could
     potentially be realized inasmuch as states are reimbursed by CMS for
     90 percent of the costs related to planning for and administering the
     Medicaid EHR program, including the cost of creating their attestation
     tools. 48 Furthermore, CMS currently collects this information on behalf
     of the states for some Medicaid providers, in addition to collecting this
     information for all Medicare providers. 49 If CMS were to offer to collect
     this information from all Medicaid providers on behalf of states, as the
     agency currently does for some Medicaid providers, it could alleviate
     the need for some states—especially those that have not yet
     developed their attestation tools—to have to create similar web-based
     attestation tools, which could potentially yield cost savings at both the
     federal and state levels. Furthermore, even states that have already
     developed these tools to capture meaningful use attestations in 2012
     will need to make changes to their attestation tools in subsequent
     years of the program. Having CMS capture meaningful use
     attestations on the states’ behalf in subsequent years would alleviate
     the need for them to make these changes.




48
  The HITECH Act appropriated $300 million over the course of fiscal years 2009
through 2016 for carrying out the Medicaid EHR program. Pub. L. No. 111-5, § 4201(b),
123 Stat. 494 (2009). The costs associated with carrying out the Medicaid EHR program,
which CMS generally refers to as administrative costs, vary across states. For example, to
develop web-based attestation tools, officials from one state we reviewed reported that the
state will spend more than $1 million whereas officials from another state reported
spending considerably less because they shared costs with other states.
49
  CMS already collects meaningful use attestation information on behalf of the states for
hospitals that are eligible to receive both Medicare and Medicaid EHR incentive payments.
CMS has not reported that this process delayed incentive payments to hospitals.




Page 28                                              GAO-12-481 Electronic Health Records
                           Most providers participating in the first year of the Medicare EHR program
Most Medicare              through December 8, 2011, exercised program flexibility to exempt
Providers Exempted         themselves from reporting on at least one mandatory meaningful use
                           measure. In addition, many providers also reported at least one clinical
Themselves from            quality measure based on few patients.
Reporting Certain
Measures and Many
Reported Others
Based on Few
Patients
Most Providers Exercised   During the first year of the Medicare EHR program through December 8,
Program Flexibility to     2011, most participating providers exercised flexibility allowed under the
Exempt Themselves from     program to claim an exemption from reporting at least one mandatory
                           meaningful use measure. Specifically, 72.4 percent of professionals and
Reporting on Certain       79.6 percent of hospitals claimed such an exemption. 50 Providers may
Mandatory Measures         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.




                           50
                             We analyzed full-year data for hospitals and partial-year data for professionals. For
                           more information on the data we analyzed, including information on providers we included
                           and excluded from our analysis, see app. II.




                           Page 29                                            GAO-12-481 Electronic Health Records
We also found that among specialists, the largest specialty group of
participating professionals, over three-quarters claimed at least one
exemption. (See table 5.)

Table 5: Percentage of Professionals Who Participated in the Medicare EHR
Program That Claimed an Exemption for at Least One Meaningful Use Measure,
through December 8, 2011

                                                                             Number of             Percentage
                                                                           participating      reporting at least
    Professional characteristics                                          professionals         one exemption
    Overall                                                                          23,844                72.4
    Professional specialty
        Dentist                                                                         14                100.0
        Chiropractor                                                                   202                 99.0
        Optometrist                                                                    737                 92.0
        Specialist                                                                   11,046                75.9
        Podiatrist                                                                    1,212                75.5
        Generalist                                                                    9,569                66.2
                                        a
        Other eligible physician                                                       900                 69.0
                        b
    Practice location
        Rural                                                                         2,725                78.1
        Urban                                                                        21,099                71.7
    Amount of 2010 Medicare Part B charges
        ≤ 25th percentile                                                             1,027                83.0
        > 25th percentile, but ≤ 50th percentile                                      3,392                77.9
        > 50th percentile, but ≤ 75th percentile                                      7,867                75.6
        > 75th percentile                                                            11,199                67.5
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Note: This analysis is based on partial-year data for professionals. Specifically, we analyzed data
professionals reported to demonstrate meaningful use for the Medicare EHR program from April
2011, when CMS began collecting these data, through December 8, 2011. To demonstrate
meaningful use for the 2011 program year, professionals could continue to report these data through
February 29, 2012. The sum of the number of professionals listed by professional specialty, practice
location, and amount of 2010 Medicare Part B charges is not equal to the overall number of
professionals due to missing data. Unless otherwise noted, all differences among groups are
significant at the 0.05 level.
a
 “Other eligible physician” 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.
b
 The difference between the percentage reporting at least one exemption for professionals practicing
in urban and rural locations is not statistically significant.




Page 30                                                                  GAO-12-481 Electronic Health Records
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. 51 (See table 6.)




51
 Acute care hospitals refer to hospitals described in Section 1886(d) of the Social
Security Act, which are paid under the inpatient prospective payment system.




Page 31                                              GAO-12-481 Electronic Health Records
Table 6: Percentage of Hospitals That Participated in the Medicare EHR Program
That Claimed an Exemption for at Least One Meaningful Use Measure, 2011

                                                                  Number of    Percentage reporting
    Hospital characteristics                          participating hospitals at least one exemption
    Overall                                                                          803                79.6
    Type of hospital
        Critical access hospital                                                     174                85.1
                                  a
        Acute care hospital                                                          626                78.1
                       b
    Ownership type
        Proprietary                                                                  169                84.6
        Government-owned                                                             189                78.8
        Nonprofit                                                                    442                78.1
    Bed size
        1 to 49 beds                                                                 240                84.2
        50 to 99 beds                                                                128                79.7
        100 to 199 beds                                                              145                82.1
        200 or more beds                                                             287                74.6
                           b
    Hospital location
        Rural                                                                        300                81.0
        Urban                                                                        500                78.8
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Note: The sum of the number of hospitals listed by type of hospital, ownership type, bed size, and
location is not equal to the overall number of hospitals due to missing data. Unless otherwise noted,
all differences among groups are significant at the 0.05 level.
a
 Acute care hospitals refer to hospitals described in Section 1886(d) of the Social Security Act, which
are paid under the inpatient prospective payment system
b
The difference in the percentage of hospitals reporting at least one exemption based on this variable
was not statistically significant.


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).




Page 32                                                                  GAO-12-481 Electronic Health Records
                            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. 52 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. 53 It is unclear what effect, if any, such a
                            change would have on participation levels in future program years.


Many Providers Reported     Our analysis of clinical quality measures found that many providers
Clinical Quality Measures   reported at least one such measure based on few patients—less than
Based on Few Patients       seven—during the first year of the Medicare EHR program through
                            December 8, 2011. 54 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




                            52
                              See CMS, Final Rule, Medicare and Medicaid Programs: Electronic Health Record
                            Incentive Program; 75 Fed. Reg. 44314 (July 28, 2010).
                            53
                              In the preamble to CMS’s Rule on the Electronic Health Record Incentive Program, the
                            agency stated that it allowed 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. See
                            75 Fed. Reg. 44328-44329 (July 28, 2010).
                            54
                              The meaningful use reporting period is 90 days in the first year; providers will be
                            required to report meaningful use for an entire year during subsequent years. Assuming a
                            steady rate of change, 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.




                            Page 33                                              GAO-12-481 Electronic Health Records
Hospital Association and others, could detract from providers’ abilities to
use those measures as meaningful tools for quality improvement. 55

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.)




55
  In other programs, CMS has recognized 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 is thus too small to reliably tell how well the hospital
was performing.




