EHR Payment Incentives for Providers Ineligible for Payment Incentives and Other Funding Study. Appendices.

06/01/2013

Appendices

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APPENDICES
APPENDIX A: Medicare and Medicaid EHR Incentive Programs
APPENDIX B: Definitions and Certification of EHR Technology
APPENDIX C: Public Health Service Act Section 3000(3) as Added by HITECH Section 13101 -- Provider Analysis
APPENDIX D: Ineligible Provider Characteristics
APPENDIX E: Long-Term and Post-Acute Care Provider Profiles
APPENDIX F: Behavioral Health Provider Profiles
APPENDIX G: Safety Net Provider Profiles
APPENDIX H: Other Health Care Provider Profiles
APPENDIX I: Table Summary of Patient Protection and Affordable Care Act Provisions with Relationship to Ineligible Providers and Health IT Use
APPENDIX J: Behavioral Health Provider Analysis
APPENDIX K: Grant, Demonstrations and Cooperative Agreement Programs
APPENDIX L: Loan Programs
APPENDIX M: Technical Assistance Programs
APPENDIX N: Administrative Infrastructure Building Programs
APPENDIX O: Anti-Kickback Statute EHR Safe Harbor Regulation
APPENDIX P: Private Sector Programs to Advance Certified EHR Technology
APPENDIX Q: Regulations for Medical Records
APPENDIX R: Technical Advisory Group Summary
APPENDIX S: Evaluating Benefits and Costs of New Incentives for EHR Adoption by Ineligible Providers
APPENDIX T: CIO Consortium EMR Cost Study Data
APPENDIX U: Abbreviations and Acronyms
APPENDIX V: References

 

APPENDIX A. MEDICARE AND MEDICAID EHR INCENTIVE PROGRAMS

This appendix provides a general overview of the Medicare and Medicaid EHR Incentive Programs, although it is not a complete summary of program requirements. Program highlights are presented in table format followed by a narrative description. The last section of the appendix includes a summary of the proposals advanced by various stakeholder groups to extend EHR incentives to health care provider types that are currently ineligible to receive incentive payments under the Medicare and Medicaid EHR Incentive Programs.

A. Program Highlights

Authority and Funder Description Recipient: State Provider Geographic Location Ineligible Provider Type Impacted Amount
(if known)
  1. See https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/#BOOKMARK1.
  2. See https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/#BOOKMARK2.
Direct Incentives: Financial
CMS Medicare EHR Incentive Programa HITECH Medicare EHR Incentive Program Voluntary payment incentive program to use Certified EHR Technology (CEHRT) in a meaningful way.

Eligible professionals receive up to $44,000 over 5 years if begin in 2011 or 2012. Eligible hospitals receive $2M base amount adjusted by Medicare discharges, charity care and a transition factor that gradually phases the incentive out over 4 years.

Payment adjustments begin in 2015.

Provider

Eligible Hospitals

Eligible Professionals

All eligible providers in the U.S. and D.C. Stage II requires increased electronic coordination of care efforts by eligible providers and hospitals  
CMS Medicaid EHR Incentive Programb HITECH Medicaid EHR Incentive Program. Medicaid State Plan authority for reimbursement to providers.

Voluntary incentive payments for eligible professionals and hospitals who first adopt and then "meaningfully" use CEHRT. Volume thresholds for Medicaid apply. Eligible professionals can receive up to $63,750. Eligible hospitals use a similar formula as under Medicare substituting Medicaid discharges. No payment adjustments in the Medicaid program.

State pays incentives to Eligible Hospitals Eligible Professionals; Federal Government shares in state's costs All eligible providers in the U.S. who meet specific Medicaid volume thresholds Stage 2 requires increased electronic coordination of care efforts by eligible professionals and hospitals  

B. Summary

HITECH Medicare EHR Incentive Payments

The American Recovery and Reinvestment Act of 2009 (ARRA) was enacted February 17, 2009. It includes the HITECH Act, which outlines the requirements for the EHR Incentive Program, designed to incent Medicare and Medicaid eligible hospitals (EHs), Critical Access Hospitals (CAHs) and eligible professionals (EPs) to electronically collect, store, transmit, and use health care information in a meaningful, secure, and timely way with other health entities and government agencies.1 Priority areas include e-prescribing, and the exchange of lab results and clinical summaries.2

The EHR Incentive Program, which aligns financial incentives with five health goals (improving care coordination, improving quality, efficiency and patient safety and reducing health disparities, promoting public and population health, engaging patients and families and ensuring privacy and security), has specific and different timelines and requirements for eligibility for Medicaid and Medicare financial incentives. CMS is mandated to operate the Medicare EHR Incentive Program. EPs may receive either the Medicare or Medicaid incentives, but not both for the same payment year. To be eligible, among other requirements, at least 50 percent of an EP's patient encounters during the EHR reporting period must occur at locations equipped with CEHRT. EHs may receive both Medicare and Medicaid incentives for the same payment year.

Table A1 identifies certain requirements applicable to the Medicare and Medicaid EH and EP EHR Incentive programs. The table identifies maximum EHR incentive payment amounts, the period of time over which incentives are available, whether downward payment adjustments are applied for failure to be a meaningful user, and factors that determine or adjust that payment rate.

To implement the EHR Incentive Programs, CMS publishes rules regarding Meaningful Use (MU) requirements that eligible professionals and hospitals must meet to be considered meaningful users of CEHRT. Currently eligible professionals attest to using CEHRT to meet 15 "Stage 1 MU" core objectives and five out of ten menu objectives (for a total of 20 objectives), in addition to six clinical quality measurements (CQMs) (three core or alternate core, and three from a list of 38 additional CQMs).3 Eligible hospitals must attest to 14 core objectives and five from a menu of ten objectives (for a total of 19).

CMS issued a Final Rule for Stage 2 MU in September 2012, which delays the start date of Stage 2 requirements until 2014 and establishes more rigorous requirements for the meaningful use of CEHRT. Eligible Professionals still have 20 objectives, but 17 are core and three are from a menu of six and the total of objectives for Eligible Hospitals (EHs) remains at 19, with 16 core and three from a menu of six. CMS increased the total number of clinical quality measures regardless of stage of meaningful use to nine out of 64 total and 16 out of 24 for eligible professionals and eligible hospitals, respectively.

HITECH Medicaid EHR Incentive Program

Participation in the Medicaid EHR Incentive Program by States and Territories is voluntary. As of May 2012, with the exception of one state (Hawaii) all states and territories had set up programs.4 For states and territories that do participate, there is a 90 percent federal financial participation (FFP) match for administrative functions and 100 percent for payments to EPs and EHs. States must receive approval of their State Medicaid Health Information Technology Plan (SMHP), which must address individuals in long-term care settings; aged, blind and disabled individuals; and coordination of care across multiple service providers, funding sources, settings, and patient conditions in order to receive FFP for infrastructure development. States must also gain approval of their Health Information Technology Planning Advance Planning Document (HIT PAPD) and Health Information Technology Implementation Advance Planning Document (HIT IAPD) in order to received FFP for infrastructure.5

When registering, eligible professionals must designate which state and which program (Medicare or Medicaid) they are seeking eligibility for EHR incentive payments. Hospitals may be eligible for both Medicare and Medicaid incentive payments, and if a hospital demonstrates meaningful use for purposes of the Medicare incentive payment program, it will be deemed to have done so for purposes of the Medicaid incentive payment program. The hospital must still meet the patient volume and other requirements of the Medicaid EHR Incentive Program. Medicaid EHR incentives for Meaningful Use, unlike Medicare, include funding to adopt, implement or upgrade (AIU) as well as incentive payments for demonstrating the MU of a certified EHR system.6

TABLE A1. Medicare and Medicaid EHR Incentive Programa
  Medicare Medicaid
EPs EHs EPs EHs
  1. An Introduction to the Medicare EHR Incentive Program for Eligible Professionals. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Beginners_Guide.pdf.
Maximum Payment $44,000 over 5 years if begin in 2011 or 2012 Up to 4 years of payments

$2M base amount plus a discharge-related amount, adjusted based on the Medicare share and a transition factor that decreases from 1 to ¼ over 4 years.

$63,750 over 6 years 3-6 years of payments

Sum over 4 years of a $2M base amount plus a discharge-related amount, adjusted based on the Medicaid share and a transition factor that decreases from 1 to ¼ over 4 years.

Patient Volume Requirement No specific patient volume requirement No specific patient volume requirement EPs: 30% Medicaid Patient Volume

Pediatricians: 20% Medicaid Patient Volume

EPs practicing predominantly in an FQHC/RHC: 30% Needy Individual Patient Volume

Acute: 10% Medicaid Patient Volume

Children's: no patient volume requirement

Payment Adjustments To avoid the 2015 payment adjustment the EP who is demonstrating meaningful use for the first time in 2014 must attest no later than October 1, 2014 which means they must begin their 90 day EHR reporting period no later than July 2, 2014

Payment adjustment as % of Medicare Physician Fee Schedule:

  • 2015: 99% (or 98% if also subject to e-prescribing penalty in 2014)
  • 2016: 98%
  • 2017: 97%
  • 2018: 97% except can go down to 96% in certain circumstances.
  • 2019 and thereafter: 97% except can go down to 96 or 95% in certain circumstances.
To avoid the 2015 payment adjustment the hospital that is demonstrating meaningful use for the first time in 2014 must attest no later than July 1, 2014 meaning they must begin their 90 day EHR reporting period no later than April 1, 2014

Decrease in the Percentage Increase to the IPPS Payment Rate that the hospital would otherwise receive for that year:  25% 2015,  50% 2016, 75% 2017 and thereafter

No payment adjustments in the Medicaid Program

If a meaningful EHR user under Medicaid, will also be considered a meaningful user for purposes of avoiding Medicare payment adjustments for that period.

No payment adjustments in the Medicaid Program
Payment for Adopt, implement, upgrade (AIU), or meaningfully use EHR technology No AIU No AIU Yes Yes
EHR reporting period (note: the EHR reporting periods in 2014 are not reflected) 1st Year continuous 90 days

Calendar Year

1st Year continuous 90 days

Federal Fiscal Year

1st Year continuous 90 days

Calendar Year

1st Year continuous 90 days

Federal Fiscal Year

Eligibility Either Medicare or Medicaid Both Either Medicare or Medicaid Both
Provider Definitions Must be a physician (defined as MD, DO, DDM/DDS, optometrist, podiatrist, chiropractor)

Must have Part B Medicare allowed charges

Must not be hospital-based

Must be enrolled in Provider Enrollment, Chain and Ownership System (PECOS) and in an ‘approved status'

Subsection (d) hospitals, as defined under section 1886(d)(1)(B) of the Social Security Act, located in one of the 50 states or D.C.

Critical Access Hospitals

Must be one of the following:
  • Physician;
  • Dentist;
  • Certified nurse-midwife;
  • Nurse practitioner.
  • Physician assistant practicing in a Federally qualified health center (FQHC) led by a physician assistant or a rural health clinic (RHC), that is so led by a physician assistant.

Must:

  • Have >30% Medicaid patient volume (>20% for pediatricians only); or
  • Practice predominantly in an FQHC or RHC with >30% needy individual patient volume

Licensed, credentialed

No OIG exclusions, living

Must not be hospital-based, unless qualifying as predominantly practicing at a FQHC/RHC

Acute care hospital with at least 10% Medicaid patient volume includes general, short-term stay; cancer; Critical Access Hospitals)

Children's hospitals

 

TABLE A2. Stage 2 CMS MU Objectivesa
Health Outcomes Policy Priority Stage 2 Objectives Stage 2 Measures
Eligible Professionals Eligible Hospitals and CAHs
  1. See http://www.regulations.gov/#!documentDetail;D=CMS-2012-0022-1128.
Core Set
Improving quality, safety, efficiency, and reducing health disparities Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines Use CPOE for medication, laboratory and radiology orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.
Generate and transmit permissible prescriptions electronically (eRx)   More than 50% of all permissible prescriptions, or all prescriptions written by the EP and queried for a drug formulary and transmitted electronically using CEHRT.
Record the following demographics
  • Preferred language
  • Sex
  • Race
  • Ethnicity
  • Date of birth
Record the following demographics
  • Preferred language
  • Sex
  • Race
  • Ethnicity
  • Date
  • of birth Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH
More than 80% of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have demographics recorded as structured data.
Record and chart changes in vital signs:
  • Height/length
  • Weight
  • Blood pressure (age 3 and over)
  • Calculate and display BMI
  • Plot and display growth charts for patients 0-20 years, including BMI
Record and chart changes in vital signs:
  • Height/length
  • Weight
  • Blood pressure (age 3 and over)
  • Calculate and display BMI
  • Plot and display growth charts for patients 0-20 years, including BMI
More than 80% of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data
Record smoking status for patients 13 years old or older Record smoking status for patients 13 years old or older More than 80% of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) during the EHR reporting period have smoking status recorded as structured data
Use clinical decision support to improve performance on high-priority health conditions Use clinical decision support to improve performance on high-priority health conditions
  1. Implement 5 clinical decision support interventions related to 4 or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent 4 clinical quality measures related to an EP, eligible hospital or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. It is suggested that one of the 5 clinical decision support interventions be related to improving health care efficiency.
  2. The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug drug and drug allergy interaction checks for the entire EHR reporting period.
Incorporate clinical lab-test results into CEHRT as structured data. Incorporate clinical lab-test results into CEHRT as structured data More than 55% of all clinical lab tests results ordered by the EP or by authorized providers of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative affirmation or numerical format are incorporated in CEHRT as structured data.
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least 1 report listing patients of the EP, eligible hospital or CAH with a specific condition.
Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminder, per patient preference.   More than 10% of all unique patients who have had 2 or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available.
  Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR). More than 10% of medication orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period for which all doses are tracked using eMAR.
Engage patients and families in their health care Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP.  
  1. More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information.
  2. More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information.
  Provide patients the ability to view online, download, and transmit information about a hospital admission.
  1. More than 50% of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge.
  2. More than 5% of all patients (or their authorized representatives) who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH view, download or transmit to a third party their information during the reporting period.
Provide clinical summaries for patients for each office visit.   Clinical summaries provided to patients or patient-authorized representatives within 1 business day for more than 50% of office visits.
Use CEHRT to identify patient-specific education resources and provide those resources to the patient Use CEHRT to identify patient-specific education resources and provide those resources to the patient Patientspecific education resources identified by CEHRT are provided to patients for more than 10% of all unique patients with office visits seen by the EP during the EHR reporting period.

More than 10% of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) are provided patient-specific education resources identified by CEHRT.

Use secure electronic messaging to communicate with patients on relevant health information   A secure message was sent using the electronic messaging function of CEHRT by more than 5% of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period.
Improve care coordination The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP, eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23).
The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral. The eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral.
  1. The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals.
  2. The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10%  of such transitions and referrals either--(a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network.
  3. An EP, eligible hospital or CAH must satisfy one of the two following criteria:
    1. Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at §495.6(j)(14)(ii)(B) and for eligible hospitals and CAHs the measure at §495.6(l)(11)(ii)(B)) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR 170.314(b)(2); or
    2. Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.
Improve population and public health Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire EHR reporting period.
  Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice Successful ongoing submission of electronic reportable laboratory results from CEHRT to public health agencies for the entire EHR reporting period.
  Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period.
Ensure adequate privacy and security protections for personal health information Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process.
Menu Set
Improving quality, safety, efficiency, and reducing health disparities     Record whether a patient 65 years old or older has an advance directive More than 50% of all unique patients 65 years old or older admitted to the eligible hospital's or CAH's inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data.
Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT. Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT. More than 10% of all tests whose result is one or more images ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 and 23) during the EHR reporting period are accessible through CEHRT.
Record patient family health history as structured data Record patient family health history as structured data More than 20% of all unique patients seen by the EP or admitted to the eligible hospital or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have a structured data entry for 1 or more first-degree relatives.
  Generate and transmit permissible discharge prescriptions electronically (eRx) More than 10% of hospital discharge medication orders for permissible prescriptions (for new, changed, and refilled prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT.
Record electronic notes in patient records Record electronic notes in patient records Enter at least 1 electronic progress note created, edited and signed by an eligible professional for more than 30% of unique patients with at least 1 office visit during the EHR reporting period.

Enter at least one electronic progress note created, edited and signed by an authorized provider of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) for more than 30% of unique patients admitted to the eligible hospital or CAH's inpatient or emergency department during the EHR reporting period. Electronic progress notes must be textsearchable. Non-searchable notes do not qualify, but this does not mean that all of the content has to be character text. Drawings and other content can be included with searchable text notes under this measure.