Page 34                                              GAO-12-481 Electronic Health Records
Table 7: Percentage of Professionals Who Participated in the Medicare EHR
Program That Reported at Least One Clinical Quality Measure That Was Calculated
Based on Few Patients, through December 8, 2011

                                                                                             Percentage reporting
                                                                                              at least one clinical
                                                                         Number of                quality measure
                                                                       participating             using fewer than
                                                                                                                  a
    Professional characteristics                                      professionals                seven patients
    Overall                                                                      23,844                       41.3
    Professional specialty
        Dentist                                                                        14                     78.6
        Chiropractor                                                                  202                     79.7
        Optometrist                                                                   737                     87.7
        Specialist                                                               11,046                       52.8
        Podiatrist                                                                   1,212                    52.8
        Generalist                                                                   9,569                    21.2
                                        b
        Other eligible physician                                                      900                     51.7
    Practice location
        Rural                                                                        2,725                    35.7
        Urban                                                                    21,099                       42.0
    Amount of 2010 Medicare Part B charges
        ≤ 25th percentile                                                            1,027                    62.3
        > 25th percentile, but ≤ 50th percentile                                     3,392                    44.3
        > 50th percentile, but ≤ 75th percentile                                     7,867                    35.5
        > 75th percentile                                                        11,199                       42.0
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Note: This analysis is based on partial-year data for professionals. Specifically, we analyzed data
professionals reported to demonstrate meaningful use for the Medicare EHR program from April
2011, when CMS began collecting these data, through December 8, 2011. To demonstrate
meaningful use for the 2011 program year, professionals could continue to report these data through
February 29, 2012. The sum of the number of professionals listed by professional specialty, practice
location, and amount of 2010 Medicare Part B charges is not equal to the overall number of
professionals due to missing data. All differences among groups are significant at the 0.05 level.
a
 For our analysis, we identified clinical quality measures as unreliable if fewer than seven patients
met inclusion criteria for the calculation. 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.
b
 “Other eligible physician” 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.




Page 35                                                                  GAO-12-481 Electronic Health Records
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.)




Page 36                                     GAO-12-481 Electronic Health Records
Table 8: Percentage of Hospitals That Participated in the Medicare EHR Program
That Reported at Least One Clinical Quality Measure That Was Calculated Based on
Few Patients, 2011

                                                                                            Percentage reporting
                                                                                             at least one clinical
                                                                        Number of          quality measure using
                                                                      participating             fewer than seven
                                                                                                                 a
                                                                         hospitals                      patients
    Overall                                                                          803                     86.9
    Type of hospital
        Critical access hospital                                                     174                     99.4
                                  b
        Acute care hospital                                                          626                     83.5
    Ownership type
        Government-owned                                                             189                     95.2
        Proprietary                                                                  169                     89.9
        Nonprofit                                                                    442                     82.4
    Bed size
        1 to 49 beds                                                                 240                      100
        50 to 99 beds                                                                128                     93.0
        100 to 199 beds                                                              145                     85.5
        200 or more beds                                                             287                     74.2
    Hospital location
        Rural                                                                        300                     96.7
        Urban                                                                        500                     81.2
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Note: The sum of the number of hospitals listed by type of hospital, ownership type, bed size, and
location is not equal to the overall number of hospitals due to missing data. All differences among
groups are significant at the 0.05 level.
a
 For our analysis, we identified clinical quality measures as unreliable if fewer than seven patients
met inclusion criteria for the calculation. 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.
b
 Acute care hospitals refer to hospitals described in Section 1886(d) of the Social Security Act, which
are paid under the inpatient prospective payment system.


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


Page 37                                                                  GAO-12-481 Electronic Health Records
                           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.


                           Providers identified challenges to participating in the first year of the
For the First Program      Medicare and Medicaid EHR programs and strategies used to help
Year, Providers            providers participate. Numerous professionals and hospitals have signed
                           agreements with Regional Extension Centers for technical assistance,
Experienced                which includes services to facilitate providers’ participation in the
Challenges and Used        Medicare and Medicaid EHR programs.
Strategies and
Services to Facilitate
Participation

Providers Identified       Acquiring and implementing a certified EHR system are among the first
Challenges and Used        challenges providers face as they take steps to qualify for a Medicare or
Strategies to Facilitate   Medicaid EHR incentive payment. Challenges to acquiring EHR systems
                           described by providers and officials from the American Medical
First Year Participation   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



                           Page 38                                    GAO-12-481 Electronic Health Records
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.




Page 39                                      GAO-12-481 Electronic Health Records
Numerous Providers Have    As of December 2011, about 115,000 professionals and about 1,000
Signed Agreements with     hospitals have signed agreements to receive technical assistance from
Regional Extension         one of the 62 Regional Extension Centers. 56 This assistance includes
                           services to facilitate providers’ participation in the Medicare and Medicaid
Centers for Services to    EHR programs. 57 Of these professionals, 54,241 had implemented an
Facilitate Participation   EHR system, of which 4,072 had demonstrated meaningful use. 58 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.




                           56
                            We analyzed Regional Extension Center program data as of December 19, 2011.
                           57
                             Providers sign technical assistance agreements with the Regional Extension Centers
                           that specify the services that will be provided to them and the terms and amount (if any) of
                           payment the centers will charge for these services.
                           58
                             These data are reported by the Regional Extension Centers to ONC and do not
                           necessarily mean that the provider received an incentive payment from either the
                           Medicare or Medicaid EHR programs.




                           Page 40                                              GAO-12-481 Electronic Health Records
Figure 4: Practice Settings of Professionals with Signed Technical Assistance
Agreements with Regional Extension Centers, through December 19, 2011




Note: The figure shows the distribution of the 115,921 priority primary care professionals that signed
agreements with one of the 62 Regional Extension Centers.
a
 The Office of the National Coordinator for Health Information Technology defines collaborative
networks of small practices as practices of 10 or fewer professionals that share services, purchasing
arrangements, and/or patient coverage.


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




Page 41                                                     GAO-12-481 Electronic Health Records
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. 59 Examples
of the services offered by the Regional Extension Centers during each of
these steps are described in figure 5.




59
  Some services provided by the Regional Extension Centers, such as sharing information
on the Medicare and Medicaid EHR programs, workflow support, and project
management, may be offered to providers during more than one step. In addition, not all
providers need the Regional Extension Centers’ assistance at all steps. For example,
some providers have selected and implemented a certified EHR system before retaining
the services of one of the centers.




Page 42                                           GAO-12-481 Electronic Health Records
Figure 5: Examples of Services Provided by Regional Extension Centers




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. 60 For
example, officials from one Regional Extension Center told us they
helped providers determine whether they would qualify for the Medicare


60
  Regional Extension Center officials generally identified providing information and
guidance on the EHR programs and workflow redesign services as the services that
providers value most highly.




Page 43                                             GAO-12-481 Electronic Health Records
              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.


              The aim of the Medicare and Medicaid EHR programs is not just to
Conclusions   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.




              Page 44                                    GAO-12-481 Electronic Health Records
                      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.


                      In order to improve the efficiency and effectiveness of processes to verify
Recommendations for   whether providers meet program requirements for the Medicare and
Executive Action      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.




                      Page 45                                      GAO-12-481 Electronic Health Records
                     We provided a draft of this report to HHS for comment. In its written
Agency Comments      comments (reproduced in app. V), HHS concurred with three of our
and Our Evaluation   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


                     Page 46                                     GAO-12-481 Electronic Health Records
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.




Page 47                                       GAO-12-481 Electronic Health Records
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.




Linda T. Kohn
Director, Health Care




Page 48                                    GAO-12-481 Electronic Health Records
List of Committees

The Honorable Max Baucus
Chairman
The Honorable Orrin G. Hatch
Ranking Member
Committee on Finance
United States Senate

The Honorable Tom Harkin
Chairman
The Honorable Michael B. Enzi
Ranking Member
Committee on Health, Education, Labor, & Pensions
United States Senate

The Honorable Fred Upton
Chairman
The Honorable Henry A. Waxman
Ranking Member
Committee on Energy and Commerce
House of Representatives

The Honorable Dave Camp
Chairman
The Honorable Sander M. Levin
Ranking Member
Committee on Ways and Means
House of Representatives




Page 49                                 GAO-12-481 Electronic Health Records
Appendix I: Scope and Methodology
             Appendix I: Scope and Methodology




             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. 1 We analyzed data submitted by providers from April
             18, 2011, the date CMS began collecting these data, through December
             8, 2011. 2 As a result, the data we analyzed for hospitals included full-year
             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.

             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



             1
              The National Level Repository is a database that contains information on providers
             pertaining to the Medicare EHR program, including information on providers that
             registered for the incentive program; whether those providers attested to meaningfully
             using an EHR system; and the amount of incentive payments, if applicable. The National
             Level Repository also contains some information on providers pertaining to the Medicaid
             EHR program, which we did not include in our analysis.
             2
              In general, our analysis does not include data providers affiliated with Medicare
             Advantage Organizations reported to demonstrate meaningful use. However, we did
             analyze data reported by professionals who may ultimately qualify for incentive payments
             under the Medicare Advantage EHR program. At the time of our analysis, CMS had not
             yet determined whether the professionals or the Medicare Advantage Organizations would
             receive the incentive payments.




             Page 50                                            GAO-12-481 Electronic Health Records
Appendix I: Scope and Methodology




    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. 3 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


3
 Some clinical quality measures are comprised of more than one submeasure. In these
cases, we analyzed the submeasure for which providers reported the greatest number of
patients in the denominator of the measure.




Page 51                                           GAO-12-481 Electronic Health Records
Appendix I: Scope and Methodology




    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); 4 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); 5 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. 6

•   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




4
 During the course of our work, CMS transitioned from using the Online Survey,
Certification, and Reporting System to using the Certification and Survey Provider
Enhanced Reports System to store certain data on hospital characteristics, and we were
unable to obtain more recent data from the latter in time for our analysis.
5
 Although the Area Resource File is typically released annually, at the time of our
analysis, the 2010-2011 Area Resource File had not yet been made publicly available.
6
 Three hospitals (less than 0.4 percent) are missing from our analysis of hospital
characteristics because we were unable to match the hospitals to records contained in
CMS’s Online Survey, Certification, and Reporting System. CMS later provided
clarification on this issue, which enabled us to match the hospitals to records contained in
the Online Survey, Certification, and Reporting System, though we did not receive this
information in time to include those hospitals in our analysis.




Page 52                                               GAO-12-481 Electronic Health Records
Appendix I: Scope and Methodology




    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. 7 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. 8

•   Professionals’ Medicare Part B charges. We obtained all 2010
    Medicare Part B charges from CMS. 9 For each professional (identified


7
 We classified doctors of medicine and osteopathic medicine that specialize in family
practice, general practice, or internal medicine as generalists; all other doctors of medicine
and osteopathic medicine were classified as specialists.
8
 Of the 900 professionals who were classified as other eligible physicians, 856 had
permissible professional specialties listed in a July 2011 extract from CMS’s Provider
Enrollment, Chain, and Ownership System, which is the system that CMS uses to verify
whether professionals are a permissible provider type. CMS provided documentation to
support that the remaining 44 professionals also had permissible professional specialties.
9
 Medicare Part B charges refer to payments for physician, outpatient hospital, home
health care, and certain other services.




Page 53                                               GAO-12-481 Electronic Health Records
Appendix I: Scope and Methodology




     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. 10 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. 11 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



10
  Percentiles were created using information on 2010 Medicare Part B charges for all
professionals who had greater than $0 in charges.
11
  Practice location zip codes contained in CMS’s National Plan and Provider Enumeration
System are self-reported by professionals to CMS. We did not independently verify that
professionals’ practices were located in the self-reported zip code.




Page 54                                             GAO-12-481 Electronic Health Records
Appendix I: Scope and Methodology




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.




Page 55                                      GAO-12-481 Electronic Health Records
Appendix II: How Medicare and Medicaid
                                               Appendix II: How Medicare and Medicaid EHR
                                               Program Incentive Payments Are Calculated



EHR Program Incentive Payments Are
Calculated

Provider type       EHR program                Incentive payment
                a
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
                                                                                                                   b
                                               $18,000 and the total over a 5-year period cannot exceed $44,000. To earn the
                                               maximum amount, professionals must first demonstrate meaningful use in calendar year
                                               2011 or 2012. Professionals who first demonstrate meaningful use in calendar year 2015
                                               or later will not receive an EHR incentive payment.
                                           c
                    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
                                                                                                                  d
                                               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.
            e
Hospitals           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
                                                                                                                                 f
                                               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.
                                           c
                    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.
                                               Source: GAO analysis of CMS documents.
                                               a
                                                Professionals may not receive incentive payments under both the Medicare and Medicaid programs
                                               during the same year; they must choose in which program to participate. Until 2015, professionals
                                               eligible for both the Medicare and Medicaid EHR programs may switch programs only once after the
                                               first incentive payment is initiated.
                                               b
                                                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.
                                               c
                                                   Medicaid providers can only receive incentive payments from one state in the same payment year.
                                               d
                                                Pediatricians with at least 20 percent Medicaid patient volume, but less than 30 percent Medicaid
                                               patient volume only qualify to receive $14,167 in the first year, $5,667 in subsequent years, and the
                                               total amount over a 6-year period cannot exceed $42,500.
                                               e
                                               Hospitals may qualify to receive incentive payments under the Medicare EHR program and the
                                               Medicaid EHR program during the same year.
                                               f
                                               Acute care hospitals refer to hospitals described in Section 1886(d) of the Social Security Act, which
                                               are paid under the inpatient prospective payment system.




                                               Page 56                                                     GAO-12-481 Electronic Health Records
Appendix III: Meaningful Use and Clinical
              Appendix III: Meaningful Use and Clinical
              Quality Measures for the Medicare EHR
              Program, 2011


Quality Measures for the Medicare EHR
Program, 2011
              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. 1 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. 2 Table 9 below provides
              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.




              1
               To receive incentive payments during the first year of the Medicare EHR program,
              providers must collect data related to the meaningful use measures in any 90 consecutive
              days during that first payment year and report those data to CMS. To receive incentive
              payments in subsequent years, providers must collect data related to the meaningful use
              measures over a full year and report that data to CMS.
              2
               According to CMS, clinical quality measures help quantify health care processes,
              outcomes, patient perceptions, and organizational structure.




              Page 57                                             GAO-12-481 Electronic Health Records
                                            Appendix III: Meaningful Use and Clinical
                                            Quality Measures for the Medicare EHR
                                            Program, 2011




Table 9: Number of Measures Providers Must Report or Claim Allowed Exemptions from Reporting for the Medicare EHR
Program, 2011

Type of measure                                                                              Professionals                              Hospitals
Meaningful use measures
              a
    Mandatory                                                                                            15                                 14
                                                                                                          b                                  b
                                                                                     (6 allowed exemptions )            (3 allowed exemptions )
    Menu                                                                          5 from a menu of 10                      5 from a menu of 10
                                                                                                    b                                        b
                                                                      (8 on menu allowed exemptions )          (4 on menu allowed exemptions )
Total meaningful use measures that providers must                                                        20                                      19
report if no exemptions claimed
Clinical quality measures
                                                      c
    Core measures and/or alternate core measures                                                      3 to 6                                     15
    Menu                                                                                3 from a menu of 38                                    N/A
    Total clinical quality measures that must be reported                                             6 to 9                                     15
                                            Source: GAO analysis of CMS documents.
                                            a
                                             One of the mandatory meaningful use measures requires professionals and hospitals to report
                                            clinical quality measures.
                                            b
                                             Professionals and hospitals may report to CMS that certain measures are not relevant to them; this
                                            is referred to as claiming an exemption.
                                            c
                                             Professionals report all three core clinical quality measures, even if none of their patients could be
                                            included in the calculation of the measures. However, for any core clinical quality measure for which
                                            zero patients could be included in the calculation, professionals must pick a replacement from the
                                            alternate core measures.