  Provide structured electronic lab results to ambulatory providers Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20% of electronic lab orders received
Improve Population and Public Health Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice   Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period
Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice.   Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period
Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.   Successful ongoing submission of specific case information from CEHRT to a specialized registry for the entire EHR reporting period.

 

TABLE A3. 2014 Edition Certification Criteria for Base EHR Definitiona
Base EHR Capabilities 2014 Edition Certification Criteria
  1. Office of the Federal Register. "Health Information Technology, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology." https://www.federalregister.gov/articles/2012/09/04/2012-20982/health-information-technology-standards-implementation-specifications-and-certification-criteria-for#table_of_tables.
Includes patient demographic and clinical health information, such as medical history and problem lists Demographics §170.314(a)(3)
Problem List §170.314(a)(5)
Medication List §170.314(a)(6)
Medication Allergy List §170.314(a)(7)
Capacity to provide clinical decision support Clinical Decision Support §170.314(a)(8)
Capacity to support physician order entry Computerized Provider Order Entry §170.314(a)(1)
Capacity to capture and query information relevant to health care quality Clinical Quality Measures §170.314(c)(1) through (3)
Capacity to exchange electronic health information with, and integrate such information from other sources Transitions of Care §170.314(b)(1) and (2) Data Portability §170.314(b)(7)
Capacity to protect the confidentiality, integrity, and availability of health information stored and exchanged Privacy and Security §170.314(d)(1) through (8)

C. Proposals to Extend EHR Incentives to Ineligible Provider

The following table identifies some of the actions that some stakeholders have stated are needed to extend the EHR Incentive Programs under HITECH to include many provider types that are currently ineligible to receive incentive payments under those programs, such as long-term and post-acute, and behavioral health providers. This summary is not intended to be a complete list of options that have been proposed to extend the EHR Incentive Programs to ineligible provider types. Rather the list serves to highlights some of the suggestions by some stakeholders of extending these incentive programs. Further, this list is not intended as endorsement of any one of these options. Instead, the summary serves only to list some of the actions that have been proposed that could support the use of EHR technology by ineligible providers. The text in the table below quotes from the referenced documents.

Stakeholder Group Source and Statement of Proposed Action
State Medicaid Directors Association (NASMD)

NASMD a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies
(including D.C. and the territories).

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules, published in the January 13, 2010 Federal Register.

"GUIDING PRINCIPLES" (p.3)
"(1) The provider incentive program should ensure that we are not creating a two tiered system in which Medicaid is not fully integrated into the improved care delivery system enabled through this initiative....

(3) The provider incentive program should foster EHR adoption and meaningful use among eligible Medicaid providers pursuant to the NPRM, and strive towards including non-eligible providers that are critical to improve the quality and value of the Medicaid program, such as long-term care and behavioral health providers."

"Provisions in the Proposed Rule: Alignment of Medicare and Medicaid" (p.4)
"Alignment of Medicare and Medicaid"

The states support alignment across Medicare and Medicaid; however, the current clinical measures do not reflect key clinical services and issues for the Medicaid population, including behavioral health, dental, long-term care, and care coordination (particularly across physical and behavioral health care).

The states recommend that CMS work with the Medicaid Medical Directors and ONC and consider the development and inclusion of clinical and non-clinical quality measures that are more representative of the Medicaid population."

"State Match Requirements" (p.7)
"The states request that CMS allow in-kind contributions--such as state staff ‘on loan' to the Medicaid program for the provider incentive program--as part of the 10% state match. In today's economic reality of severe state deficits, states may otherwise not be able to secure the funding needed to participate in this program."

"Eligible Medicaid Providers" (p.9)
The states request that CMS recognize that the Act excludes many relevant and key providers from participating in the incentive program. Specifically, the states argue that community mental health centers and other behavioral health providers, nursing homes, community long-term care providers, and home health care providers should be eligible for incentive payments as they are critical partners in improving the quality and coordination of care for the Medicaid population. The states recognize that this is a statutory issue, but feel strongly that exclusion of these critical providers impacts Medicaid's ability to improve the quality and efficiency of care. The states recommend that CMS allow states and the regional extension centers (RECs) to provide education and training, technical assistance, and infrastructure as relevant to support these excluded providers pursuant to the 90/10 funding. By including these excluded providers in education and training, the states can set the stage for eventually achieving the long-term goal of helping all providers serving Medicaid exchanging data and be meaningful users of EHRs."

American Medical Directors Association (AMDA)

AMDA represents approximately 5,200 medical directors, attending physicians, and others who practice in the long-term care continuum.

AMDA: comments on the proposed rule Medicare and Medicaid Programs; Electronic Health Records Incentive Program--Stage 2.

(p.1)
"While the proposed rule does not preclude long term care physicians from adopting health information systems to achieve meaningful use, AMDA encourages the Centers for Medicare & Medicaid Services (CMS) to include language that supports and encourages adoption of electronic health records (EHR) in long-term/post-acute care settings (LTPAC)...To meet nationally stated goals of a) improving quality, safety, efficiency, and reduce health disparities; b) improving care coordination; and c) engaging patients and families, the health care team caring for a patient/resident must be able to electronically exchange meaningful clinical information throughout the entire spectrum of care, which includes LTPAC."

Leading Age (formerly known as AAHSA (American Association for Homes and Services for the Aging))

Leading Age 5,800 member organizations, many of which have served their communities for generations, offer the continuum of aging services: adult day services, home health, community services, senior housing, assisted living residences, continuing care retirement communities and nursing homes.

AAHSA Public Policy Priorities 2008 (pp.8-9)
"One thing is clear: Technology will make a tremendous difference in quality and cost...We therefore will advocate for:...Creating and standardizing private, and portable Personal and Electronic Health Records, which take into account the unique requirements of aging services, to be available to every senior (or citizen) in America to ensure continuity of information, continuity of care, reduced unnecessary interventions and errors, and increased ownership of one's medical history.

Statement for the Record. Investing in Health IT: A Stimulus for a Healthier America. January 15, 2009 (p.3)
"HITECH...recognizes that hospitals and physicians need serious incentives to encourage adoption of information technology, and allocates $20 billion in incentive payments. However, it is critically important that we not allow the long-term side of the health care system to languish while the acute-care side is built up. We need to build both sides at the same time, if we are to ensure that patients are not lost in the process.

We therefore urge you to include long-term care providers in any incentives you adopt, including direct bonuses, so as to enable long-term providers to prepare their information and communications infrastructure and deploy new technologies, including Health Information Technologies (HIT) and interoperable EHR systems, as well as other technologies enabling direct care workers to document their patients' care.

Secondly, we urge that any data collection by the Centers for Medicare and Medicaid be through interoperable systems. We will not be able to achieve the goal of interoperability by 2014 if data collection in long-term care is done through a proprietary format, as CMS plans to do with the new MDS 3.0. This will inevitably set back the efforts to integrate long-term care data collection with the rest of the health care system and ultimately increase cost of making all systems interoperable by 2014....

Such HIT infrastructure and EHR systems, that are interoperable across provider settings, ensure the continuity of information, and thus the continuity of care, and can lead to reducing medical errors, duplicative procedures and expenditures, while improving care quality, especially for the aging population."

AAHSA Public Policy Priorities 2010
AAHSA supports (p.11)

  • "Standards for electronic health records (EHR) that include long term services and supports. Pilot projects for EHR technology should be on-going in aging services;
  • Federal funding to advance technology applications in aging services including funds from the American Recovery and Reinvestment Act; and
  • Development of large-scale technology adoption projects involving aging services providers."

AAHSA Public Policy Priorities 2011 (p.4)
LeadingAge supports "

  • Advancement of technology applications in long-term services and supports; and
  • Inclusion of this sector in federal programs to encourage broad use of health information technology"

Financing (p.6)
"Financing aging services also requires support for infrastructure, including access to capital for construction and improvements that add value and cost-saving efficiency, such as technology."

Technology (p.8)
"The application of technology in aging services can help people to continue living in the community, delaying entry into expensive nursing home care. Technology can help to reduce costs associated with chronic conditions such as diabetes. It also can reduce costs by making services more efficient, both in nursing homes and in the community.

The Affordable Care Act provides for a number of exciting opportunities to better integrate acute and post-acute care services through collaboration among a variety of health care providers. This kind of collaboration will require extensive data sharing to ensure continuity and quality of services. Data collection and sharing, in turn, will absolutely depend on the use of health information technology.

A report by the LeadingAge Center for Aging Services Technology (CAST) discusses the ways in which technology can change the culture, delivery options and financing of health care and long-term services and supports. We support incorporating aging services technologies into accountable care organizations, medical homes and other innovative service delivery systems to help realize cost savings and quality improvements."

LeadingAge supports:

  • "Standards for electronic health records (EHR) that include long-term services and supports. Pilot projects for EHR technology should be on-going in aging services;
  • Federal financial incentives to advance technology applications in aging services;
  • A pilot program to provide incentives for home health agencies across the country to use home monitoring and communications technologies, giving seniors greater access to the care they need."
Centers for Aging Services Technology, Homecare Technology Association of America (CAST)

CAST is leading the charge to expedite the development, evaluation and adoption of emerging technologies that can improve the aging experience. CAST has become an international coalition of more than 400 technology companies, aging services organizations, research universities, and government representatives.

"IMPEDIMENTS TO THE ROLL-OUT OF IT HEALTHCARE STRATEGIES (pp.1-2)
Interoperable Electronic Health Records (EHR) & Personal Health Records (PHR) in Long-Term Care. The development of interoperable electronic health record and personal health records is critical to the success of technology implementation. We support the national initiatives to develop EHRs and encourage work on PHRs. These activities form the foundation for the future vision of how networked health care systems will operate between older adults, caregivers, family members and health care providers....Key to maximizing the benefits of such networked healthcare system is the inclusion of long-term care settings, such as assisted living, skilled nursing, home health, home care and specialty services providers...[and] necessitates that the standards for such electronic record systems take into account the requirements of the long-term care providers, including functional assessment data and patient summaries, to allow the electronic exchange of critical health information among different care providers, including long-term care providers. Lack of interoperability is one of the important barriers to the adoption of these technologies...

More incentives, in the form of grants, tax-credits and low-interest loans, are needed to enable long-term providers to prepare their information and communications infrastructure and deploy new technologies, including Health Information Technologies (HIT) and interoperable EHR systems, and other technologies including technologies for care documentation by direct care workers that improve the quality of care. Such HIT infrastructure and EHR systems, that are interoperable across provider settings, ensure the continuity of information, and thus the continuity of care, and can lead to reducing medical errors, duplicative procedures and expenditures, while improving care quality, especially for the aging population."

National Association of Home Care (NAHC)

Home Care Technology Association of America (HCTAA)

HCTAA is a wholly-owned affiliate of the NAHC, and is organized to advance the accessibility and use of technology in home care and hospice settings. HCTAA was established to unite the home care technology industry into a stronger, more effective voice to Congress, the Administration, state legislatures, the home care industry, consumers, and the media. HCTAA believes that home care and hospice providers that are properly equipped with technological solutions will serve a central role in the delivery of healthcare by ensuring quality, efficiency, and patient care coordination.

NAHC and HCTAA: comments on the definition of "Meaningful Use" of Electronic Health Records (EHR), as required by the American Recovery and Reinvestment Act of 2009" (June 25, 2009):

(pp.2-3)
"...in fashioning the "meaningful use" definition, the Office of the National Coordinator for Health Information Technology (ONCHIT) should bear in mind that neither true health care reform nor our national goal of creating an effective and inclusive nationwide health information network can be achieved without an expansion of its current scope of work to include health care sectors. We urge that home care and hospice be specifically identified as components of the health information network and be included as equally important partners in the delivery of comprehensive quality healthcare."

"...the home care sector is still lacking the support and inclusion that would make our providers, and consequently the overall health care system, meaningful users of HIT."

"We specifically would urge the ONCHIT to ensure that:

  • HIE grant funding be made to RHIOs/HIEs emphasize the need to include and support home health care providers to effectively facilitate the electronic exchange of health information across different care settings;
  • Grants and loans be made available to home health care providers to plan for and implement certified, interoperable HIT solutions;
  • Regional Extension Centers provide technical assistance for home health care providers seeking integration into the health information network, in addition to other acute care providers in their regions;
  • CMS adopts HITSP-accepted interoperability standards as it goes forward with new patient assessment requirements for home health agencies and other provider settings to accelerate the adoption and use of interoperable EHRs by these providers; and
  • Adopts HIT incentives, similar in principle to those offered currently to other acute care providers, to be extended to home health care providers...."

"...as we have stated, the goal of care coordination requires the exchange of timely health information among all care providers. This goal cannot be achieved unless it is inclusive of home health care and hospice providers. With appropriate resources for implementation and standardization of EHRs, further steps can be taken by the home care and hospice community to meet the objectives of the meaningful use of EHRs and care coordination."

"NAHC/HCTAA is also exploring strategies to obtain incentives such as small business loans, tax incentives and grants that could be available to LTPAC providers for the adoption of EHRs."

NAHC and HCTAA comments on the proposed rule to define the "meaningful use" of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs (March 15, 2010) (pp.1-2):

  • "Recognize that the common definition of "meaningful use" that serves as the standard for providers participating in the Medicare...EHR incentive program and ... the Medicaid EHR incentive program affects the process of establishing standards of meaningful use of EHRs for non-eligible health care providers (such as home health care and hospice providers) and that future redefinitions of meaningful use should consider applying criteria for meaningful use more broadly to inpatient and outpatient hospital settings and long-term post acute care (LTPAC) providers."
  • "Consider that the standards for Certified EHR technologies and the means by which EPs and eligible hospitals demonstrate meaningful use should work for all provider types; including home health care and hospice to ensure the maximization of the functionality of EHRs."
  • "Recognize that standards for improved care coordination and the exchange of meaningful clinical information among the professional health care team should involve all health care provider types (including health care professionals who are defined within the scope of home health care service providers, such as: physician assistants, nurse practitioners, registered nurses, physical therapist, and clinicians)."
  • "Encourage stakeholders to conduct demonstration projects that test the exchange of meaningful clinical information between EPs, eligible hospitals and home health care and hospice providers and provide data on the outcomes and cost effectiveness of care coordination and the sharing of clinical data amongst a broad scope of health care providers."
  • "Encourage EPs (physicians) and hospitals in future rulemaking to partner with other health care providers, as defined by Section 3000(3) of the HITECH Act, by directly linking the formation of collaborative partnerships with home health care and hospice providers with the demonstration of meaningful use or by some other incentivizing means."
  • "Consider expanding clinical quality measures in future rulemaking to include both long-term care and post acute care.

NAHC/HCTAA comments on the 2011- 2015 Federal Health Information Technology Strategic Plan (May 6, 2011):
(p.2)

"In describing the barriers that have slowed the acceptance of EHRs and widespread health information exchange the ONC noted that providers in small and medium-sized practices do not have sufficient capital to adopt EHR systems. We also share this experience within the home care and hospice industry and because of our non-incentivized status within the meaningful use program; we are also cognizant that these barriers are most problematic to all providers who serve underserved communities in rural and urban areas. Therefore, we recommend that you provide clear details regarding the government's plan to develop technology and policy solutions that build on meaningful use and fit the unique needs of ineligible providers, including home care and hospice providers...."

(p.2)
"It is promising that the RECs will work with the community-based organizations and we hope that if this partnership extends to home care and hospice agencies that we will be able to help the RECs better serve not only underserved and communities of color but also disabled persons. The ONC should advise the 62 Regional Extension Centers across the country to extend their guidance and technical assistance on certified EHR adoption and utilization to ineligible providers, including home care and hospice providers. This strategy would foster a business model for RECs that supports all health care providers and will enable them to operate without federal grant funds beyond 2015."

(pp.2-3)
"The ONC needs to recognize that establishing a criteria and process to certify EHR technologies for hospitals and eligible providers has created a trajectory that must be adhered to by all providers, even those that are non-incentivized, if they want to be able to participate in the capture and exchange of health information. The ONC should link the goals...to provide support and build awareness of not only ONC-ATCB Certified EHRs but also other certified EHRs, such as the CCHIT Certified EHR home health add-on, that is interoperable with the federal standards. Currently, the vendor community is not developing the home health add-on because there is no federal government support or financial incentives attributed to the home care end user."

(p.3)
"It would also be helpful if the ONC would help educate incentivized providers and hospitals about the benefits of accepting clinical information from home care and hospice providers so that the information they receive from the community is not devalued because it is not ONC Certified. Facilitating the exchange and receipt of health information between physicians, hospitals, and other clinical professionals within the care continuum will help to improve patient care coordination especially for those who are chronically ill."