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                                                 Appendix III: Meaningful Use and Clinical
                                                 Quality Measures for the Medicare EHR
                                                 Program, 2011




Table 10: Meaningful Use Measures for Professionals and Hospitals in the Medicare EHR Program, 2011

                                                                                             Professionals               Hospitals
                                                                                                              a                         a
Meaningful use measure                                                                   Mandatory     Menu         Mandatory    Menu
                                                                                              b
Use computerized provider order entry for medication orders: At least one                    X                          X
medication order entered using computerized provider order entry for more than
30 percent of patients with at least one medication in their medication lists
Implement drug-drug and drug-allergy interaction checks: Enable the EHR                      X                          X
system’s ability to check for these interactions
Maintain an up-to-date problem list of current and active diagnoses: Record list             X                          X
of current and active diagnoses or indicate no known problems for more than
80 percent of patients
                                                                                              b
Generate and transmit permissible prescriptions electronically: Generate and                 X
transmit more than 40 percent of permissible prescriptions electronically
Maintain active medication list: Record at least one entry or indicate no current            X                          X
prescriptions for more than 80 percent of patients
Maintain active medication allergy list: Record at least one entry or indicate no            X                          X
known medication allergies for more than 80 percent of patients
Record demographics: Record preferred language, gender, race, ethnicity, and                 X                          X
date of birth for more than 50 percent of patients; hospitals must also record
date and preliminary cause of death in the event of mortality
                                                                                              b
Record and chart changes in vital signs: Record height, weight, and blood                    X                          X
pressure for more than 50 percent of patients age 2 and older; calculate and
display body mass index and plot and display growth charts for children age 2
though 20
                                                                                              b                          b
Record smoking status for patients 13 years old or older: Record smoking status              X                          X
for more than 50 percent of patients age 13 and older
                                            c
Report clinical quality measures to CMS                                                      X                          X
Implement one clinical decision support rule: Implement one clinical decision                X                          X
support rule related to specialty or high clinical priority along with the ability to
track compliance with that rule
                                                                                              b                          b
Provide patients with an electronic copy of their health information: Provide                X                          X
information (for professionals and hospitals, provide diagnostic test results,
problem list, medication lists, and medication allergies, and for hospitals also
provide discharge summary and procedures) within 3 business days to more
than 50 percent of patients who requested that information
                                                                                              b                          b
For professionals, provide patients with clinical summaries for each office visit            X                          X
within 3 business days; for hospitals, provide patients with electronic copy of
discharge instructions at the time of discharge, upon request: For professionals,
provide information for more than 50 percent of visits; for hospitals, provide
information for more than 50 percent of patients who requested that information
Exchange key clinical information electronically: Perform at least one test of               X                          X
EHR technology’s capacity to exchange key clinical information
Protect electronic health information created or maintained by the certified EHR             X                          X
technology: Conduct or review a security risk analysis, implement security
updates as necessary, and correct identified security deficiencies




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                                              Appendix III: Meaningful Use and Clinical
                                              Quality Measures for the Medicare EHR
                                              Program, 2011




                                                                                               Professionals                      Hospitals
                                                                                                                     a                                a
Meaningful use measure                                                                    Mandatory          Menu           Mandatory          Menu
                                                                                                                 b
Implement drug formulary checks: Enable this functionality and maintain access                                 X                                X
to at least one internal or external formulary
                                                                                                                 b
Incorporate clinical lab-test results into EHR as structured data: Incorporate into                            X                                X
the EHR technology more than 40 percent of the clinical lab test results ordered
whose results are positive, negative, or in numerical format
Generate patient lists by specific conditions: Generate at least one report listing                             X                               X
patients with a specific condition to use for quality improvement, reduction of
disparities, research, or outreach
                                                                                                                 b
Send patient reminders per patient preference for preventive or follow-up care:                                X
Send appropriate reminders to more than 20 percent of patients age 65 and
older or age 5 and younger
                                                                                                                 b
Provide patients with timely electronic access to their health information: Provide                            X
electronic access to health information (including lab results, problem list,
medication lists, and allergies) to at least 10 percent of patients within
4 business days
Use certified EHR technology to identify patient-specific education resources                                   X                               X
and provide those resources to the patient if appropriate: Provide to more than
10 percent of patients
                                                                                                                 b
Perform medication reconciliation for patients received from another setting of                                X                                X
care or provider of care: Perform for more than 50 percent of transitions of care
                                                                                                                 b
Provide summary care record for each transition of care or referral care: Provide                              X                                X
for more than 50 percent of transitions of care and referrals
                                                                                                                 b                               b
Submit electronic data to immunization registries or immunization information                                  X                                X
systems: Perform at least one test of EHR technology’s capacity to submit
electronic data to immunization registries and follow up submission if the test is
successful
                                                                                                                 b                               b
Submit electronic syndromic surveillance data to public health agencies: Perform                               X                                X
at least one test of EHR technology’s capacity to submit electronic syndromic
surveillance data to public health agencies
                                                                                                                                                 b
Submit electronic data on reportable lab results to public health agencies:                                                                     X
Perform at least one test of EHR technology’s capacity to submit electronic
reportable (as required by state or local law) lab results to public health agencies
and follow up submission if the test is successful
                                                                                                                                                 b
Record advance directives for patients 65 years or older: Record indication of                                                                  X
advance directive status for more than 50 percent of all unique patients age 65
and older
Total measures                                                                                 15              10                14             10
    Measures with exemptions                                                                    6               8                3              4
                                              Source: GAO analysis of CMS documents.
                                              a
                                               Menu clinical quality measures refer to the set of 10 clinical quality measures from which CMS allows
                                              providers the flexibility to select 5 measures to report.
                                              b
                                              Providers may claim exemptions from reporting the measure if, according to the providers, the
                                              measure is not relevant to their patient populations or clinical practices.
                                              c
                                               Professionals generally must report on 6 clinical quality measures from a list of 44 measures
                                              identified by CMS. Hospitals must report on 15 clinical quality measures.




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                                             Appendix III: Meaningful Use and Clinical
                                             Quality Measures for the Medicare EHR
                                             Program, 2011




Table 11: Clinical Quality Measures for Professionals in the Medicare EHR Program, 2011

                                                                                                                National Quality Forum
                                                                                                                                      a
Clinical quality measure                                                                                             measure number
Core measures (3)
Blood pressure measurement for hypertension patients: Percent of visits for patients ages 18 years and                            0013
older with hypertension who have been seen for at least two office visits and have had blood pressure
recorded
Tobacco use assessment and cessation intervention: Percent of patients ages 18 years and older who                                0028
have been seen for at least 2 office visits who were queried about tobacco use and, if applicable, received
a cessation intervention
Adult weight screening and follow-up: Percent of patients ages 18 years and older with a body mass index                          0421
documented within the past 6 months and, if the most recent body mass index is outside parameters, a
follow-up plan is documented
Alternate core measures (3)
Weight assessment and counseling for children and adolescents: Percent of patients ages 2-17 years who                            0024
had an outpatient visit with a primary care physician or obstetrician/gynecologist who had a body mass
index documented and received counseling for nutrition and physical activity
Influenza immunization for patients ages 50 years and older: Percent of patients ages 50 years and older                          0041
who received an influenza immunization during the flu season
Childhood immunization status: Percent of children aged 2 years who had recommended childhood                                     0038
immunizations by their second birthday
Menu measures (38)
Hemoglobin A1c poor control for diabetics: Percent of patients ages 18-75 years with diabetes who had                             0059
hemoglobin A1c > 9 percent
Cholesterol management and control for diabetics: Percent of patients ages 18-75 years with diabetes who                          0064
had low density lipoprotein cholesterol < 100 mg/dL
Blood pressure management for diabetics: Percent of patients ages 18-75 years with diabetes who had                               0061
blood pressure <140/90 mmHg
Treatment for heart failure: Percent of patients ages 18 years and older with heart failure and left                              0081
ventricular systolic dysfunction who were prescribed an angiotensin-converting enzyme inhibitor or
angiotensin receptor blocker
Beta-blocker therapy for coronary artery disease patients: Percent of patients ages 18 years and older with                       0070
a diagnosis of coronary artery disease and a prior myocardial infarction who were prescribed beta-blocker
therapy
Pneumonia vaccination for older adults: Percent of patients ages 65 years and older who have received a                           0043
pneumococcal vaccine
Breast cancer screening: Percent of women ages 40-69 years who had a mammogram to screen for breast                               0031
cancer
Colorectol cancer screening: Percent of adults ages 50-75 who had appropriate screening for colorectol                            0034
cancer
Oral antiplatelet therapy for patients with coronary artery disease: Percent of patients ages 18 years and                        0067
older with coronary artery disease who were prescribed oral antiplatelet therapy
Beta-blocker therapy for heart failure patients: Percent of patients ages 18 years and older with a diagnosis                     0083
of heart failure and left ventricular systolic dysfunction who were prescribed beta-blocker therapy




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                                               Quality Measures for the Medicare EHR
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                                                                                                                    National Quality Forum
                                                                                                                                          a
Clinical quality measure                                                                                                 measure number
Antidepressant medication management: Percent of patients ages 18 years and older who were diagnosed                                  0105
with a new episode of major depression, were treated with antidepressant medication, and remained on
antidepressant medication
Optic nerve evaluation for glaucoma patients: Percent of patients ages 18 years and older with primary                                0086
open angle glaucoma who have been seen for at least two office visits and have had an optic nerve
evaluation
Diabetic retinopathy assessment: Percent of patients ages 18 years and older with diabetic retinopathy                                0088
who had a dilated macular or fundus examination that included documentation of the level of severity of
retinopathy and the presence or absence of macular edema
Diabetic retinopathy communication: Percent of patients ages 18 years and older with diabetic retinopathy                             0089
for whom the results of a dilated macular or fundus examination was communicated to the physician
responsible for managing ongoing care
Asthma pharmacologic therapy: Percent of patients ages 5-40 years with persistent asthma who were                                     0047
prescribed a preferred medication or acceptable alternative treatment
Asthma assessment: Percent of patients ages 5-40 years with asthma who have been seen for at least two                                0001
office visits and received an asthma symptom assessment
Appropriate testing for children with pharyngitis: Percent of children ages 2-18 years with pharyngitis who                           0002
were dispensed an antibiotic and received a group A streptococcus test
Hormonal therapy for breast cancer: Percent of female patients ages 18 years and older with stage IC - IIIC                           0387
estrogen receptor/progesterone receptor positive breast cancer who were prescribed tamoxifen or
aromatase inhibitor
Chemotherapy for stage III colon cancer patients: Percent of patients ages 18 years and older with                                    0385
Stage III colon cancer who are referred for, prescribed, or have previously received adjuvant chemotherapy
Avoidance of overuse of bone scan for staging low-risk prostate cancer: Percent of patients with low-risk                             0389
prostate cancer who were treated and did not have a bone scan performed since being diagnosed with
prostate cancer
Smoking and tobacco use cessation assistance: Percent of patients ages 18 years and older who smoked                                  0027
or used tobacco, were seen by a professional, and received advice to quit smoking or using tobacco or
discussed cessation medications, methods, or strategies
Eye exam for diabetics: Percent of patients ages 18-75 years with diabetes who had a retinal or dilated eye                           0055
exam or a negative retinal exam by an eye care professional
Urine screening for diabetics: Percent of patients ages 18-75 years with diabetes who had a nephropathy                               0062
screening test or evidence of nephropathy
Foot exam for diabetics: Percent of patients ages 18-75 years with diabetes who had a foot exam                                       0056
Cholesterol-lowering therapy for coronary artery disease patients: Percent of patients ages 18 years and                              0074
older with coronary artery disease who were prescribed a lipid-lowering therapy
Warfarin therapy for heart failure patients with atrial fibrillation: Percent of patients ages 18 years and older                     0084
with heart failure and atrial fibrillation who were prescribed warfarin therapy
Blood pressure management for patients with ischemic vascular disease: Percent of patients ages 18                                    0073
years and older who had an acute myocardial infarction, coronary artery bypass graft, or percutaneous
transluminal coronary angioplasty, or had a diagnosis of ischemic vascular disease and whose blood
pressure was in control




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                                            Appendix III: Meaningful Use and Clinical
                                            Quality Measures for the Medicare EHR
                                            Program, 2011




                                                                                                                        National Quality Forum
                                                                                                                                              a
Clinical quality measure                                                                                                     measure number
Use of an antithrombic for ischemic vascular disease patients: Percent of patients ages 18 years and older                                     0068
who had an acute myocardial infarction, coronary artery bypass graft, or percutaneous transluminal
coronary angioplasty, or had a diagnosis of ischemic vascular disease and who had documentation of use
of aspirin or another antithrombotic
Initiation and engagement of alcohol and other drug dependence treatment: Percent of adolescent and                                            0004
adult patients with a new episode of alcohol and other drug dependence who initiate treatment within 14
days of the diagnosis and had two or more additional alcohol and other drug services within 30 days of the
initiation visit
Prenatal screening for Human Immunodeficiency Virus: Percent of patients who gave birth who were                                               0012
screened for human immunodeficiency virus during the first or second prenatal care visit
Prenatal anti-D immune globulin: Percent of D (Rh) negative, unsensitized patients who gave birth and                                          0014
received anti-D immune globulin at 26-30 weeks gestation
High blood pressure control: Percent of patients ages 18-85 years with hypertension and whose blood                                            0018
pressure was adequately controlled
Cervical cancer screening: Percent of women ages 21-64 years who received one or more Pap tests to                                             0032
screen for cervical cancer
Chlamydia screening for women: Percent of women ages 15-24 years who were identified as sexually                                               0033
active who had at least one test for chlamydia
Use of appropriate medications for asthma: Percent of patients ages 5-50 years with persistent asthma and                                      0036
were appropriately prescribed medication
Use of imaging studies for low back pain: Percent of patients with low back pain who did not have an                                           0052
imaging study within 28 days of diagnosis
Lipid panel and cholesterol control for ischemic vascular disease patients: Percent of patients ages 18                                        0075
years and older who had an acute myocardial infarction, coronary bypass, or coronary angioplasty, or had
a diagnosis of ischemic vascular disease who had a complete lipid profile performed and whose low
density lipoprotein cholesterol < 100 mg/dL
Hemoglobin A1c control for diabetics: Percent of patients ages 18-75 years with diabetes who had                                               0575
hemoglobin A1c < 8 percent
                                            Source: GAO analysis of CMS documents.