(p.3)
"Although we understand that the major payers are focused on the physician population and hospitals that are being incentivized to adopt Certified EHRs, we do not believe that the private sector is providing incentives to home care or hospice providers to achieve meaningful use."

National Council for Community Behavioral Healthcare (NCCBHC) (aka The National Council)

The National Council, a non-profit association representing over 1700 community mental health centers and other community-based mental health and addiction providers, is dedicated to fostering clinical and operational innovation and promoting policies that ensure that the more than 6 million low-income children, adults, and families our members serve have access to high quality services.

March 12, 2010. The National Council comments on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program, Proposed Rule.

(p.1)
"...we believe that the adoption and utilization of electronic health records is a vital component of the appropriate delivery of high-quality health care and builds upon previous advancements to better serve consumers."

(p. 2)
"The Federal government should encourage the widespread adoption of electronic health records, computer-based clinical decision-support systems, computerized provider order entry, and other forms of information technology for M/SU [Mental Health and Substance Abuse] care by:

  • Offering financial incentives to individual M/SU clinicians and organizations for investments in information technology needed to participate fully in the emerging NHII.
  • Providing capital and other incentives for the development of virtual networks to give individual and small-group providers standard access to software, clinical and population data and health records, and billing and clinical decision-support systems. (emphasis added)1"
    Footnote: 1 Institute Of Medicine of the National Academies (2006) Improving the Quality of Health Care for Mental and Substance-Use Conditions, Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders; Board on Health Care Services, The National Academies Press, Washington, DC.

(p.6)
"While the National Council is aware and supportive of SAMHSA's request of $4 million in new funds for BHC HIT for the Office of the National Coordinator in the 2011 budget, we strongly urge that this request not be viewed as adequate to close the gap, and should not be viewed as a alternative to our recommendations.

Given that the Proposed Rule is meant to support the "Expanded use of health information technology (HIT) and EHRs [to] improve the quality and value of American health care," the EHR incentives should be readily accessible to CBHOs, whose providers treat many consumers with chronic health conditions."

LTPAC Health IT Collaborative

Collaborative of associations representing health information technology (HIT) issues for long-term and post acute care (LTPAC) providers, professionals, and support services in skilled nursing facilities, nursing facilities, assisted living, home health agencies, etc.

Members include: American Health Care Association, American Health Information Management Association, Home Care Technology Association of America, American Society of Consultant Pharmacists, Center for Aging Services Technology, Leading Age, National Association of Home Care and Hospice, National Association for the Support of Long-Term Care, National Center for Assisted Living, Program for All Inclusive Care for the Elderly

April 16, 2009. Inclusion of Long-Term Care Settings in ARRA Funded Projects Letter to the David Blumenthal (the National HIT Coordinator)

(pp.1-2)
We are also aware of the ARRA-required investments in grants and loans programs that will be administered through your office to drive the adoption of interoperable HIT nationally. We are contacting you today to provide two recommendations designed to maximize the return on this significant one time investment in the national HIT infrastructure:

  1. We recommend that ONC include language in the ARRA requests for HIT grant and loan proposals advising applicants of the benefits of and need to seek partners from different care settings, including long-term care and providing such help as may be necessary to help identify potential partners (such as providing lists of federally certified providers in various areas).
  2. In addition, we recommend that ONC specify that one of the evaluation criteria for selecting grant/loan recipients will be a preference for those who do partner with long-term care providers (and other healthcare providers who will not receive financial incentives).

We believe that implementing our ARRA recommendations would substantially help ensure that organizations likely to be primary drivers of adoption of standards-based EHRs and facilitators of health information exchange, such as Health Information Exchanges (HIEs), Regional Health Information Organizations (RHIOs) and Regional Health Information Technology Extensions Centers, are inclusive of all provider settings and serve broad and diverse populations, including persons requiring long-term care. Advancing policies that extend interoperable health information exchange and use to support the needs of persons requiring long-term care (including the use of standards for patient assessments) will be necessary to meet the ARRA goal that each person in the U.S. use an EHR by 2014.

June 11, 2009 Health IT Extension Program Comments. Letter to the David Blumenthal (the National HIT Coordinator)

(p.1)
"Our collaborative has worked to ensure that long-term care is included in the health information technology (health IT) provisions in the American Recovery and Reinvestment Act (ARRA) of 2009 and Health Information technology for Economic and Clinical Health (HITECH) Act. Fully including this substantial sector of the health care community in interoperable electronic health records (EHRs) is critical to reforming the health care system."

"The Extension Program includes provisions addressing the unique needs of providers of historically underserved populations including long-term care. In order to achieve the goals of HITECH, Regional HIT Extension Centers must offer technical assistance to long-term care providers (nursing homes, assisted-living, home health, PACE providers, etc.) as a priority group.

This technical assistance is essential so that the health care community (both acute and post-cute) become "meaningful users", have the training and support necessary to create and implement the EHR infrastructure and exchange health information across care settings. Technical assistance to achieve meaningful user status will give acute care providers the opportunity to receive incentive payments under Medicare and Medicaid. Technical assistance will enhance long-term care providers' ability to further improve the quality of care for residents. Furthermore, we request that the scope of work for the Regional HIT Extension Centers require specific inclusion of long-term care providers as stakeholders, partners and an important priority group for receiving direct technical assistance.

Excluding long-term care will slow down the adoption of interoperable EHRs for each person in the U.S. and cause harm to our most vulnerable citizens as they migrate through the health care system with numerous providers during single episodes of care and overtime across multiple episodes of care."

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules.
This rule proposes to define the "meaningful use" of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs. (http://www.ltpachealthit.org/system/files/MU%20Comments%20March%202010%20v4%205%20%284%29.pdf)

LTPAC Recommendations on "Meaningful Use" (pp.1-2)

  • Recognize that the common definition of "meaningful use" that serves as the standard for providers participating in the Medicare Fee-for-Service and Medicare Advantage EHR incentive program and for EPs and eligible hospitals participating in the Medicaid EHR incentive program affects the process of establishing standards of meaningful use of EHRs for non-eligible health care providers (such as LTPAC providers) and that future redefinitions of meaningful use should consider applying criteria for meaningful use for LTPAC providers.
  • Recognize that the means by which EPs and eligible hospitals demonstrate meaningful use should work for all provider types.
  • Consider that the Certified EHRs technologies approved for use by EPs and eligible hospitals must be measured by their ability to successfully send and receive standards-based patient summary records and clinical information and share them with all health care providers types (including skilled nursing facilities, nursing facilities, home health, etc.) as defined by the HITECH Act.
  • Encourage EPs (physicians) and hospitals in future rulemaking to partner with other providers, as defined by Section 3000(3) of the HITECH Act, by directly linking the formation of partnerships with LTPAC providers with the demonstration of meaningful use or by some other incentivizing means.
  • Recognize that the standards of meaningful use of Certified EHRs for 2013 must, at a minimum, include a defined standard for the transfer of care documentation between all providers as defined by Section 3000(3) of the HITECH Act. The recommendation of the LTPAC is for this to be addressed in 2011 rulemaking so that the industry has sufficient time to implement these standards and support meaningful use Stage 2.
  • Recognize that improved care coordination and the exchange of meaningful clinical information among the professional health care team should involve all health care provider types and that demonstration projects should be devised to demonstrate the exchange of meaningful clinical information between EPs, eligible hospitals and LTPAC providers.
  • Consider expanding clinical quality measures in future rulemaking to include both long-term care and post acute care."

(p.2)
"To meet nationally stated goals of a) improving quality, safety, efficiency, and reduce health disparities; b) improving care coordination; and c) engaging patients and families, the health care team caring for a patient/resident must be able to electronically exchange meaningful clinical information between the professional health care team over the entire spectrum of care. This spectrum is not limited to physician practices and hospitals. Rather, it is inclusive of all provider settings, including LTPAC."

(p.3)
"Effective electronic health information exchange with LTPAC providers reduces hospital readmissions and medical errors, improves quality, supports the continuity of care, and reduces costs with the resultant higher quality of care and quality of life. Our country's health care system will only reach the primary goal of improved quality and care coordination, and hence meaningful use, when all providers across the spectrum of care are included in HIT initiatives."

(p.3)
"Even through LTPAC is not currently funded for financial incentives; it can be included in the demonstration of meaningful use by linking incentive payments to EPs and hospitals who partner with other providers including LTPAC. Without the engagement of LTPAC, the goals of HITECH won't be achieved since physicians and hospitals cannot become meaningful users in isolation."

(p.4)
"In summary, this regulatory effort to transform the health care delivery system and emphasize that this goal can only be realized if the health care system recognizes the vital role LTPAC plays in the full spectrum of care and thus the need to include LTPAC in the electronic exchange of health information to make the use of HIT truly meaningful. As our recommendations propose, LTPAC's inclusion in this initial meaningful use effort can be expanded without additional cost by refining the criteria is a way that will incentivize EPs and hospitals to partner with all provider groups as defined by the HITECH Act. Implementing these recommendations would ensure attaining a meaningful use of HIT across the total spectrum of care, as required by ARRA, achieving a meaningful return on ARRA funds invested, and meeting the ARRA goal that each person in the U.S. has an EHR by 2014."

January 18, 2011. President's Council of Advisors on Science and Technology "Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward" Letter to ONC.

(pp.1-2)
"The report urges the Centers for Medicare and Medicaid Services (CMS) to focus on increasing health information exchange and to exercise its' influence as a major payer to drive health information exchange. While currently long term care providers are not eligible for Meaningful Use incentives for adoption of a certified electronic health record under ARRA-HITECH, CMS could leverage federally mandated LTPAC functional status assessments (such as MDS, OASIS and IRF-PAI) to accelerate the adoption of interoperable EHRs in this sector and increase the exchange of health information across health care provider settings. ONC should also support the creation of health data exchange programs that target and engage long-term and post-acute care providers."

(p.2)
"We strongly support the recommendation that CMS modernize their information systems and develop a strategy to use technology and standards that are consistent with the rest of the health care industry to leverage their influence and advance health information exchange activities for clinical, administrative, public health and research purposes and not deploy IT requirements that only fit CMS business processes."

May 6, 2011. LTPAC HIT Collaborative Public Comments on ONC Federal HIT Strategic Plan 2011-2015. (http://www.ltpachealthit.org/system/files/LTPAC%20HIT%20Collaborative%20Comments%20on%20ONC%20Federal%20HIT %20Strategic%20Plan%205_9_11_FINALv2.pdf)

(p.1)
"The LTPAC Health IT Collaborative is very supportive of the goals of this comprehensive strategic plan, and certainly applauds the ONC creating Strategy I.C.3. to support health IT adoption and information exchange in long-term/post-acute, behavioral health, and emergency care settings."

(p.1)
"...the Collaborative broadly recommends full inclusion of the LTPAC health sector in the Federal Health Information Technology Strategic Plan to improve quality and reduce care disparities through meaningful use and systematic exchange of health information among all providers in all settings."

(pp.2-5)
"The following comments build on what is contained in the Strategic Plan and further extend it to better meet the needs of the large population that LTPAC serves....

OBJECTIVE I.A: Accelerate adoption of Electronic Health Records (EHR) STRATEGY I.A.7: Align federal programs and services with the adoption and meaningful use of certified EHR

  • We applaud the ONC for planning to include methods to encourage providers that are not eligible for the incentive programs such as post-acute and long-term care to achieve meaningful use of IT as well.

OBJECTIVE I.B: Facilitate information exchange to support meaningful use of EHR

  • Suggest including long-term and post-acute care settings" with any example of provider settings.

STRATEGY I.B.I: Foster Business models that create health information exchange

  • Health Information Exchange strategies include the LTPAC community.
  • The ONC Direct engages a variety of providers in Health Information Exchange. Ensure that LTPAC providers are included in Direct Projects...
  • It is not readily apparent in the Strategic Plan that LTPAC is part of the Direct Project.

OBJECTIVE I.C: Support health information technology adoption and information exchange for public health and populations with unique needs.
STRATEGY I.C.3: Support health IT adoption and information exchange in long-term/post-acute, behavioral health, and emergency care settings

The Federal HIT Strategic Plan notes ONC is working with SAMHSA and HRSA to address the policies and standards concerning the unique needs of behavioral health IT adoption and information exchange. The LTPAC Health IT Collaborative supports the inclusion of the unique needs of behavioral health identified in the strategic plan and offers these recommendations below supporting the unique needs of the LTPAC community:

  • Support for effective care delivery which maintains health care quality outside of the hospital and acute care setting where most of the elder population--both Medicare and Medicaid beneficiaries as well as "dual eligibles" reside.
  • Policies, standards, and incentives for vital links between health care providers to be encouraged to accelerate the care process outside current settings being incentivized [eligible hospitals, CAH, eligible professionals].
  • Policies, standards, and incentives to provide sustained effective care for the large numbers of vulnerable populations in settings outside acute systems.
  • Policies, standards, and incentives to develop communication between providers eligible for EHR incentive payments to establish and maintain connections supporting data exchange with those outside agencies who are NOT EHR incentive payment eligible to support consumer centric care across the continuum that includes the longitudinal care planning being discussed by HIT Policy Committee for inclusion in the future stages of Meaningful Use.
  • Support for effective electronic health information exchange with ALL health professionals involved in delivering LTPAC needs of the consumer including include Home Care services such as Care Management, Private Duty, and Skilled Nursing--and also the personal care needs, infusion, nutrition, rehabilitation, PT, OT, Speech therapy as well as durable medical equipment providers
  • Support for Longitudinal assessments across the continuum which identify the patient's story....
  • Health information exchange from LTPAC facilities to hospitals and vice versa to facilitate better transitions to meet unique needs.
  • Support for services or service delivery structure to the current EHR that provide a means to track unique needs of patients transitioning between settings. This includes patient care services--not just medical decision making.
  • Support for the concept of a problem that is not disease specific or a medical problem; examples of other issues that need to be addressed include transportation, personal care, activities of daily living (ADLs), financial issues which are barriers to sustained effective care beyond acute care and often result in hospitalizations, re-hospitalizations and greater medical costs.
  • Support for health care delivery for of ALL levels of care and prevention--not just support for traditional health care delivery episodes of care "check in to check out" or "admission to discharge".

OBJECTIVE II.A: Support more sophisticated uses of EHRs and other health IT to improve health system performance
STRATEGY II.A.1: Identify and implement best practices that use EHRs and other health IT to improve care, efficiency, and population health.

  • Consider enhancing current language to "Clinical decision support (CDS) systems are tools that leverage EHRs to improve clinical processes--ADD NEW--"across ALL venues of care including LTPAC, behavioral health, and emergency care settings".
  • Usability is a critical issue that needs to be addressed in this GOAL so that systems providing clinical decision support provide consistent messaging and alerting across the continuum from acute care to long-term and post-acute care.

OBJECTIVE II.D: Support new approaches to the use of health IT in research, public and population health, and national health security
STRATEGY II.D.1: Establish new approaches to and identify ways health IT can support national prevention, health promotion, public health, and national health security.

  • Include a plan to integrate LTPAC. Include clinical decision support systems integrated across the continuum to consistently support meaningful use by all care providers, not just providers currently eligible for the EHR Incentive Program.
  • Collaboration with LTPAC providers to define supporting strategies, policy and standards needed regarding risk assessment and clinical decision support in a long-term or post-acute care setting.
  • Support for a link between quality and core processes important across the continuum which include medication reconciliation, care transitions, change of condition, and risk identification.
  • Support for health records associated with the longitudinal care plan and outcomes of care in various care settings that capture the essence of an individual's life in the community which are vital to the continuum of care. A more specific plan should be included for including these records in the near term meaningful use plans. This is particularly important for populations served by LTPAC.
  • Support for family histories which are a vital and rich part of the longitudinal care plan and unique assessment of the nursing home and long term or post-acute care environment.

Notes

  1. The Office of the National Coordinator for Health Information Technology. Electronic Health Records and Meaningful Use. http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2. Accessed 5/1/12.

  2. Ibid. Accessed 5/1/12.

  3. Centers for Medicare & Medicaid Services. Clinical Quality Measures (CQMs). https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html. Accessed 5/19/12.

  4. Centers for Medicare & Medicaid Services.Medicaid State Information. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/MedicaidStateInfo.html.

  5. Centers for Medicare & Medicaid Services. Health Information Technology Implementation Advanced Planning Document (HIT IAPD) Template. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ Medicaid_HIT_IAPD_Template.pdf. Accessed 6/1/2012.