                                            Note: To demonstrate meaningful use, professionals must report on all 3 core clinical quality
                                            measures and select an additional 3 measures from a menu of 38 measures to report. Professionals
                                            must report all 3 core clinical quality measures, even if none of their patients could be included in the
                                            calculation of the measures. However, for any core clinical quality measure for which zero patients
                                            could be included in the calculation, professionals must pick a replacement from the alternate core
                                            measures. As a result, professionals could report up to 6 core and alternate core clinical quality
                                            measures if zero patients could be included in the calculation of all 3 core measures. For additional
                                            information about these measures, see 75 Fed. Reg. 44314 (July 28, 2010).
                                            a
                                             The measure number refers to a number that can be used to search for and review additional
                                            information regarding the quality measure on the National Quality Forum’s website. See
                                            http://www.qualityforum.org/Measures_List.aspx. The National Quality Forum is a nonprofit member
                                            organization that fosters agreement on national standards for measuring and public reporting of
                                            health care performance data.




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                                             Appendix III: Meaningful Use and Clinical
                                             Quality Measures for the Medicare EHR
                                             Program, 2011




Table 12: Clinical Quality Measures for Hospitals in the Medicare EHR Program, 2011

                                                                                                                    National Quality Forum
                                                                                                                                          a
Clinical quality measure                                                                                                 measure number
Emergency Department Throughput – 1: Median time from emergency department arrival to time of                                            0495
departure from the emergency room for patients admitted to the facility from the emergency department
Emergency Department Throughput – 2: Median time from admit decision time to time of departure                                           0497
from the emergency department of emergency department patients admitted to inpatient status
Stroke patients discharged on anti-thrombotics: Percent of ischemic stroke patients prescribed                                           0435
antithrombotic therapy at hospital discharge
Stroke patients discharged on anticoagulants: Percent of ischemic stroke patients with atrial                                            0436
fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge
Stroke patients that received thrombolytic therapy within 2 hours: Percent of acute ischemic stroke                                      0437
patients who arrived at the hospital within 2 hours of symptom onset and received thrombolytic therapy
within 3 hours of symptom onset
Stroke patients that received antithrombotic therapy within 2 days: Percent of acute ischemic stroke                                     0438
patients administered antithrombotic therapy by the end of hospital day 2
Stroke patients discharged on statins: Percent of ischemic stroke patients with elevated low-density                                     0439
lipoprotein cholesterol, for whom cholesterol was not measured, or who were prescribed lipid-lowering
medications prior to hospital admission that were prescribed a statin medication at hospital discharge
Stroke patients that received stroke education: Percent of ischemic or hemorrhagic stroke patients or                                    0440
their caregivers who were given educational materials that address specific topics during the hospital
stay
Stroke patients that received a rehabilitation assessment: Percent of ischemic or hemorrhagic stroke                                     0441
patients who were assessed for rehabilitation services
Venous thromboembolism prophylaxis within 24 hours: Percent of patients who received venous                                              0371
thromboembolism prophylaxis or have documentation of why no such prophylaxis was given the day of
or the day after hospital admission or surgery
Venous thromboembolism prophylaxis in intensive care units: Percent of patients who received venous                                      0372
thromboembolism prophylaxis or have documentation of why no such prophylaxis was given the day of
or the day after admission to the intensive care unit or surgery
Anticoagulation overlap therapy: Percent of patients with venous thromboembolism who received an                                         0373
overlap of parenteral anticoagulation and warfarin therapy
Platelet monitoring for patients on heparin: Percent of patients with venous thromboembolism who                                         0374
received intravenous unfractionated heparin therapy and had their platelet counts monitored
Venous thromboembolism discharge instructions: Percent of patients with venous thromboembolism                                           0375
who are discharged to selected settings with written discharge instructions that address four criteria
Potentially preventable venous thromboembolism: Percent of patients with venous thromboembolism                                          0376
during hospitalization who did not receive venous thromboembolism prophylaxis between hospital
admission and the day before the embolism diagnostic testing was ordered
                                             Source: GAO analysis of CMS documents.

                                             Note: For additional information about these measures, see 75 Fed. Reg. 44314 (July 28, 2010).
                                             a
                                              The measure number refers to a number that can be used to search for and review additional
                                             information regarding the quality measure on the National Quality Forum’s website. See
                                             http://www.qualityforum.org/Measures_List.aspx. The National Quality Forum is a nonprofit member
                                             organization that fosters agreement on national standards for measuring and public reporting of
                                             health care performance data.




                                             Page 64                                                  GAO-12-481 Electronic Health Records
Appendix IV: Regional Extension Center
              Appendix IV: Regional Extension Center
              Program, Goals, and Progress in Helping
              Providers Demonstrate Meaningful Use


Program, Goals, and Progress in Helping
Providers Demonstrate Meaningful Use
              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. 1

              •   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. 2

              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.




              1
               The technical assistance agreement specifies the services the Regional Extension
              Center will provide and the terms and amount (if any) of payment the center will charge for
              these services.
              2
               This milestone is documented even if the professional or hospital is not eligible to receive
              incentive payments under the Medicare or Medicaid EHR programs.




              Page 65                                               GAO-12-481 Electronic Health Records
                                           Appendix IV: Regional Extension Center
                                           Program, Goals, and Progress in Helping
                                           Providers Demonstrate Meaningful Use




Table 13: Goals and Number of Professionals Assisted in Progressing Towards Demonstrating Meaningful Use, by Regional
Extension Center, through December 19, 2011

                                                                                 Number of professionals (percent of the goal)
                                                                                      Signed an
                                                                                     agreement
                                                             Goal number of               with a
                                                              professionals            Regional
                                                                targeted for          Extension    Implemented      Demonstrated
Location    Regional Extension Center name                       assistance              Center         an EHR     meaningful use
AK          Alaska eHealth Network                                      1,000           338 (34)        184 (18)             30 (3)
AL          The Alabama Regional Extension Center                       1,304         1,213 (93)        684 (53)             58 (4)
AR          Arkansas Foundation for Medical Care                        1,280           949 (74)        515 (40)             23 (2)
AZ          Arizona Regional Extension Center                           1,958         1,755 (90)        590 (30)             48 (3)
CA          California Health Information Partnership                   3,403           719 (72)        333 (33)              0 (0)
            Services Organization North
CA          California Health Information Partnership                   2,784        3,777 (111)      1,311 (39)             35 (1)
            Services Organization South
CA          CalOPTIMA Regional Extension Center                         1,000         2,766 (99)        747 (27)             40 (1)
CA          Health Information Technology Extension                     3,000         2,575 (86)      1,038 (35)             27 (1)
            Center for Los Angeles
CO          Colorado Regional Health Information                        2,295        2,435 (106)      1,548 (68)          226 (10)
            Organization
CT          eHealthConnecticut Regional Extension                       1,308         1,131 (87)        498 (38)             33 (3)
            Center
DC          District of Columbia Regional Extension                     1,000           884 (88)        593 (59)              6 (1)
            Center
DE          Quality Insights of Delaware, Inc.                          1,000        1,133 (113)        870 (87)          130 (13)
FL          Center for the Advancement of Health                        2,026         1,353 (67)        594 (29)             19 (1)
            Information Technology
FL          Central Florida Health Information Technology               1,363         1,209 (89)        456 (34)             41 (3)
            Initiative
FL          PaperFree Florida Collaborative Health                      1,000        1,019 (102)        477 (48)             13 (1)
            Information Technology Regional Extension
            Center
FL          South Florida Regional Extension Center                     2,500         2,221 (89)        525 (21)             10 (0)
GA          Georgia Health Information Technology                       5,200         4,099 (79)      2,433 (47)             83 (2)
            Regional Extension Center
HI          Hawaii Health Information Exchange                          1,000           295 (30)        101 (10)              1 (0)
IA          Telligen                                                    1,200        1,225 (102)        438 (37)             16 (1)
IL          Chicago Health Information Technology                       1,486         1,449 (98)        447 (30)             18 (1)
            Regional Extension Center
IL          Illinois Health Information Technology                      1,300        1,384 (107)        690 (53)             38 (3)
            Regional Extension Center