  6. Centers for Medicare & Medicaid Services. EHR Incentive Programs. http://www.cms.gov/Regulations-and-Guidance/legislation/EHRincentiveprograms/. Accessed 5/1/12.

[Return to the Table of Contents]

 

APPENDIX B. DEFINITIONS AND CERTIFICATION OF EHR TECHNOLOGY

This appendix provides the statutory language for the study and key terms used in this study. In addition, it provides summary information about the certification process for EHR technology and the regulatory definition for a Base EHR.

A. HITECH Act Section 4104(a) Requirements

Section 4104(a)1 of the HITECH Act, which requires the Secretary of Health and Human Services (HHS) to conduct a study to determine the extent to which, and manner in which, payment incentives and other funding for implementing and using certified EHR technology should be made available to those providers who receive minimal or no payment incentives or other funding under the HITECH Act, Medicare, Medicaid, or otherwise, for such purposes. The Secretary is required to submit a report to Congress on the findings, addressing the following factors:

SEC. 4104. STUDIES AND REPORTS ON HEALTH INFORMATION TECHNOLOGY.
(a) STUDY AND REPORT ON APPLICATION OF EHR PAYMENT

INCENTIVES FOR PROVIDERS NOT RECEIVING OTHER INCENTIVE PAYMENTS.

  1. STUDY.

    REPORT. Not later than June 30, 2010, the Secretary shall submit to Congress a report on the findings and conclusions of the study conducted under paragraph (1).

    1. (A) IN GENERAL. The Secretary of Health and Human Services shall conduct a study to determine the extent to which and manner in which payment incentives (such as under title XVIII or XIX of the Social Security Act) and other funding for purposes of implementing and using certified EHR technology (as defined in section 1848(o)(4) of the Social Security Act, as added by section 4101(a)) should be made available to health care providers who are receiving minimal or no payment incentives or other funding under this Act, under title XIII of division A, under title XVIII or XIX or such Act, or otherwise, for such purposes.

    2. (B) DETAILS OF STUDY. Such study shall include an examination of--

      1. the adoption rates of certified EHR technology by such health care providers;
      2. the clinical utility of such technology by such health care providers;
      3. whether the services furnished by such health care providers are appropriate for or would benefit from the use of such technology;
      4. the extent to which such health care providers work in settings that might otherwise receive an incentive payment or other funding under this Act, under title XIII of division A, under title XVIII or XIX of the Social Security Act, or otherwise;
      5. the potential costs and the potential benefits of making payment incentives and other funding available to such health care providers; and
      6. any other issues the Secretary deems to be appropriate.2
  2. REPORT. Not later than June 30, 2010, the Secretary shall submit to Congress a report on the findings and conclusions of the study conducted under paragraph (1).

B. Definition of Providers

The complexity of the U.S. health care delivery and payment system, variability in classifying healthcare providers across the states, and overlap in services between providers creates challenges in identifying the types of providers who are the focus of this study. The methodology used to determine which health care provider types are the focus of this study was:

  • Identify and define the health care provider types in section 3000(3) of the Public Health Service Act (PHSA) as modified in section 13101 of HITECH.
  • Identify which of these providers in section 3000(3) could participate in either Medicare or Medicaid programs.
  • Which of these provider types are eligible to receive EHR incentive payments under HITECH, and which of these providers are not eligible for such incentive payments.
  • For those providers who were determined to be eligible to participate in Medicare and/or Medicaid programs but not eligible for the EHR Incentive Program, we considered whether any of these provider types received other funding (e.g., in the form of grants) to support their use of EHR technology. In brief, with one exception, any available "other funding" was not found to be sufficient to support wide-spread adoption and use of EHR technology by any of these ineligible provider types thus this report focuses on those provider types who are ineligible to participate in the EHR Incentive Program.

See Section II.A (Identifying Ineligible Providers) of the report for a complete description of the methodology and criteria used to identify the types of health care providers that were the focus of this study.

  1. HEALTH CARE PROVIDER.--The term ‘health care provider' includes a hospital, skilled nursing facility, nursing facility, home health entity or other long-term care facility, health care clinic, community mental health center (as defined in section 1913(b)(1)), renal dialysis facility, blood center, ambulatory surgical center described in section 1833(i) of the Social Security Act, emergency medical services provider, federally qualified health center, group practice, a pharmacist, a pharmacy, a laboratory, a physician (as defined in section 1861(r) of the Social Security Act), a practitioner (as described in section 1842(b)(18)(C) of the Social Security Act), a provider operated by, or under contract with, the Indian Health Service or by an Indian tribe (as defined in the Indian Self-Determination and Education Assistance Act), tribal organization, or urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act), a rural health clinic, a covered entity under section 340B, an ambulatory surgical center described in section 1833(i) of the Social Security Act, a therapist (as defined in section 1848(k)(3)(B)(iii) of the Social Security Act), and any other category of health care facility, entity, practitioner, or clinician determined appropriate by the Secretary. (PHSA §3000(3))

C. Definitions of Certified EHR Technology

HITECH Section 4104(a) requires, among other things, a study of what is known about the ineligible provider's adoption of certified EHR technology. This study applies the definition of certified EHR technology and qualified EHR from Section 3000(1) and (13) of the PHSA as added by the HITECH Act:3

  1. CERTIFIED ELECTRONIC HEALTH RECORD TECHNOLOGY. The term "certified EHR technology" means a qualified electronic health record that is certified pursuant to section 3001(c)(5) as meeting standards adopted under section 3004 that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals).

  1. QUALIFIED ELECTRONIC HEALTH RECORD. The term "qualified electronic health record" means an electronic record of health-related information on an individual that--

    1. includes patient demographic and clinical health information, such as medical history and problem lists; and

    2. has the capacity--

      1. to provide clinical decision support;
      2. to support physician order entry;
      3. to capture and query information relevant to health care quality; and
      4. to exchange electronic health information with, and integrate such information from other sources.

D. Certification and Certification Criteria for Ineligible Providers

ONC provided guidance to other health care settings (including ineligible providers) on the types of certified EHR technology that support electronic health information exchange with EPs, EHs, and CAHs in the ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health IT.4

The ONC Final Rule provides the following guidance to other health care settings:5

We appreciate the interest in other health care settings expressed by commenters. We agree that it makes good policy sense to support interoperability and the secure electronic exchange of health information between all health care settings. We believe the adoption of EHR technology certified to a minimal amount of certification criteria adopted by the Secretary can support this goal. To this end, we encourage EHR technology developers to certify EHR Modules to the transitions of care certification criteria (§ 170.314(b)(1) and (2)) as well as any other certification criteria that may make it more effective and efficient for EPs, EHs, and CAHs to electronically exchange health information with health care providers in other health care settings. The adoption of EHR technology certified to these certification criteria can facilitate the secure electronic exchange of health information. We concur with commentersthat there are currently private sector organizations that are addressing requests for certification programs for other health care settings.

Transition of Care Criteria (§ 170.314(b)(1) and (2)):6

  1. Transitions of care--receive, display, and incorporate transition of care/referral summaries.

    1. Receive. EHR technology must be able to electronically receive transition of care/referral summaries in accordance with:

      1. The standard specified in § 170.202(a).
      2. Optional. The standards specified in § 170.202(a) and (b).
      3. Optional. The standards specified in § 170.202(b) and (c).
    2. Display. EHR technology must be able to electronically display in human readable format the data included in transition of care/referral summaries received and formatted according to any of the following standards (and applicable implementation specifications) specified in: § 170.205(a)(1), § 170.205(a)(2), and § 170.205(a)(3).

    3. Incorporate. Upon receipt of a transition of care/referral summary formatted according to the standard adopted at § 170.205(a)(3), EHR technology must be able to:

      1. Correct patient. Demonstrate that the transition of care/referral summary received is or can be properly matched to the correct patient.
      2. Data incorporation. Electronically incorporate the following data expressed according to the specified standard(s):
        1. Medications. At a minimum, the version of the standard specified in § 170.207(d)(2);
        2. Problems. At a minimum, the version of the standard specified in § 170.207(a)(3);
        3. Medication allergies. At a minimum, the version of the standard specified in §170.207(d)(2).
      3. Section views. Extract and allow for individual display each additional section or sections (and the accompanying document header information) that were included in a transition of care/referral summary received and formatted in accordance with the standard adopted at § 170.205(a)(3).
  2. Transitions of care--create and transmit transition of care/referral summaries.7

    1. Create. Enable a user to electronically create a transition of care/referral summary formatted according to the standard adopted at § 170.205(a)(3) that includes, at a minimum, the Common Meaningful Use Data Set and the following data expressed, where applicable, according to the specified standard(s):

      1. Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard specified § 170.207(a)(3);
      2. Immunizations. The standard specified in § 170.207(e)(2);
      3. Cognitive status;
      4. Functional status; and
      5. Ambulatory setting only. The reason for referral; and referring or transitioning provider's name and office contact information.
      6. Inpatient setting only. Discharge instructions.
    2. Transmit. Enable a user to electronically transmit the transition of care/referral summary treated in paragraph (b)(2)(i) of this section in accordance with:

      1. The standard specified in § 170.202(a).
      2. Optional. The standards specified in § 170.202(a) and (b).
      3. Optional. The standards specified in § 170.202(b) and (c).

ONC HIT Certification Program

Section 3001(c)(5) of the PHSA, as added by HITECH, requires the Office of the National Coordinator to keep or recognize a program for the voluntary certification of health information technology as being in compliance with applicable certification criteria. ONC established the ONC HIT Certification Program, under which health information technology products are tested and certified by authorized entities. ONC established both temporary and permanent testing and certification programs through rulemaking. The temporary program authorized ONC Authorized Testing and Certification Bodies (ONC-ATCBs). In subsequent rulemaking, ONC sunset the temporary program which referred to ONC-ATCBs and launched the ONC HIT Certification Program, which now includes ONC-Authorized Certification Bodies (ONC-ACBs) and Accredited Testing Laboratories (ATLs).8

The ONC HIT Certification Program requires that ONC-ACBs certify health IT including complete EHRs and/or EHR modules. Section 170.102 of the Code of Federal Regulations includes the following definition of base, complete and modular EHR:9

Base EHR means an electronic record of health-related information on an individual that:

  1. Includes patient demographic and clinical health information, such as medical history and problem lists;

  2. Has the capacity:

    1. To provide clinical decision support;
    2. To support physician order entry;
    3. To capture and query information relevant to health care quality;
    4. To exchange electronic health information with, and integrate such information from other sources;
    5. To protect the confidentiality, integrity, and availability of health information stored and exchanged; and
  3. Has been certified to the certification criteria adopted by the Secretary at: § 170.314(a)(1), (3), and (5) through (8); (b)(1), (2), and (7); (c)(1) through (3); (d)(1) through (8).

  4. Has been certified to the certification criteria at § 170.314(c)(1) and (2):

    1. For no fewer than 9 clinical quality measures covering at least 3 domains from the set selected by CMS for eligible professionals, including at least 6 clinical quality measures from the recommended core set identified by CMS; or
    2. For no fewer than 16 clinical quality measures covering at least 3 domains from the set selected by CMS for eligible hospitals and critical access hospitals.

Certified EHR Technology means:

  1. For any Federal fiscal year (FY) or calendar year (CY) up to and including 2013:

    1. A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition EHR certification criteria or the equivalent 2014 Edition EHR certification criteria; or

    2. A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition EHR certification criteria or the equivalent 2014 Edition EHR certification criteria, and the resultant combination also meets the requirements included in the definition of a Qualified EHR; or

    3. EHR technology that satisfies the definition for FY and CY 2014 and subsequent years specified in paragraph (2);

  2. For FY and CY 2014 and subsequent years, the following: EHR technology certified under the ONC HIT Certification Program to the 2014 Edition EHR certification criteria that has:

    1. The capabilities required to meet the Base EHR definition; and

    2. All other capabilities that are necessary to meet the objectives and associated measures under 42 CFR 495.6 and successfully report the clinical quality measures selected by CMS in the form and manner specified by CMS (or the States, as applicable) for the stage of meaningful use that an eligible professional, eligible hospital, or critical access hospital seeks to achieve. Common MU Data Set means the following data expressed, where indicated, according to the specified standard(s):

      1. Patient name.
      2. Sex.
      3. Date of birth.
      4. Race--the standard specified in § 170.207(f).
      5. Ethnicity--the standard specified in § 170.207(f).
      6. Preferred language--the standard specified in § 170.207(g).
      7. Smoking status--the standard specified in § 170.207(h).
      8. Problems--at a minimum, the version of the standard specified in § 170.207(a)(3).
      9. Medications--at a minimum, the version of the standard specified in § 170.207(d)(2).
      10. Medication allergies--at a minimum, the version of the standard specified in § 170.207(d)(2).
      11. Laboratory test(s)--at a minimum, the version of the standard specified in § 170.207(c)(2).
      12. Laboratory value(s)/result(s).
      13. Vital signs--height, weight, blood pressure, BMI.
      14. Care plan field(s), including goals and instructions.
      15. Procedures--
        1. At a minimum, the version of the standard specified in § 170.207(a)(3) or § 170.207(b)(2).
        2. Optional. The standard specified at § 170.207(b)(3).
        3. Optional. The standard specified at § 170.207(b)(4).
      16. Care team member(s).

Complete EHR, 2011 Edition means EHR technology that has been developed to meet, at a minimum, all mandatory 2011 Edition EHR certification criteria for either an ambulatory setting or inpatient setting.

Complete EHR, 2014 Edition means EHR technology that meets the Base EHR definition and has been developed to meet, at a minimum, all mandatory 2014 Edition EHR certification criteria for either an ambulatory setting or inpatient setting.

Discussion of the Relationship of EHR Certification for an Ineligible Provider

This section includes excerpts from the HHS/ASPE report "Opportunities for Engaging LTPAC Providers in Health Information Exchange", a study in which the relationship and challenges of EHR certification related to ineligible providers was discussed.10

HITECH requires the use of certified EHR technology for certain providers (e.g., physicians and short-term acute care hospitals) to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs ("EHR Incentive Programs"). For purposes of the EHR Incentive Programs, two types of certifications can be issued to EHR technology that meets certification criteria adopted by the Secretary of HHS: (1) Complete EHR, or (2) EHR Module. To be eligible for meaningful use incentive payments, eligible hospitals (EHs) and eligible professionals (EPs) must use EHR technology that has been certified by an entity authorized by ONC. To date, four ONC-Authorized Certification Bodies (ONC-ACBs)11 have been authorized to test and certify EHR technology that can be used by eligible professionals and hospitals in the EHR Incentive Programs.12 For example, EHR certification criteria include (but are not limited to) vocabulary standards (e.g., Systematized Nomenclature of Medicine (SNOMED), International Classification of Diseases (ICD), Logical Observation Identifiers Names and Codes (LOINC)) and content exchange standards (e.g., Clinical Document Architecture (CDA) and Continuity of Care Document (CCD)).

While some EHR technology certification criteria used for the EHR Incentive Programs for EPs and EHs would be applicable to the workflow in LTPAC setting, there is growing concern and awareness that not all of the certification criteria are applicable to EHR technology used by LTPAC providers. For example, the capability to plot growth charts or submit to immunization registries would not be a typical feature of a LTPAC EHR technology. Additionally, the adopted EHR technology certification criteria do not reflect the requirements that are uniquely needed by LTPAC providers.

For several years, the LTPAC provider and vendor community worked with Health Level 7 (HL7) (a Standards Development Organization) to produce an EHR Functional Profile for LTPAC. This Profile was used by LTPAC stakeholders and the Certification Commission for Health Information Technology (CCHIT) to identify LTPAC EHR certification criteria.13 It should be noted that the CCHIT LTPAC EHR Certification Program has not been recognized by ONC. While there is significant overlap in the EHR criteria that have been adopted for the EHR Incentive Programs and the LTPAC EHR Certification Criteria, there are also differences in the criteria that have been identified in these two programs. This misalignment has created confusion and uncertainty among LTPAC providers regarding whether they should purchase certified EHRs and if so, what type of certified EHR product would support the workflow of the LTPAC provider. ONC is aware of the uncertainties and questions regarding EHR certification confronting LTPAC and other providers that are ineligible under the EHR Incentive Programs and is working with stakeholders to better understand their EHR technology needs.