                                           Page 66                                             GAO-12-481 Electronic Health Records
                                          Appendix IV: Regional Extension Center
                                          Program, Goals, and Progress in Helping
                                          Providers Demonstrate Meaningful Use




                                                                                Number of professionals (percent of the goal)
                                                                                     Signed an
                                                                                    agreement
                                                            Goal number of               with a
                                                             professionals            Regional
                                                               targeted for          Extension    Implemented      Demonstrated
Location    Regional Extension Center name                      assistance              Center         an EHR     meaningful use
IN          Indiana Health Information Technology                      2,200         2,125 (97)      1,226 (56)             61 (3)
            Extension Center
KS          Kansas Foundation for Medical Care                         1,200        1,266 (106)        634 (53)             92 (8)
KY          Kentucky Regional Extension Center                         1,000        1,048 (105)        302 (30)              1 (0)
LA          Louisiana Health Care Quality Forum                        1,042        1,091 (105)        231 (22)              8 (1)
MA          Massachusetts eHealth Institute                            2,487        2,607 (105)      1,572 (63)            142 (6)
MD          Chesapeake Regional Information System for                 1,000        1,408 (141)        461 (46)             16 (2)
            our Patients
ME          HealthInfoNet                                              1,000        1,036 (104)        357 (36)             10 (1)
MI          Michigan Center for Effective Information                  3,724        3,781 (102)      1,405 (38)            106 (3)
            Technology Adoption
MN & ND     Regional Extension Assistance Center for                   3,600        4,352 (121)      2,202 (61)             76 (2)
            Health Information Technology
MO          Missouri Health Information Technology                     1,167        1,473 (126)        664 (57)             69 (6)
            Assistance Center
MS          Mississippi Regional Extension Center                      1,000        1,167 (117)        736 (74)             26 (3)
MT & WY     Health Technology Services Regional                        1,000           880 (88)        322 (32)              0 (0)
            Extension Center
NC          North Carolina Regional Extension Center                   3,465         3,145 (91)      1,628 (47)             88 (3)
NE          Wide River Technology Extension Center                     1,129           967 (86)        340 (30)             31 (3)
NH          Regional Extension Center of New Hampshire                 1,000        1,108 (111)        800 (80)          107 (11)
NJ          New Jersey Health Information Technology                   5,000        5,271 (105)      2,417 (48)            263 (5)
            Extension Center
NM          New Mexico Health Information Technology                   1,035           970 (94)        498 (48)             14 (1)
            Regional Extension Center
NV & UT     HealthInsight                                              1,463        1,596 (109)        866 (59)             98 (7)
NY          New York eHealth Collaborative                             5,107         3,624 (80)      1,864 (41)             49 (1)
NY          New York City Regional Electronic Adoption                 4,543        5,113 (100)      2,689 (53)            277 (5)
            Center for Health
OH, IN, &   Greater Cincinnati Health Bridge Inc.                      1,739        1,857 (107)      1,014 (58)            118 (7)
KY
OH          Ohio Health Information Partnership                        6,000        6,129 (102)      2,745 (46)            248 (4)
OK          Oklahoma Foundation for Medical Quality                    1,000        1,089 (109)        544 (54)             39 (4)
OR          Oregon Health Information Technology                       2,674        2,719 (102)      1,577 (59)            118 (4)
            Regional Extension Center




                                          Page 67                                             GAO-12-481 Electronic Health Records
                                                Appendix IV: Regional Extension Center
                                                Program, Goals, and Progress in Helping
                                                Providers Demonstrate Meaningful Use




                                                                                                         Number of professionals (percent of the goal)
                                                                                                              Signed an
                                                                                                             agreement
                                                                           Goal number of                         with a
                                                                            professionals                      Regional
                                                                              targeted for                    Extension             Implemented         Demonstrated
Location       Regional Extension Center name                                  assistance                        Center                  an EHR        meaningful use
PA             Pennsylvania Regional Extension &                                           5,700               2,901 (51)                 1,339 (24)          300 (5)
               Assistance Center for Health Information
               Technology East
PA             Pennsylvania Regional Extension &                                           3,000               2,106 (70)                   990 (33)          111 (4)
               Assistance Center for HIT West
PR             Ponce Medical School Foundation, Inc.                                       4,038               3,211 (80)                   425 (11)             2 (0)
RI             Rhode Island Quality Institute                                              1,000                 904 (90)                   528 (53)            84 (8)
SC             South Carolina Regional Extension Center                                    1,000             1,133 (113)                    628 (63)            17 (2)
SD             HealthPOINT                                                                 1,070                 690 (65)                   105 (10)             1 (0)
TN             Tennessee Regional Extension Center                                         1,343             1,474 (110)                  1,179 (88)            44 (3)
Tribal lands   National Indian Health Board                                                2,925                 843 (84)                   405 (41)            24 (2)
TX             CentrEast                                                                   1,000               1,131 (40)                   307 (11)            22 (1)
TX             Gulf Coast Regional Extension Center                                        2,855                 952 (64)                   444 (30)            86 (6)
TX             North Texas Regional Extension Center                                       1,498                 729 (64)                   201 (18)             0 (0)
TX             West Texas Health Information Technology                                    1,133               1,875 (64)                   548 (19)             0 (0)
               Regional Extension Center
VA             Virginia Health Information Technology                                      2,285             2,320 (102)                  1,432 (63)          196 (9)
               Regional Extension Center
VT             Vermont Information Technology Leaders,                                        845                828 (98)                   553 (65)            17 (2)
               Inc.
WA & ID        Washington & Idaho Regional Extension                                       2,369             2,391 (101)                  1,592 (67)            72 (3)
               Center
WI             Wisconsin Health Information Technology                                     1,625             1,695 (104)                    940 (58)            70 (4)
               Extension Center
WV             West Virginia Health Information Technology                                 1,000                 987 (99)                   459 (46)            74 (7)
               Regional Extension Center
                                                Source: GAO analysis of Office of the National Coordinator for Health Information Technology data.

                                                Notes: Professionals who have signed an agreement with a Regional Extension Center to receive
                                                technical assistance include those who have implemented an EHR and demonstrated meaningful
                                                use, and professionals who have implemented an EHR include those who have demonstrated
                                                meaningful use. The data on the number of professionals at each milestone are reported by Regional
                                                Extension Centers to the Office of the National Coordinator for Health Information Technology and as
                                                a result do not necessarily mean that these providers received an incentive payment from either the
                                                Medicare or Medicaid EHR programs.