During the discussion at the 2011 LTPAC HIT Summit at the session on "Moving LTPAC Providers in the Nationwide Health IT Infrastructure," providers and vendors concluded that there is likely a core set of EHR criteria that will be common across all EHR products (e.g., requirements related to privacy/ security, medication reconciliation, problem list, etc.).14 During this discussion, providers and vendors suggested that ONC consider: (1) meeting with LTPAC providers and vendors to identify what EHR certification criteria are needed to support the workflow in LTPAC; and (2) working with the Meaningful Use Workgroup of the Health IT Policy Committee to identify the types of HIE activities that are needed in and from LTPAC. The Longitudinal Coordination of Care Workgroup (LCCWG) created through the ONC-sponsored S&I Framework (described in more detail below) is beginning to examine the health IT standards needed to support HIE on behalf of persons receiving LTPAC. The HIE activities targeted in this S&I effort are expected to advance the meaningful use of EHRs and shed some light on some of the EHR certification criteria needed by LTPAC providers.ad

Experts interviewed as part of this study noted that there is growing discussion about the need to integrate LTPAC providers in HIE activities to support quality, continuity, and collaborative care (Appendix A: Stakeholder Interview Summary). To support efficient and interoperable HIE, some LTPAC providers and EHR vendors believe that it is important to use EHR products that support at least some of the standards incorporated in certification criteria for the Meaningful Use Incentive Program.

As reported at the 2011 LTPAC Health IT Summit, some vendors expressed an interest in obtaining certification for their EHR products as either: (1) meeting the meaningful use requirements; and/or (2) complying with the LTPAC CCHIT comprehensive EHR criteria.15 At least one LTPAC vendor has obtained hospital modular EHR certification (through an ONC-ATCB) for their product to support the interoperable and secure exchange of health information such as demographics, problem lists, physician order entry, medication lists, medication reconciliation, and advance directives. This LTPAC health IT vendor and one other have also obtained LTPAC CCHIT EHR certification.16

To support widespread adoption of appropriate and interoperable EHRs for LTPAC, the LTPAC health IT Collaborative recommended in the LTPAC 2010-2012 Health IT Roadmap17 that policy guidance be provided for the EHR certification criteria needed to enable the exchange of health information between hospitals, physicians and LTPAC providers. The members of the Collaborative believe that such criteria would facilitate HIE with and by LTPAC providers, support the meaningful use of EHRs by a wide array of health care providers, and support the emerging nationwide infrastructure.

At this time the ONC has not established a specialty EHR certification program (e.g., a certification and testing program for EHR products for LTPAC providers (or other specialty providers)) or identified EHR certification criteria that are unique to the workflow requirements in LTPAC or other specialty providers. Establishing such a program or identifying EHR certification criteria is complex, could be costly, and requires careful consideration of the advantages and disadvantages. An objective in the draft roadmap of the recently established LCCWG under the ONC-sponsored S&I Framework is to "develop certification requirements for EHR and LTPAC vendors in anticipation of LTPAC pilots."18 As described above, in Section D "Certification and Certification Criteria for Ineligible Providers," in the Final Rule for EHR Standards, Implementation Specifications, and certification Criteria for the Stage 2 EHR Incentive Programs, ONC encouraged EHR technology developers to certify EHR Modules to the transitions of care certification criteria as well as any other certification criteria that may make it more effective and efficient for EPs, EHs, and CAHs to electronically exchange health information with health care providers in other health care settings."

Notes

  1. Section §4104(a): "The Secretary of Health and Human Services shall conduct a study to determine the extent to which and manner in which payment incentives (such as under title XVIII or XIX of the Social Security Act) and other funding for purposes of implementing and using certified EHR technology (as defined in section 1848(o)(4) of the Social Security Act, as added by section 4101(a)) should be made available to health care providers who are receiving minimal or no payment incentives or other funding under this Act, under title XIII of division A, under title XVIII or XIX or such Act, or otherwise, for such purposes."

  2. The Secretary has not specified any additional issues to be addressed in the report (item vi).

  3. American Recovery and Reinvestment Act of 2009. Title XIII: Health Information Technology. Section 3000: Definitions. Accessed September 2012 at http://thomas.loc.gov/cgi-bin/query/F?c111:1:./temp/~c111CFl6DB:e356887.

  4. ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health IT http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf.

  5. Federal Register page 54275. ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health IT http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf.

  6. Federal Register page 54288. ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health IT http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf.

  7. Federal Register page 54288. ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health IT http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf.

  8. The Office of the National Coordinator for Health Information Technology. "Permanent Certification Program for EHR Technology." http://www.healthit.gov/policy-researchers-implementers/certification-bodies-testing-laboratories.

  9. Federal Register pages 54283-54284. ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health IT http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf.

  10. Dougherty, Michelle, and Jennie Harvell. Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information.U.S. Department of Health and Human Services. Office of the Assistant Secretary for Planning & Evaluation, December 2011. Accessed September 2012 at http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm.

  11. See http://www.healthit.gov/policy-researchers-implementers/certification-bodies-testing-laboratories#ABC.

  12. Establishment of the Permanent Certification Program for Health Information Technology. 45 CFR Part70. 2011.

  13. The CCHIT is the only entity to date that has established criteria for LTPAC EHR products.

  14. Harvell, J. Moving LTPAC Providers in the Nationwide Health IT Infrastructure Boardroom Session at the 2011 LTPAC HIT Summit. June 2011.

  15. 2011 CCHIT Certification for Long Term and Post Acute Care. http://www.cchit.org/certify/2011/cchit-certified-2011-long-term-post-acute-care-ltpac-ehr.

  16. ONC-ATCB ONC Certified Technology. CCHIT.Accessed at: http://www.cchit.org/products/onc-atcb/all/2000.

  17. A Roadmap for Health IT in Long Term and Post Acute Care (LTPAC), 2010-2012. LTPAC Health IT Collaborative.AHIMA. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047579.pdf.

  18. LCCWG, LTPAC WG Roadmap. ONC Standards & Interoperability Framework. http://wiki.siframework.org/LTPAC+WG+Roadmap.

[Return to the Table of Contents]

 

APPENDIX C. PUBLIC HEALTH SERVICE ACT SECTION 3000(3) AS ADDED BY HITECH SECTION 13101 -- PROVIDER ANALYSIS

This appendix provides an analysis of the providers identified in Section 3000(3) of the Public Health Service Act (PHSA), as added by Section 13101 of HITECH, to determine whether they were eligible or ineligible to receive EHR incentive payments under Medicare or Medicaid. If a provider was identified in the PHSA Section 3000(3) but not defined, another source for a definition was researched in Table C1. For those providers identified in the PHSA Section 3000(3), but considered ineligible for the EHR incentive payments under Medicare or Medicaid, a further analysis was done by health care cluster in Tables C2-C5. The four health care clusters of provider types include long-term and post-acute care providers, behavioral health providers, safety net providers, and other. Although certain types of provider entities are not eligible for EHR incentive payments under Medicare or Medicaid, we note that the professionals who practice in those entities may themselves be eligible and may be able to reassign their EHR incentive payments to the provider entity in accordance with the reassignment rules under Medicare.

Section 13101 of HITECH added the following definition of health care provider in Section 3000(3) of the PHSA:1

The term "health care provider" includes a hospital, skilled nursing facility, nursing facility, home health entity or other long-term care facility, health care clinic, community mental health center (as defined in section 1913(b)(1)), renal dialysis facility, blood center, ambulatory surgical center described in section 1833(i) of the Social Security Act, emergency medical services provider, federally qualified health center, group practice, a pharmacist, a pharmacy, a laboratory, a physician (as defined in section 1861(r) of the Social Security Act), a practitioner (as described in section 1842(b)(18)(C) of the Social Security Act), a provider operated by, or under contract with, the Indian Health Service or by an Indian tribe (as defined in the Indian Self-Determination and Education Assistance Act), tribal organization, or urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act), a rural health clinic, a covered entity under section 340B, an ambulatory surgical center described in section 1833(i) of the Social Security Act, a therapist (as defined in section 1848(k)(3)(B)(iii) of the Social Security Act), and any other category of health care facility, entity, practitioner, or clinician determined appropriate by the Secretary.

TABLE C1. Environmental Scan of Health Care Provider Defined and Providers Eligible/Ineligible for Incentives
Health Care Providers in PHSA Section 2000(3) Defined in PHSA 2000(3) Defined Elsewhere in HITECH? In SSA Medicare or Medicaid? Other Definition? Receives EHR Incentives Under HITECH?
  1. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-f.
  2. See http://www.ssa.gov/OP_Home/ssact/title18/1814.htm#act-1814-b.
  3. See http://www.ssa.gov/OP_Home/ssact/title18/1891.htm#act-1891-a.
  4. See http://www.ssa.gov/OP_Home/ssact/title18/1812.htm#act-1812-a-5.
  5. See http://www.ssa.gov/OP_Home/ssact/title18/1812.htm#act-1812-d.
  6. See http://www.ssa.gov/OP_Home/ssact/title19/1905.htm#ft153#ft153.
  7. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-dd-1.
  8. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-dd-2.
  9. See http://www.ssa.gov/OP_Home/ssact/title18/1812.htm#act-1812-d-2-a.
  10. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-f.
  11. See http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/WhatisaPRTF.pdf.
  12. See http://www.law.cornell.edu/cfr/text/42/483.352.
  13. See http://www.law.cornell.edu/cfr/text/42/483.
  14. See http://www.hhs.gov/dab/decisions/cr649.html.
  15. See http://www.federalregister.gov/articles/2011/06/17/2011-14673/ medicare-program-conditions-of-participation-cops-for-community-mental-health-centers.
  16. See http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/EstablishmentRegistration/BloodEstablishment Registration/default.htm.
  17. See http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Blood/UCM164981.pdf.
  18. See http://www.ssa.gov/OP_Home/ssact/title18/1832.htm#act-1832-a-2-f-i.
  19. See http://www.ssa.gov/OP_Home/ssact/title18/1833.htm#act-1833-i-1-a.
  20. See http://www.ssa.gov/OP_Home/ssact/title18/1833.htm#act-1833-i-2-a.
  21. See http://www.ssa.gov/OP_Home/ssact/title18/1833.htm#act-1833-i-2-a-iii.
  22. See http://www.ems.gov/index.htm.
  23. See http://www.ems.gov/pdf/EMSWorkforceReport_June2008.pdf.
  24. See http://www.ems.gov/nemsis/overview.html.
  25. See http://www.cms.gov/MedicareProviderSupEnroll/Downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf.
  26. See https://www.cms.gov/center/ambulance.asp.
  27. See https://www.cms.gov/MLNproducts/downloads/AmbSurgCtrFeepymtfctsht508-09.pdf.
  28. See http://oig.hhs.gov/fraud/docs/complianceguidance/032403ambulancecpgfr.pdf.
  29. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#ft302#ft302.
  30. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa-1.
  31. See http://www.ssa.gov/OP_Home/ssact/title19/1905.htm#ft150#ft150.
  32. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa-2-b.
  33. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c05.pdf.
  34. See http://www.ssa.gov/OP_Home/ssact/title18/1814.htm#act-1814-a.
  35. See http://www.ssa.gov/OP_Home/ssact/title18/1832.htm#act-1832-a-2-f-ii.
  36. See http://www.ssa.gov/OP_Home/ssact/title18/1835.htm.
  37. See http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf.
  38. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa-5.
  39. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-bb-2.
  40. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-gg-2.
  41. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-hh-1.
  42. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-ii.
  43. See http://www.ihs.gov/index.cfm.
  44. See http://www.ihs.gov/recovery/index.cfm?module=dsp_arra_meaningful_use.
  45. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-s-2-a.
  46. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-s-10.
  47. See http://www.ssa.gov/OP_Home/ssact/title18/1866.htm.
  48. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa.
  49. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa-2.
  50. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa-2-b.
  51. See http://www.cga.ct.gov/2006/rpt/2006-R-0720.htm.
  52. See http://www.hrsa.gov/opa.
Hospital No Yes. SSA.

Medicare Hospital: §1886(d)(1)(B) ... "subsection (d) hospital" means a hospital located in one of the 50 states or the District of Columbia other than-- (i) a psychiatric hospital (as defined in section 1861(f)1), (ii) a rehabilitation hospital (as defined by the Secretary), (iii) a hospital whose inpatients are predominantly individuals under 18 years of age, (iv) (I) a hospital which has an average inpatient length of stay (as determined by the Secretary) of greater than 25 days, or... (v) (I) a hospital that the Secretary has classified, at any time on or before December 31, 1990, (or, in the case of a hospital that, as of the date of the enactment of this clause, is located in a state operating a demonstration project under section 1814(b)2, on or before December 31, 1991) for purposes of applying exceptions and adjustments to payment amounts under this subsection, as a hospital involved extensively in treatment for or research on cancer... and, in accordance with regulations of the Secretary, does not include a psychiatric or rehabilitation unit of the hospital which is a distinct part of the hospital (as defined by the Secretary)."

Medicaid: Hospital §1905(a)(1) (a) The term "medical assistance" means payment of part or all of the cost of the following care and services... (1) inpatient hospital services (other than services in an institution for mental diseases (IMD)).

Yes.

Medicare EHR Incentives available to subsection(d) hospitals

Medicaid EHR incentives available to: Short-term acute care hospitals, children's hospitals, and hospitals in the territories (e.g., Puerto Rico)

Critical access hospitals and cancer hospitals.

EHR incentives not available for a subset of hospitals and hospital units excluded from the Medicare IPPS under SSA §1886(d)(1)(B), specifically:

  • psychiatric
  • rehabilitation
  • long-term care hospitals
Skilled Nursing Facility No Yes. SSA.

§1819(a) A Medicare participating institution that provides skilled nursing care and related services for residents who require medical or nursing care; or provide rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases, has in effect a transfer agreement with a hospital(s), and meets the federal requirements for participation as specified under the Act.

EHR incentives are not available for:
  • Nursing Homes: Medicare SNFs and Medicaid NFs
  • Medicare and Medicaid Home Health Agencies and Hospice Providers
Nursing Facility No Yes. SSA.

§1905(a) the term "medical assistance" means payment of part or all of the cost of the following care and services.

§1905(a)(4)(A) nursing facility services (other than services in an IMD) for individuals 21 years of age or older...

§1919(a) A Medicaid participating institution (NF), that is primarily engaged in providing: skilled nursing care and related services for residents who require medical or nursing care; rehabilitation of injured, disabled, or sick persons; or, on a regular-basis, health-related care and services to individuals who because of their mental/physical condition require care and services above the level of room and board which can be made available through institutional facilities, and is not primarily for the care and treatment of mental diseases; and has in effect a transfer agreement with a hospital(s), and meets the federal requirements for participation as specified under the Act. Also includes facilities located on an Indian reservation and is certified by the Secretary to as meeting the NF definition and requirements in the Act.

Home health entity or other long-term care facility No Neither Medicare nor Medicaid defines "home health entity" or "long-term care facility" as participating providers. However, the following providers are defined in Medicare and/or Medicaid:

HOME HEALTH AGENCY (HHA):

1. Home health services: SSA §1861(m) "home health services" means the following items and services furnished to an individual, under the care of a physician, by a home health agency or by others under arrangements, under a plan established and periodically reviewed by a physician, provided on a visiting basis in a place of residence used as such individual's home--

  1. part-time or intermittent nursing care provided by/under supervision of a registered professional nurse;
  2. physical or occupational therapy or speech-language pathology services;
  3. medical social services under the direction of a physician;
  4. to the extent permitted in regulations, part-time or intermittent services of a HH aide;
  5. medical supplies and durable medical equipment while under such a plan;
  6. in the case of a HHA affiliated with a hospital, medical services provided by an intern or resident-in-training of such hospital, under a teaching program of such hospital...; and
  7. any of the foregoing items and services provided on an outpatient basis, under arrangements made by the HHA, at a hospital or skilled nursing facility, or at a rehabilitation center which meets such standards as may be prescribed in regulations, and--...

Home Health Agency. §1861(o): The term "home health agency" means a public agency or private organization, or a subdivision of such an agency or organization, which:

  1. is primarily engaged in providing skilled nursing services and other therapeutic services;
  2. has policies, established by a group of professional personnel (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services (referred to in paragraph (1)) which it provides, and provides for supervision of such services by a physician or registered professional nurse;
  3. maintains clinical records on all patients;
  4. in the case of an agency or organization in any state in which state or applicable local law provides for the licensing of agencies or organizations of this nature, (A) is licensed pursuant to such law, or (B) is approved, by the agency of such state or locality responsible for licensing agencies or organizations of this nature, as meeting the standards established for such licensing;
  5. has in effect an overall plan and budget that meets the requirements of subsection (z);
  6. meets the conditions of participation specified in section 1891(a)3and such other conditions of participation as the Secretary may find necessary in the interest of the health and safety of individuals who are furnished services by such agency or organization;
  7. provides the Secretary with a surety bond --...
  8. meets such additional requirements (including conditions relating to bonding or establishing of escrow accounts as the Secretary finds necessary for the financial security of the program) as the Secretary finds necessary for the effective and efficient operation of the program; except that for purposes of part A such term shall not include any agency or organization which is primarily for the care and treatment of mental diseases. The Secretary may waive the requirement of a surety bond under paragraph (7) in the case of an agency or organization that provides a comparable surety bond under state law.

Hospice Care. SSA §1861(dd)(1): The term "hospice care" means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual's attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program--

  1. nursing care provided by or under the supervision of a registered professional nurse,
  2. physical or occupational therapy, or speech-language pathology services,
  3. medical social services under the direction of a physician,
  4. (i) services of a home health aide who has successfully completed a training program approved by the Secretary and
    (ii) homemaker services,
  5. medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan,
  6. physicians' services,
  7. short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days,
  8. counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death, and
  9. any other item or service which is specified in the plan and for which payment may otherwise be made under this title.

The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home. §1814(i) Medicare payment for hospice.

Hospice Program. §1861(dd)(2) The term "hospice program" means a public agency or private organization (or a subdivision thereof) which--

  1. (i) is primarily engaged in providing the care and services described in paragraph (1) and makes such services available (as needed) on a 24-hour basis and which also provides bereavement counseling for the immediate family of terminally ill individuals and services described in section 1812(a)(5)4,
    (ii) provides for such care and services in individuals' homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization, except that--
    (I) the agency or organization must routinely provide directly substantially all of each of the services described in subparagraphs (A), (C), and (H) of paragraph (1), except as otherwise provided in paragraph (5), and
    (II) in the case of other services described in paragraph (1) which are not provided directly by the agency or organization, the agency or organization must maintain professional management responsibility for all such services furnished to an individual, regardless of the location or facility in which such services are furnished; and
    (iii) provides assurances satisfactory to the Secretary that the aggregate number of days of inpatient care described in paragraph (1)(G) provided in any 12-month period to individuals who have an election in effect under section 1812(d)5 with respect to that agency or organization does not exceed 20 percent of the aggregate number of days during that period on which such elections for such individuals are in effect;
  2. has an interdisciplinary group of personnel which--
    (i) includes at least--
    (I) one physician (as defined in subsection (r)(1)),
    (II) one registered professional nurse, and
    (III) one social worker, employed by or, in the case of a physician described in subclause (I), under contract with the agency or organization, and also includes at least one pastoral or other counselor,
    (ii) provides (or supervises the provision of) the care and services described in paragraph (1), and
    (iii) establishes the policies governing the provision of such care and services;
  3. maintains central clinical records on all patients;
  4. does not discontinue the hospice care it provides with respect to a patient because of the inability of the patient to pay for such care;
  5. (i) utilizes volunteers in its provision of care and services in accordance with standards set by the Secretary, which standards shall ensure a continuing level of effort to utilize such volunteers, and
    (ii) maintains records on the use of these volunteers and the cost savings and expansion of care and services achieved through the use of these volunteers;
  6. in the case of an agency or organization in any state in which state or applicable local law provides for the licensing of agencies or organizations of this nature, is licensed pursuant to such law; and
  7. meets such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals who are provided care and services by such agency or organization.

2. Medicaid Home health agencies (HHAs):
Medicaid: §1905(a) the term "medical assistance" means payment of part or all of the cost of the following care and services:

  • §1905(a)(7) home health care services. HH services are a mandatory Medicaid service for financially eligible person 21 years of age and older.

Medicaid Hospice. Mandatory Medicaid benefit.
Medicaid: §1905(a) the term "medical assistance" means payment of part or all of the cost of the following care and services:

  • §1905(a)(18) hospice care (as defined in subsection (o));
  • §1905(o)(1)(A) Subject to subparagraphs (B) and (C)[153]6, the term "hospice care" means the care described in section 1861(dd)(1)7 furnished by a hospice program (as defined in section 1861(dd)(2)8) to a terminally ill individual who has voluntarily elected (in accordance with paragraph (2)) to have payment made for hospice care instead of having payment made for certain benefits described in section 1812(d)(2)(A)9 and for which payment may otherwise be made under title XVIII and intermediate care facility services under the plan. For purposes of such election, hospice care may be provided to an individual while such individual is a resident of a skilled nursing facility or intermediate care facility, but the only payment made under the State plan shall be for the hospice care.

LONG-TERM CARE FACILITES:
The concept of "long-term care facility" could include the following Medicaid residential provider types described below.

  • Medicaid ICF/IID. (Intermediate Care Facilities for Individuals with Intellectual Disabilities, previously referred to as Intermediate Care Facilities for the Mentally Retarded) §1905(d) Optional Medicaid benefit, The term "intermediate care facility for the mentally retarded" means an institution (or distinct part thereof) for the mentally retarded or persons with related conditions if--
    1. the primary purpose of such institution (or distinct part thereof) is to provide health or rehabilitative services for mentally retarded individuals and the institution meets such standards as may be prescribed by the Secretary;
    2. the mentally retarded individual with respect to whom a request for payment is made under a plan approved under this title is receiving active treatment under such a program; and...
  • Inpatient Psychiatric Hospital Services for individuals under the age of 21 §1905(a)(16), as defined in (h).

    §1905(h)(1) For purposes of paragraph (16) of subsection (a), the term "inpatient psychiatric hospital services for individuals under age 21" includes only--

    1. inpatient services which are provided in an institution (or distinct part thereof) which is a psychiatric hospital as defined in section 1861(f)10 or in another inpatient setting that the Secretary has specified in regulations;
    2. inpatient services which, in the case of any individual (i) involve active treatment which meets such standards as may be prescribed in regulations by the Secretary, and (ii) a team, consisting of physicians and other personnel qualified to make determinations with respect to mental health conditions and the treatment thereof, has determined are necessary on an inpatient basis and can reasonably be expected to improve the condition, by reason of which such services are necessary, to the extent that eventually such services will no longer be necessary; and
    3. inpatient services which, in the case of any individual, are provided prior to (i) the date such individual attains age 21, or (ii) in the case of an individual who was receiving such services in the period immediately preceding the date on which he attained age 21, (I) the date such individual no longer requires such services, or (II) if earlier, the date such individual attains age 22.

    §1905(i) The term "institution for mental diseases" means a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

  • IMD provides services to persons 65 and over--Inpatient/ nursing facility services for individuals 65 and over in an IMD (over 8 beds includes hospitals).

    §1905(a)(14) inpatient hospital services and nursing facility services for individuals 65 years of age or over in an IMD;

Psychiatric Residential Treatment Facility (PRTF).11 A PRTF is any non-hospital facility with a provider agreement with a State Medicaid Agency to provide the inpatient services benefit to Medicaid-eligible individuals under the age of 21 (psych under 21 benefit)...

PRTFs must also meet the requirements in §441.151 through 441.182 of the CFT...

The regulatory authority for PRTFs includes Section 1864(a) of the SSA, which authorizes the Secretary to enter into an agreement with the state.

42 CFR 441.151 General Requirements:
(a) Inpatient psychiatric services for individuals under age 21 must be:

  1. Provided under the direction of a physician; (2) Provided by--
    (i) A psychiatric hospital...
    (b) Inpatient psychiatric services furnished in a PRTF as defined in §483.35212 of this chapter, must satisfy all requirements in subpart G of part 483 of this chapter13 governing the use of restraint and seclusion.
EHR Incentives not available for home health entities or long-term care facilities.
Health care clinic No Health care clinics include:
  • Federally qualified health center (FQHC) (see below)
  • Rural health clinic (RHC) descriptions (see below)
 
Community mental health center (as defined in §1931(b)(1) (of the Public Health Services Act) Yes
PHSA
§1931(b)(1)
Yes. SSA.

1. Community Mental Health Clinic defined under Partial Hospitalization Services §1861(ff)

  1. "partial hospitalization services" means the items and services described in paragraph (2) prescribed by a physician and provided under a program described in paragraph (3) under the supervision of a physician pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such program), which plan sets forth the physician's diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan.
  2. The items and services described in this paragraph are--
    1. individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under state law),
    2. occupational therapy requiring the skills of a qualified occupational therapist,
    3. services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients,
    4. drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered),
    5. individualized activity therapies that are not primarily recreational or diversionary,
    6. family counseling (the primary purpose of which is treatment of the individual's condition),
    7. patient training and education (to the extent that training and educational activities are closely and clearly related to individual's care and treatment),
    8. diagnostic services, and
    9. such other items and services as the Secretary may provide (but in no event to include meals and transportation);that are reasonable and necessary for the diagnosis or active treatment of the individual's condition, reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement).
  3.  
    1. A program described in this paragraph is a program which is furnished by a hospital to its outpatients or by a CMHC (as defined in subparagraph (B)), and which is a distinct and organized intensive ambulatory treatment service offering less than 24-hour-daily care.
    2. For purposes of subparagraph (A), the term "community mental health center" means an entity that--(i)(I) provides the mental health services described in section 1931(c)(1) of the PHSA; or (II) in the case of an entity operating in a state that by law precludes the entity from providing itself the service described in subparagraph (E) of such section, provides for such service by contract with an approved organization or entity (as determined by the Secretary); (ii) meets applicable licensing or certification requirements for CMHCs in the state in which it is located; and (iii) meets such additional conditions as the Secretary shall specify to ensure (I) the health and safety of individuals being furnished such services, (II) the effective and efficient furnishing of such services, and (III) the compliance of such entity with the criteria described in section 1931(c)(1) of the PHSA.14

§1931(c)(1) PHSA: section 1931(c)(1) of the PHSA. "Under this section, the services that a CMHC must provide include the following: (i) outpatient services, including specialized outpatient services for children, the elderly, the seriously mentally ill, and residents of the...[CMHC's] service area discharged from inpatient treatment at a mental health facility; (ii) 24-hour-a-day emergency care services; (iii) day treatment or other partial hospitalization services or psychosocial rehabilitation services; and (iv) screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission."

"...Secretary of this Department has issued a regulation which defines the term "community mental health center." There, a CMHC is defined as an entity that (1) Provides outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of its mental health service area who have been discharged from inpatient treatment at a mental health facility; (2) Provides 24-hour-a-day emergency care services; (3) Provides day treatment or other partial hospitalization services, or psychosocial rehabilitation services; (4) Provides screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission; (5) Provides consultation and education services; and (6) Meets applicable licensing or certification requirements for CMHC's in the state in which it is located. 42 C.F.R. 410.2"

In 2007, 224 certified CMHCs billed Medicare for partial hospitalization services for 25,087 Medicare beneficiaries. In June 2011, CMS proposed a set of requirements that Medicare-certified CMHCs must meet in order to participate in the Medicare program.15

EHR Incentive payments not available for:
  • Community Mental Health Centers (CMHCs)
Renal dialysis facility No Yes. SSA.

§1881 Medicare coverage for End Stage Renal Disease Patients

§1881(b)(1) Payments under this title with respect to services...furnished to individuals who have been determined to have end stage renal disease shall include (A) payments...to providers of services and renal dialysis facilities...

EHR incentives not available for:
  • End Stage Renal Dialysis Facilities (ESRD Facilities)
Blood center No Yes. Federal Food, Drug, and Cosmetic Act, §510

All owners or operators of establishments that manufacture blood products are required to register with the FDA, pursuant to section 510 of the Federal Food, Drug, and Cosmetic Act, unless they are exempt under 21 CFR 607.65. A list of every blood product manufactured, prepared, or processed for commercial distribution must also be submitted.16

Blood and blood components applicable to the prevention, treatment, or cure of human diseases or injuries are biological products subject to regulation pursuant to Section 351 of the Public Health Service (PHS) Act [42 U.S.C. 262].17

Blood establishments should be aware that under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), establishments performing laboratory testing, including blood banks, transfusion services, and plasmapheresis centers, must also comply with applicable regulations in 42 CFR, Part 493. These regulations, generally effective September 1, 1992, establish standards for laboratory personnel, quality control, proficiency testing, patient test management, and QA based on test complexity and patient risk factors.

EHR incentives not available for:
  • Blood Centers
Ambulatory surgical center (as described in §1833(i) of the SSA) Yes

SSA §1833(i)

Yes. SSA.

§1833(i)(1) The Secretary shall,...--(A) specify those surgical procedures which are appropriately (when considered in terms of the proper utilization of hospital inpatient facilities) performed on an inpatient basis in a hospital but which also can be performed safely on an ambulatory basis in an ASC (meeting the standards specified under section 1832(a)(2)(F)(i)18), critical access hospital, or hospital outpatient department, and (B) specify those surgical procedures which are appropriately (when considered in terms of the proper utilization of hospital inpatient facilities) performed on an inpatient basis in a hospital but which also can be performed safely on an ambulatory basis in a physician's office.

§1832(a)(2)(F) facility services furnished in connection with surgical procedures specified by the Secretary--(i) pursuant to section 1833(i)(1)(A)19 and performed in an ASC (which meets health, safety, and other standards specified by the Secretary in regulations) if the center has an agreement in effect with the Secretary by which the center agrees to accept the standard overhead amount determined under section 1833(i)(2)(A)20 as full payment for such services (including intraocular lens in cases described in section 1833(i)(2)(A)(iii)21) and to accept an assignment

EHR incentives not available for:
  • Ambulatory Surgical Centers (ASCs)
Emergency medical services provider No No commonly accepted definition.

A Federal Interagency Committee on Emergency Medical Services (FICEMS) was established in 2005 by the U.S. Department of Transportation Reauthorization, Public Law 109-59 (Section 10202), to ensure coordination among federal agencies involved with state, local, tribal, and regional emergency medical services and 9-1-1 systems, since there is no single agency in charge. There is no definition at the FECEMS website of an "EMS provider." In response to the FAQ "Who delivers prehospital emergency medical care?," this answer is given:

"The delivery of emergency medical care is a local function and is organized in a variety of ways. Local communities design their own EMS systems, using local resources to fill local needs. The organizational structure of EMS, as well as who provides and finances the services, varies significantly from community to community. Prehospital services can be based in a fire department, a hospital, an independent government agency (i.e., public health agency), non-profit corporation (e.g., Rescue Squad) or provided by commercial for-profit companies."22 A federally-sponsored report found at that site discusses the importance of Emergency Medical Technicians (EMTs) and paramedics as part of the system.23 "The National EMS Information System (NEMSIS) will provide the framework for collecting, storing, and sharing standardized EMS data from states nationwide. The new NEMSIS database, to be housed at NHTSA's National Center for Statistics and Analysis, will empower EMS stakeholders at the local, state, and national levels with the information necessary to accurately assess EMS needs and performance today--and strategically plan for tomorrow."24

The term "Emergency medical services provider" is commonly used for:

  • "ambulance services provider,"
  • "rescue squads," and
  • semi-professionals such as EMTs,
  • Ambulance Service.

Ambulance providers/service are eligible to enroll in Medicare.25,26,27,28

"The ambulance benefit is defined in title XVIII of the SSA in §1861(s)(7): "ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations."

EHR incentives not available for:
  • Emergency medical service providers, including Medicare ambulance providers
Federally Qualified Health Center No Yes.

Medicare: §1861(aa)(3) and (4) SSA. §1861(aa) (3) "Federally qualified health center services" (FQHC) means--(A) services of the type described in subparagraphs (A) through (C) of paragraph (1) (related to RHC) and services described in subsections (qq) (related to "diabetes outpatient self-management training services") and (vv) (related to "medical nutrition therapy services"); and (B) preventive primary health services that a center is required to provide under section 330 of the PHSA,[302]29 furnished to an individual as an outpatient of a FQHC and, for this purpose, any reference to a RHC or a physician described in paragraph (2)(B) is deemed a reference to a FQHC by the center or by a health care professional under contract with the center or a physician at the center, respectively...

§1861(aa)(4) and 1905(l)(2)(B) The term "Federally qualified health center" means an entity which--(A)(i) is receiving a grant under section 330 of the PHSA, or (ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and (II) meets the requirements to receive a grant under section 330 of such Act; (B)...is determined...to meet the requirements for receiving such a grant; (C) was treated ...as a comprehensive federally funded health center as of 1/1/ 90; or (D) is an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act or by an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act.

Medicaid. §1905(l)(2)(A) The term "Federally qualified health center services" means services of the type described in subparagraphs (A) through (C) of section 1861(aa)(1)30 when furnished to an individual as an[150]31 patient of a FQHC and, for this purpose, any reference to a RHC or a physician described in section 1861(aa)(2)(B)32 is deemed a reference to a FQHC or a physician at the center, respectively.