                                                Page 68                                                                       GAO-12-481 Electronic Health Records
                                          Appendix IV: Regional Extension Center
                                          Program, Goals, and Progress in Helping
                                          Providers Demonstrate Meaningful Use




Table 14: Goals and Number of Hospitals Assisted in Progressing Towards Demonstrating Meaningful Use, by Regional
Extension Center, through December 19, 2011

                                                                                    Number of hospitals (percent of the goal)
                                                                                Signed an
                                                               Goal number agreement with
                                                                of hospitals   a Regional
                                                                targeted for    Extension          Implemented     Demonstrated
Location    Regional Extension Center name                       assistance        Center               an EHR    meaningful use
AK          Alaska eHealth Network                                        14              4 (29)         2 (14)              0 (0)
AL          The Alabama Regional Extension Center                         36               0 (0)          0 (0)              0 (0)
AR          Arkansas Foundation for Medical Care                          35              9 (26)          2 (6)              2 (6)
AZ          Arizona Regional Extension Center                             20               1 (5)          0 (0)              0 (0)
CA          California Health Information Partnership                     28            23 (82)          5 (18)              0 (0)
            Services Organization North
CA          California Health Information Partnership                     15              7 (47)         5 (33)              0 (0)
            Services Organization South
CO          Colorado Regional Health Information                          38            33 (87)         12 (32)              2 (5)
            Organization
FL          Center for the Advancement of Health Information              14              4 (29)          0 (0)              0 (0)
            Technology
FL          South Florida Regional Extension Center                        3               0 (0)          0 (0)              0 (0)
GA          Georgia Health Information Technology Regional                56            34 (61)           1 (2)              1 (2)
            Extension Center
HI          Hawaii Health Information Exchange                            12              8 (67)          0 (0)              0 (0)
IA          Telligen                                                      87            63 (72)         12 (14)              5 (6)
IL          Illinois Health Information Technology Regional               60            36 (60)         15 (25)              0 (0)
            Extension Center
IN          Indiana Health Information Technology Extension               32            30 (94)         14 (44)              0 (0)
            Center
KS          Kansas Foundation for Medical Care                            95           95 (100)         24 (25)             9 (10)
KY          Kentucky Regional Extension Center                            30            22 (73)          4 (13)              2 (7)
LA          Louisiana Health Care Quality Forum                           64            20 (31)           2 (3)              2 (3)
MA          Massachusetts eHealth Institute                               11              2 (18)          0 (0)              0 (0)
ME          HealthInfoNet                                                 22            19 (86)          6 (27)              0 (0)
MI          Michigan Center for Effective Information                     36            24 (67)          9 (25)              0 (0)
            Technology Adoption
MN & ND     Regional Extension Assistance Center for Health              124            89 (72)         30 (24)              8 (7)
            Information Technology
MO          Missouri Health Information Technology                        55            54 (98)           0 (0)              0 (0)
            Assistance Center
MS          Mississippi Regional Extension Center                         45            12 (27)           3 (7)              1 (2)




                                          Page 69                                              GAO-12-481 Electronic Health Records
                                              Appendix IV: Regional Extension Center
                                              Program, Goals, and Progress in Helping
                                              Providers Demonstrate Meaningful Use




                                                                                        Number of hospitals (percent of the goal)
                                                                                    Signed an
                                                                   Goal number agreement with
                                                                    of hospitals   a Regional
                                                                    targeted for    Extension          Implemented     Demonstrated
Location       Regional Extension Center name                        assistance        Center               an EHR    meaningful use
MT & WY        Health Technology Services Regional Extension                  68            43 (63)           6 (9)              1 (2)
               Center
NE             Wide River Technology Extension Center                         66            38 (58)           4 (6)              0 (0)
NH             Regional Extension Center of New Hampshire                     13            12 (92)          4 (31)              0 (0)
NM             New Mexico Health Information Technology                       17              7 (41)         2 (12)              1 (6)
               Regional Extension Center
NV & UT        HealthInsight                                                  39              9 (23)          0 (0)              0 (0)
NY             New York eHealth Collaborative                                 10           10 (100)          6 (60)              0 (0)
OH, IN, &      Greater Cincinnati Health Bridge Inc.                          24              4 (17)          0 (0)              0 (0)
KY
OH             Ohio Health Information Partnership                            43            32 (74)         12 (28)              0 (0)
OK             Oklahoma Foundation for Medical Quality                        62            25 (40)           5 (8)              2 (3)
OR             Oregon Health Information Technology Regional                  32            28 (88)           0 (0)              0 (0)
               Extension Center
PA             Pennsylvania Regional Extension & Assistance                   15              5 (33)          1 (7)              0 (0)
               Center for Health Information Technology East
PA             Pennsylvania Regional Extension & Assistance                   12              6 (50)         3 (25)              0 (0)
               Center for Health Information Technology West
SC             South Carolina Regional Extension Center                       13              4 (31)          0 (0)              0 (0)
SD             healthPOINT                                                    48            45 (94)           1 (2)              0 (0)
TN             Tennessee Regional Extension Center                            40              6 (15)          3 (8)              2 (5)
TX             CentrEast                                                      32              6 (19)          0 (0)              0 (0)
TX             Gulf Coast Regional Extension Center                           51               4 (8)          0 (0)              0 (0)
TX             North Texas Regional Extension Center                           9              3 (33)          0 (0)              0 (0)
TX             West Texas Health Information Technology                       76            19 (25)           5 (7)              1 (1)
               Regional Extension Center
Tribal lands   National Indian Health Board                                   26            22 (85)          9 (35)              0 (0)
VA             Virginia Health Information Technology Regional                 7              5 (71)         1 (14)              0 (0)
               Extension Center
VT             Vermont Information Technology Leaders, Inc.                    9              4 (44)         2 (22)              0 (0)
WA & ID        Washington & Idaho Regional Extension Center                   47            33 (70)         16 (34)              0 (0)
WI             Wisconsin Health Information Technology                        69            41 (59)         17 (25)              2 (3)
               Extension Center




                                              Page 70                                              GAO-12-481 Electronic Health Records
                                        Appendix IV: Regional Extension Center
                                        Program, Goals, and Progress in Helping
                                        Providers Demonstrate Meaningful Use




                                                                                                    Number of hospitals (percent of the goal)
                                                                                        Signed an
                                                                       Goal number agreement with
                                                                        of hospitals   a Regional
                                                                        targeted for    Extension                         Implemented            Demonstrated
Location   Regional Extension Center name                                assistance        Center                              an EHR           meaningful use
WV         West Virginia Health Information Technology                                  17                      1 (6)                   0 (0)             0 (0)
           Regional Extension Center
                                        Source: GAO analysis of Office of the National Coordinator for Health Information Technology data.

                                        Note: Hospitals that have signed an agreement with a Regional Extension Center to receive technical
                                        assistance include those that have implemented an EHR and demonstrated meaningful use, and
                                        hospitals that have implemented an EHR include those that have demonstrated meaningful use. The
                                        data on the number of hospitals at each milestone are reported by Regional Extension Centers to the
                                        Office of the National Coordinator for Health Information Technology and as a result do not
                                        necessarily mean that these hospitals received an incentive payment from either the Medicare or
                                        Medicaid EHR programs.




                                        Page 71                                                                       GAO-12-481 Electronic Health Records
Appendix V: Comments from the Department
             Appendix V: Comments from the Department
             of Health and Human Services



of Health and Human Services




             Page 72                                    GAO-12-481 Electronic Health Records
Appendix V: Comments from the Department
of Health and Human Services




Page 73                                    GAO-12-481 Electronic Health Records
Appendix V: Comments from the Department
of Health and Human Services




Page 74                                    GAO-12-481 Electronic Health Records
Appendix V: Comments from the Department
of Health and Human Services




Page 75                                    GAO-12-481 Electronic Health Records
Appendix V: Comments from the Department
of Health and Human Services




Page 76                                    GAO-12-481 Electronic Health Records
Appendix VI: GAO Contact and Staff
                  Appendix VI: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Linda T. Kohn, (202) 512-7114 or kohnl@gao.gov
GAO Contact
                  In addition to the contact named above, E. Anne Laffoon, Assistant
Staff             Director; Julianne Flowers; Krister Friday; Melanie Krause; Shannon
Acknowledgments   Legeer; Monica Perez-Nelson; Amanda Pusey; and Stephen Ulrich made
                  key contributions to this report.




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                  Page 77                                GAO-12-481 Electronic Health Records
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