EHR incentives not available for:
  • FQHCs
  • RHCs

But incentives may be available for EPs practicing predominantly in such facilities

Group practice No Yes. CMS.

Group practice consists of 2 or more medical practice entities (e.g., physician) that bill under the same Tax Identification Number are assigned to a group practice.

See Medicare General Information, Eligibility, and Entitlement.33

Physicians, including those in group practices, may receive Medicaid EHR incentives:

§Subpart D--Requirements Specific to the Medicaid Program 495.306 Establishing patient volume.

(h) Group practices.Clinics or group practices will be permitted to calculate patient volume at the group practice/clinic level, but only in accordance with all of the following limitations: (1) The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP. (2) There is an auditable data source to support the clinic's or group practice's patient volume determination. (3) All EPs in the group practice or clinic must use the same methodology for the payment year. (4) The clinic or group practice uses the entire practice or clinic's patient volume and does not limit patient volume in any way. (5) If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP's outside encounters.

Pharmacist No Yes. HITECH Sec.13101.

PHSA Sec. 3000(12) "PHARMACIST--The term `pharmacist' has the meaning given such term in section 804(2) of the Federal Food, Drug, and Cosmetic Act." Pharmacist defined in Food, Drug, and Cosmetic Act, SEC. 804. [21 USC §384] Importation of Prescription Drugs (a) DEFINITIONS--In this section: (1) IMPORTER--The term "importer" means a pharmacist or wholesaler.(2) PHARMACIST.--The term "pharmacist" means a person licensed by a State to practice pharmacy, including the dispensing and selling of prescription drugs.

EHR incentives not available for:
  • Pharmacist
Pharmacy No No.

Not defined in HITECH. Pharmacies are licensed at the state level.

EHR incentives not available for:
  • Pharmacy
Laboratory No Yes. HITECH Sec. 13101.

PHSA Sec. 3000 (10) LABORATORY--The term `laboratory' has the meaning given such term in section 353(a).

Sec. 353.[42 U.S.C. 263a](a) Definition.--As used in this section, the term "laboratory" or "clinical laboratory" means a facility for the biological, microbiological, serological, chemical, immuno-hematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.

SSA Sec. 1833(a) (2)(D) and 1861(s)(16 and (17): outpatient clinical laboratory services are paid on a FS under Medicare Part B when they are furnished in a Medicare participating laboratory and ordered by a physician or qualified non-physician practitioner who is treating the patient.

EHR incentives not available for:
  • Laboratory
Physician (defined in §1861(r) of SSA) Yes Yes. SSA.

1861(r) The term "physician"...means (1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state..., (2) a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the state..., (3) a doctor of podiatric medicine for the purposes of subsections (k), (m), (p)(1), and (s) of this section and sections 1814(a),34 1832(a)(2)(F)(ii),35 and 183536 but only with respect to functions which he is legally authorized to perform as such by the state..., (4) a doctor of optometry, but only for purposes of subsection (p)(1) with respect to the provision of items or services described in subsection (s) which he is legally authorized to perform...by the state in which he performs them, or (5) a chiropractor who is licensed as such by the state...and who meets uniform minimum standards promulgated by the Secretary...

EHR Incentives available to physicians:

Medicare and Medicaid EHR Incentive Program Final Rule.37 Incentives are available to the following Non-Hospital based Eligible Professionals:

Medicare: Subpart B--Requirements Specific to the Medicare Program: §495.100 Definitions. Eligible professional (EP) means a physician as defined in section 1861(r) of the Act, which includes, with certain limitations, all of the following types of professionals:

  1. A doctor of medicine or osteopathy.
  2. A doctor of dental surgery or medicine.
  3. A doctor of podiatric medicine.
  4. A doctor of optometry.
  5. A chiropractor.

Medicaid Subpart D--Requirements Specific to the Medicaid Program:

Medicaid Subpart D--Requirements Specific to the Medicaid Program: §495.304 Medicaid provider scope and eligibility. (b) Medicaid EP.The Medicaid professional eligible for an EHR incentive payment is limited to the following when consistent with the scope of practice regulations, as applicable for each professional (§440.50, §440.60, §440.100; §440.165, and §440.166):

  1. A physician.
  2. A dentist.
  3. A certified nurse-midwife.
  4. A nurse practitioner.
  5. A physician assistant practicing in a FQHC led by a physician assistant or a RHC, that is so led by a physician assistant.

EHR Incentives are not available to hospital-based eligible professionals as defined in 42 C.F.R. §495.4.

Practitioner (described in §1842(b)(18)(C) of SSA) Yes
SSA
§1842(b)(18)(C)
Yes. SSA. 1842(b)(18)(C) A practitioner described in this subparagraph is any of the following:
  1. A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)38).
  2. A certified registered nurse anesthetist (as defined in section 1861(bb)(2)39).
  3. A certified nurse-midwife (as defined in section 1861(gg)(2)40).
  4. A clinical social worker (as defined in section 1861(hh)(1)41).
  5. A clinical psychologist (as defined by the Secretary for purposes of section 1861(ii)42).
  6. A registered dietitian or nutrition professional.
EHR Incentives available under Medicaid to certain practitioners: Nurse Practitioners; Certified Nurse Midwives; and Physician Assistants (PAs are eligible for incentives only when practicing in a FQHC led by a physician assistant or a RHC, that is so led by a PA.)

EHR incentive payments are not available to:

  • Clinical Social Workers
  • Clinical Psychologists
  • Registered Dieticians/nutrition professionals
Provider operated by/ under contract with the IHS or by an Indian Tribe (defined in the Indian Self-Determination and Education Assistance Act), tribal organization, or urban Indian organization (defined in §4 of the Indian Health Care Improvement Act) Partially defined Partially Defined.

Indian Health Service (IHS) provides directly or under contract a variety of health such as physician, hospital, dental, and other services. IHS is the payor of last resort, primary payors include: Medicare A and B, and Medicaid.

IHS EPs and EHs receive incentive payments for their meaningful use of certified EHRs beginning in 2011.43

The IHS received $85 million to modernize and extend electronic health information technology used by IHS, Tribal, and Urban programs.44

Note: Some IHS providers (e.g., nursing home, home health agency providers) are ineligible for EHR incentives. These ineligible provider types are integrated within the ineligible providers addressed throughout this report.

Rural health clinic No. Yes. SSA.

Medicare. §1861(aa)

  1. RHC services means --(A) physicians' services and such services and supplies as are covered under section 1861(s)(2)(A)45 if furnished as an incident to a physician's professional service and items and services described in section 1861(s)(10),46 (B) services furnished by a physician assistant (PA) or a nurse practitioner (NP) (as defined in paragraph (5)), by a clinical psychologist (as defined by the Secretary) or by a clinical social worker (as defined in subsection (hh)(1)), and such services and supplies furnished as an incident to his service as would otherwise be covered if furnished by a physician or as an incident to a physician's service, and (C) in the case of an RHC located in an area in which there exists a shortage of HHAs, part-time or intermittent nursing care and related medical supplies (other than drugs and biologicals) furnished by a registered professional nurse or licensed practical nurse to a homebound individual under a written plan of treatment (i) established and periodically reviewed by a physician described in paragraph (2)(B), or (ii) established by an NP or PA and periodically reviewed and approved by a physician described in paragraph (2)(B), when furnished to an individual as an outpatient of an RHC.
  2. An RHC is a facility which--(A) is primarily engaged in furnishing to outpatients services described in subparagraphs (A) and (B) of paragraph (1); (B) in the case of an RHC which is not a physician-directed clinic, has an arrangement (consistent with the provisions of state and local law...) with one or more physicians (as defined in subsection (r)(1)) under which provision is made for the periodic review by such physicians of...; (C) maintains clinical records on all patients; (D) has arrangements with one or more hospitals, having agreements in effect under section 1866,47 for the referral and admission of patients...; (E) has written policies...to govern those services described in paragraph (1)...; (F) has a physician, PA, or NP responsible for the execution of policies...; (G) directly provides routine diagnostic services, including clinical laboratory services,...; (H) in compliance with state and federal law, has available for administering to patients...and dispensing any drugs and biologicals; (I) has a quality assessment and performance improvement program, and...(J) has an NP, PA, or a certified nurse-midwife...available to furnish patient care services...; and (K) meets such other requirements...

Medicaid. §1905(l)(1) The terms "rural health clinic services" and "rural health clinic" have the meanings given such terms in section 1861(aa),48 except that (A) clause (ii) of section 1861(aa)(2)49 shall not apply to such terms, and (B) the physician arrangement required under section 1861(aa)(2)(B)50 shall only apply with respect to RHC services and, with respect to other ambulatory care services, the physician arrangement required shall be only such as may be required under the state plan for those services...

EHR incentives not available for:
  • RHCs
A covered entity under §340B (of the PHSA) Yes
PHS §340B
Yes.

Entities that may participate in the §340B are: health care centers, clinics, and hospitals entities that provide outpatient drugs. This provision is for a discount drug program. The providers referenced are discussed elsewhere in this table.

"The "340B Program" was established by §602 of the Veterans Health Care Act of 1992 (P.L. 102-585), which put Section 340B of the PHSA into place.51

"...the 340B Drug Pricing Program requires drug manufacturers to provide outpatient drugs to certain covered entities specified in federal law (42 U.S.C. Section 340B(a)(4)) at a reduced price. Drug manufacturers that participate in Medicaid must also agree to participate in the 340B Drug Pricing Program. Participating entities can realize significant savings on pharmaceuticals.

The 340B price defined in statute is a ceiling price...Entities can negotiate below ceiling prices with manufacturers. As a result, 340B prices are about 50% of the average wholesale price."

The program is administered by...Health Resources and Services Administration (HRSA)...(HHS;52...)"

Entities which may participate in §340B include: FQHCs.

EHR incentives not available for:
  • Drug manufacturers participating in the 340B Drug Pricing Program
Therapist (defined in SSA §1848(k)(3)
(B)(iii))
Yes
SSA §1848(k) (3)(B)(iii)
Yes. SSA.

Medicare §1848(k)(3)(B)(iii) [for purposes of quality measure reporting]"(3) Covered professional services and eligible professionals defined.--For purposes of this subsection:...
(B) Eligible professional.--The term "eligible professional" means any of the following:...
(iii) A physical or occupational therapist or a qualified speech-language pathologist.

The following therapists are not eligible for EHR incentives:
  • Physical therapy Occupational therapist
  • Qualified speech-language pathologist
Any other category of health care facility, entity, practitioner, or clinician determined appropriate by the Secretary Secretary to determine Comment: For purposes of this study, other than the providers described above, the Secretary did not identify any other health care facilities, entities, practitioners, or clinicians.  

 

TABLE C2: LTPAC HITECH Provider Analysis
Health Care Providers in PHSA Section 3000(3) Defined in PHSA 3000(3)? Defined Elsewhere? Eligible to Receive EHR Incentives? Notes/Sources
  1. See http://www.cdc.gov/nchs/data/nhsr/nhsr030.pdf.
  2. See http://www.cdc.gov/nchs/data/nhsr/nhsr030.pdf.
  3. See http://edocket.access.gpo.gov/2010/pdf/2010-17753.pdf.
  4. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-d.
Nursing Facility; Skilled Nursing Facility (NFs and skilled nursing facilities are referred together in this report as nursing homes)

Other long-term care facility (referred to in this report as ICF/IID)

No Yes No EHR incentives are not available for:
  • Nursing Homes: Medicare Skilled Nursing Facilities (SNFs) and Medicaid NFs
  • Medicare ICF/IIDs Long-term Care Facilities: Medicaid §1905(d)
  • Institutions for Mental Disease services to persons 65+: Medicaid §1905(a)(14)
Home health entity (referred to in this report as including HHAs and Hospice) No Yes No Definitions:
  • Home Health Entity: SSA §1861(m)
  • Medicare Hospice: SSA §1861(dd)(1)
  • Medicare HHAs: Medicaid §1905(a)
  • Medicaid HHA: Medicaid §1907(a)(7)
  • Medicaid Hospice: Medicaid §1905(0)(1)(A)1

Note on the relationship between Medicare HHAs and hospice providers:

  • Approximately 25% of HHAs provide: (i) HHA and hospice services; or (ii) hospice only services.2

Sometimes CMS rules cover both HHAs and hospice providers. For example:

  • Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for HHAs and Hospices.3

EHR Incentives/other funding NOT available for home health entities.

Hospital (for this cluster of providers referred to in this report as including Long-Term Care Hospitals and Inpatient Rehabilitation Facilities)

(Note: for Psychiatric hospitals see the Behavioral Health Cluster)

No Yes. No for long-term care hospitals and Inpatient Rehabilitation Facilities/units
(for non excluded hospitals see "Other" category below)
Definitions:
  • Medical Hospital: §1886(d)(1)(B)
  • Hospital Medicare §1905(a)(1)(a)

EHR funding not available for a subset of hospitals and hospital units excluded from the Medicare IPPS under SSA §1886(d)(1)(B).4

 

TABLE C3. Behavioral Health HITECH Provider Analysis
Health Care Providers in PHSA Section 3000(3) Defined in PHSA 3000(3)? Defined Elsewhere? Eligible to Receive EHR Incentives? Notes/Sources
  1. See http://www.hhs.gov/dab/decisions/cr649.html.
  2. See http://www.federalregister.gov/articles/2011/06/17/2011-14673/medicare-program-conditions-of-participation-cops-for-community-mental-health-centers.
  3. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-f.
  4. See http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-d.
  5. See http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter07-15.pdf.
Community Mental Health Center (CMHC) Yes Yes No Definitions:
  • Community Mental Health Clinic: SSA §1861(ff)(1)

EHR Incentives payments/other funding not available for CMHCs.1,2

Note: In 2007, 224 certified CMHCs billed Medicare for partial hospitalization services for 25,087 Medicare beneficiaries. In June 2011, CMS proposed a set of requirements that Medicare-certified CMHCs must meet in order to participate in the Medicare program

Hospitals: (for this cluster of providers referred to in this report as including Psychiatric Hospitals/Units and Substance Abuse Treatment Hospitals/Units) No Yes. No Definitions:
  • Medical Hospital: §1886(d)(1)(B)
  • Hospital Medicare §1905(a)(1)(a)
  • Psychiatric Hospital §1861(f)(ii)3
  • Inpatient psychiatric hospital services for individuals <21: Medicaid: §1905(h)(1)

EHR funding not available for a subset of hospitals and hospital units excluded from the Medicare IPPS under SSA §1886(d)(1)(B).4

Practitioner: (for this cluster of providers referred to in this report as including Clinical Social Workers Clinical Psychologists) Yes Yes No Definition:
  • Practitioner: SSA §1842(b)(18)(C)
  • Clinical Social Worker §1861(hh)(1)
  • Clinical Psychologist §1861(ii)
  • Registered Dietitian or Nutrition professional
Other Long-Term Care Facility : (for this cluster referred to in this report as including Residential Treatment Centers/Facilities for Mental Health and/or Substance Abuse) No Yes No Definitions:
  • Residential Treatment Facilities: Medicaid §1905(a)(16)

Note: Patients require more than room and board, are under the supervision of a physician, and requires a comprehensive package of services.5

EHR Incentives/other funding NOT available for these other long-term care facilities

 

TABLE C4. Safety Net HITECH Provider Analysis
Health Care Providers in PHSA Section 3000(3) Defined in PHSA 3000(3)? Defined Elsewhere? Eligible to Receive EHR Incentives? Notes/Sources
  1. Available at http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_4383_1239_15610_43/http%3B/wci-pubcontent/publish/onc/public_communities/ p_t/resources_and_public_affairs/reports/reports_portlet/files/quality_incentives_final_report_1_23_12.pdf.
Federally Qualified Health Center (FQHC) No Yes No Definitions: FQHC Services:
  • Medicare §1861(aa)(3), §1861(aa)(4)
  • Medicaid §1905(l)(2)(A)

Note: Funding for EHRs is available under HITECH for FQHCs although it not clear how much will be spent on health IT.

See: American Recovery and Reinvestment Act (ARRA)
Appropriations: HRSA included: $1.5B authorized for grants for construction, renovation, equipment and acquisition of health IT systems, including health center controlled networks receiving operating grants under section §330 of the PHSA.
Medicaid EP EHR incentives:

  • §1903(t)(2)(A)(iii)
  • §1903(t)(3)(A)(v)

HITECH §13113(b): Reimbursement Incentive Study and Report

Rural Health Clinic (RHC) No Yes No Definition: RHC
  • Medicare §1861(aa)(1) and (2)
  • Medicaid §1905(l)(1)

Note: Funding for EHRs is available under HITECH for RHCs although it not clear how much will be spent on health IT.

ARRA Appropriations: HRSA included:

  • $1.5 billion authorized for grants for construction, renovation, equipment, and for acquisition of health IT systems, for health centers including health center controlled networks receiving operating grants under section 330 of the PHSA.
  • Medicaid EP EHR incentives: §1903(t)(2)(A)(iii)--an EP who practices predominately in a FQHC or RHC and has at least 30% of patient volume attributed to needy individuals. These EPs may assign their incentive to the FQHC or RHC.
  • §1903(t)(3)(A)(v)--an EP includes a physician assistant practicing in a FQHC led by a physician assistant or a RHC, that is so led by a physician assistant.

HITECH §13113(b) Reimbursement Incentive Study and Report. HHS studied and developed a report to Congress on the methods to create efficient reimbursement incentives for improving health care quality in FQHs, RHCs, and free clinics.

Report: Quality Incentives for FQHCs, RHCs and Free Clinics: A Report to Congress (January 2012).1

EHR Incentives available to certain practitioners. See above regarding: Medicaid Subpart D--Requirements Specific to the Medicaid Program: §495.304 Medicaid provider scope and eligibility. Which includes:

  • certified nurse-midwives,
  • nurse practitioners, and
  • physician assistants practicing in an FQHC or RHC that is so led by a physician assistant.

 


TABLE C5. Other Health Care HITECH Provider Analysis
Health Care Providers in PHSA Section 3000(3) Defined in PHSA 3000(3)? Defined Elsewhere? Eligible to Receive EHR Incentives? Notes/Sources
  1. See http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/EstablishmentRegistration/ BloodEstablishmentRegistration/default.htm.
  2. See http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/ Blood/UCM164981.pdf.
Ambulatory surgical center Yes Yes No Definitions: ASC:
  • SSA §1833(i)(1)
  • See: §1832(a)(2)(F)

EHR incentives/other funding NOT available for ASC.

Renal Dialysis Facility No Yes No Definitions: End Stage Renal Disease Facilities:
  • SSA §1881
  • See: SSA §1881(b)(1)

EHR Incentives/Other Funding NOT available for ESRD Facilities.

Nephrologists are eligible as a physician.

Emergency Medical Service Provider No No No Definition:
  • No commonly accepted definition
  • Ambulance: SSA §1861(s)(7) title XVIII

EHR incentives/other funding NOT available for Emergency Medical Service providers.

Practitioner:
(for this cluster of providers referred to in this report as including
  • Registered Dietician/Nutritional Professionals)
Yes Yes No for dietician/ nutrition

(Psychologist and Clinical Social Worker in Behavioral Health Cluster)

Definition:
  • Practitioner: SSA §1842(b)(18)(C)
  • Physician assistant, nurse practitioner, or clinical nurse specialist §1861(aa)(5)
  • Certified registered nurse anesthetist §1861(bb)(2)
  • Certified nurse-midwife §1861(gg)(2)
  • Clinical Social Worker §1861(hh)(1)
  • Clinical Psychologist §1861(ii)
  • Registered Dietitian or Nutrition professional
Therapist:
(for this cluster of providers referred to in this report as including
  • Physical Therapist
  • Occupational Therapist
  • Qualified Speech
  • Pathologist)
Yes Yes No Definition: Therapist:
  • SSA §1848(k)(3)(B)(iii)

Note: Only certain therapists are eligible for EHR incentives/other funding. Excluded are: physical therapists; occupational therapists; qualified speech pathologists.

Pharmacist Yes Yes No Definition:
  • Pharmacist: PHSA §3000(12) (as added by HITECH §13101) refers to the definition in section 804(2) of the Federal Food, Drug, and Cosmetic Act. §804(a)(1) [21 USC S384]
  • Importer: Food, Drug, and Cosmetic Act §804(a)(2) [21 USA S384]

EHR incentives/other funding not available for Pharmacist.

Pharmacy No N/A No No Definition for Pharmacies

Pharmacies are licensed at the state level EHR incentives/other funding not available for Pharmacy.

Laboratory Yes Yes No Definitions:
  • Laboratory: PHSA §3000(10), as added by §13101 of HITECH. §353 [42 USC 263a]

See:

  • SSA §1883(a)(2)(D)
  • SSA §1861(s)(16)
  • SSA §1861(s)(17)

EHR incentives/other funding not available for Laboratory.

Blood Center No Yes No Definitions: Blood Establishment: Federal Food, Drug, and Cosmetic Act S5101,2

AHA: A facility that performs, or is responsible for the collection, processing, testing, or distribution of blood and components.

EHR Incentives/Other Funding NOT available for Blood Centers

Notes

  1. Health Information Technology for Economic and Clinical Health Act. http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechact.pdf.

[Return to the Table of Contents]

 

APPENDIX D. INELIGIBLE PROVIDER CHARACTERISTICS

This appendix provides data on ineligible health care providers to understand the size of the market, number of patients' served, expenditures for Medicare and Medicaid and other information. Comparability from one setting to the next was not always possible due to the number of diverse sources needed to produce the statistical data,1 overlapping services between health care providers, and lack of standardization across provider classifications at the federal and state levels. Please note, those expenditures in this table based on claims data generally exclude Medicare and Medicaid managed care. The assumptions made are documented in the footnotes.

Congress wanted to understand the extent to which ineligible providers work in settings that might receive EHR incentives or other funding under HITECH. Findings are documented in the "ownership" column, however data was very limited. MedPAC or the American Hospital Association survey provided the best sources of data indicating the percentage of hospitals with specialty units or services that included the ineligible provider types. There was limited to no information available for the number or percentage of the ineligible professionals/practitioners who work for eligible providers. Some eligible professionals may work in multiple types of provider settings, including settings ineligible for incentives. These providers may choose to retain their incentive payment, or assign the payment to a setting where they work. For example, physicians may assign incentive payment to their primary practice and not to the rural health clinic, ambulatory surgical center, or nursing home where they also practice. We were not able to find a source that tracked assignment of incentives.

Ineligible Provider No. of Providers No. of Patients/ Individuals Served Medicare Expenditures1 Medicaid Expenditures Total Health Care Expenditures Profitability/ Profit Margin2 Ownership3
  1. Medicare expenditures (unless otherwise noted) are from the MedPAC June 2012 data book. MedPAC estimates are generally based on fee-for-service patients, and exclude the approximately 25% of Medicare enrollees now in managed care.
  2. Profit margin information (unless otherwise noted) is based on the most recent MedPAC analysis of Medicare-certified facilities.
  3. This column reflects provider ownership or affiliation to the extent the information was available. Data may not be comparable across the various provider types. AHA data on hospital-based specialty units is from AHA (AHA Hospital Statistics, 2012 Edition).
  4. November 2011 data. Most facilities are dually-certified as Medicaid nursing facilities (NFs) and Medicare-certified skilled nursing facilities (SNFs). As of November 2011, of 15,716 total, 14,344 (91%) were dually certified; 788 (5%) were SNF only, and 594 (4%) were NF only (CMS. Compendium 2011). According to MedPAC, 15,161 NFs were Medicare-certified SNFs in 2011. AHCA statistics, based on CMS-CASPAR data as of June 2012, show a slight decrease in the number of nursing home providers--15,673. (AHCA, LTC Stats: Nursing Facility, 2012)
  5. American Health Care Association (AHCA) using CMS-CASPAR data as of June 2012. (American Health Care Association. Research Department. LTC Stats: Nursing Facility Patient Characteristics Report, June 2012 update. http://www.ahcancal.org/research_data/oscar_data/NursingFacilityPatientCharacteristics/LTC%20STATS_HSNF_PATIENT_2012Q2_FINAL.pdf).
  6. 2011 data (MedPAC, June 2012).
  7. 2010 data (MedPAC, March 2012). Spending on nursing home care varies substantially depending on source. National Health Expenditure Accounts put the figure for 2010 at $45.1B. Eiken et al. indicate Medicaid expenditures for nursing homes in 2009 was $51.3B. Kaiser's estimates the total for 2010 to have been $50.5B, based on analysis of CMS (Form 64) data.
  8. CMS, National Health Expenditures 2010.
  9. 2010 data (MedPAC, June 2012). A 2011 Government Accountability Office (GAO) report showed margins much lower than MedPAC's analysis, but also recognized wide variation between private investment facilities and other for-profit and nonprofit facilities. GAO likely was looking at all NFs, while MedPAC focuses on Medicare-certified SNFs. The GAO report noted there was also wide variation based on other factors, stating: "On average, facility margins were also higher (1) the greater the percentage of residents whose stay was paid by Medicare, (2) the greater the number of beds, (3) the greater the occupancy rate, and (4) the lesser the degree of competition in the county." (GAO, 2011)
  10. Grabowski, 2010.
  11. 2010 data. (MedPAC, March 2012)
  12. Ibid 2010 data. (MedPAC, March 2012)
  13. 2010 data. (MedPAC, June 2012)
  14. Provision of rehabilitation services is optional for state Medicaid agencies, although covered by most states. CMS puts Medicaid expenditures for rehabilitation services at $7.3 billion (Medicare and Medicaid Statistical Supplement, 2011). It is not clear what it covers and whether it includes inpatient. An analysis of IRFs in Pennsylvania estimated that, while approximately 52% of net patient revenues came from Medicare, about 8.6% of revenues were from patients receiving medical assistance. It was noted that, while Medicare covers the majority of patients served in Pennsylvania rehabilitation facilities, younger, Medicaid patients tended to have a longer length of stay. (Pennsylvania Health Care Cost Containment Council, November 2008)
  15. Based on MedPAC's estimation that Medicare pays about 60%.
  16. Profit margins vary greatly from one IRF to another depending upon geography (urban/rural), ownership (nonprofit, for-profit, government), freestanding or hospital-based, and number of beds. (MedPAC, March 2012)
  17. 2010 data. One major freestanding IRF chain accounted for almost 50% of freestanding IRF revenues, and hospital-based units accounted for almost 60% of Medicare payments to IRFs in 2010. (MedPAC, March 2012)
  18. 2011 data (MedPAC, June 2012).
  19. 2010 data (MedPAC. March 2012).
  20. 2010 data (MedPAC, June 2012).
  21. According to the Dartmouth-Hitchcock health care system, long-term acute care is a Medicare-designated level of acute care services, although Medicaid will pay for care in these facilities as long as it is a state-contracted Medicaid provider. (Dartmouth-Hitchcock, Long-Term Acute Care, http://patients.dartmouth-hitchcock.org/care_mgt/long_term_acute_care.html). Medicare is the predominant payer accounting for roughly two-thirds of LTCH patients (MedPAC, March 2012). MedPAC estimates Medicaid patient share at between 5% and 8%. (MedPAC, June 2012)
  22. Based on MedPAC's estimation that Medicare pays for about two-thirds of LTCH costs.
  23. Grabowski, 2010. In 2011, two major chains owned just over half of all LTCHs. Both major chains operate IRFs and outpatient rehabilitation clinics in addition to LTCHs. The share of discharges from freestanding facilities in 2010 was 70%. (MedPAC, March 2012)
  24. CMS. Determining Medical Necessity and Appropriateness of Care for Medicare Long Term Care Hospitals, 2011.
  25. Home health expenditures vary greatly from one data source to another. The discrepancies appear to arise both from Medicaid dollars going to Home and Community-Based Services (HCBS), Home and Community-Based Waivers (HCBW), Program of All-Inclusive Care for the Elderly (PACE), personal services, etc. (cf. CMS MBES data, https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidBudgetExpendSystem/ CMS-64-Quarterly-Expense-Report.html), and the inclusion in some estimations of providers not providing medical services. The National Association for Home Care and Hospice (NAHC), e.g. includes HHAs, hospices, as well as private duty and home care aide agencies, both Medicare certified, Medicaid approved, and private in their estimation of the number of home health providers (e-mail correspondence, Mary St. Pierre, NAHC, September 28, 2012).
  26. Medicare-certified agencies. 2011 data. MedPAC (June 2012). The National Home and Hospice Care Survey estimated 33,000 HHAs 2010, including Medicare certified HHAs, Medicare certified hospices, and an estimation of non-Medicare agencies. We chose not to use the NAHC estimate, based on concerns the number included entities not providing medical services.
  27. 2010 data (MedPAC, March 2012). NAHC estimates there were 7.6M recipients of home care services in 2007, a number cited by the National Center for Health Statistics in their survey of HHAs and hospices (Caffrey et al., 2011). NCHS does not provide an estimate of total home health patients but states on any given day in 2007, there were 1.46 million current home health care patients in the United States (CDC, Home Health Care Patients, n.d.). NAHC's estimate for 2010, which includes in-home hospice, was 12 million. (NAHC, 2010)
  28. 2011 data (MedPac, June 2012). U.S. Census Bureau estimates of home health care services revenues from Medicare (2010) are $27.4B and from Medicaid $13.5B, with total patient revenues at $65B. (Census Bureau, 2010 Service Annual Survey)
  29. CMS states Medicaid expenditures for "home health and related" service for 2010 were $54 billion, breaking it down by home health ($4,751 million), HCBW ($36,161 million), and personal care services ($13,170 million) (Data Compendium, 2011). CMS' National Health Expenditures Accounts puts the total Medicaid expenditure at $26.2 billion, of which $17.2 billion is the federal portion and $9 billion state and local. NHEA numbers cover a wide range of home health services, not limited to that provided by HHAs.
  30. Based on MedPAC estimates that Medicare pays for 45% of home health services. NHEA puts total expenditures at $70.2 billion ($31.5 billion Medicare, $26.2 billion Medicaid, $5 billion out-of-pocket, $4.5 billion private insurance, $0.8 billion Veteran's Administration, $2.2 billion other third party payers/programs). NHEA home care expenditures include any service provided in a patient's home, likely extending beyond that provided by HHAs. (CMS. NHEA, 2011)
  31. MedPAC (March 2012). http://www.medpac.gov/chapters/Mar12_Ch08.pdf.
  32. MedPAC (March 2012).
  33. 2007 data. (Park-Lee, 2010)
  34. 2010 data (NHPCO, 2012). CMS indicates 3552 hospice agencies filed claims with Medicare in 2010 (CMS, Final Rule 76 FR 47327, August 2011).
  35. 2010 data. (NHPCO, 2012)
  36. "CMS Benefit Payments by Major Program Service Categories, fiscal year 2010" (CMS Compendium, December 2011).
  37. Based on NAHC's estimate that Medicare and Medicaid pay about 90% of hospice claims. (NAHC, 2010)
  38. Profit margins range between -13% and 13% dependent on geography and ownership.
  39. Grabowski, 2010.
  40. 2007 data. (Park-Lee, 2010)
  41. ICFMR is the statutory term. These facilities are now widely referred to as ICF/IIDs including in the CMS Conditions of Participation, therefore we are using ICF/IID to represent the statutorily defined ICFMR.
  42. 2010 data (Larson et al., 2012). The AHCA counts 6465 ICFMRs, based on CMS CASPER/OSCAR data as of October 2011. (AHCA, LTC Stats: ICF/MR/DD, 2011)
  43. 2010 data (Larson et al., 2012). The Coleman Institute puts the number of persons in ICFMRs (2009) at 62,311 (20,768 (<6 persons); 41,543 (7 or more persons)) but residents in state facilities appear to be counted separately (Braddock et al., I/DD Spending by Revenue Source, 2011). AHCA indicates the total number of clients in ICFs in October 2011 was 87,400, with 55,950 in private facilities and 31,450 in public facilities. (AHCA LTC Stats: ICF/MR/DD, 2011). CMS-64 data for 2009 counts 100,723 unique beneficiaries with 5.1 million total ICF claims at a cost to Medicaid of $12.9B (CMS, Financial Management Report). The Social Security Administration put the 2009 number at 101,000. "Table 8.E1--Number of recipients, total vendor payments, and average payment, by type of medical service, fiscal years 1985-2009" (U.S. Social Security Administration, 2011, http://www.ssa.gov/policy/docs/statcomps/supplement/2011/8e.html#table8.e1). AHCA counts 87,400 total ICFMR clients as of October 2011. The CMS website indicates approximately 129,000 residents of ICFs are Medicaid-funded. According to Braddock (Braddock, Challenges, 2011) and AHCA (Eljay, LLC, 2011), numbers of institutionalized residents with intellectual and developmental disabilities are decreasing largely due to HCBW. The Coleman Institute states that, in 2009, 32,469 residents with intellectual or developmental disabilities were living in nursing facilities. (Braddock et al., The State of the States, 2011)
  44. Medicare does not cover the types of custodial services ICFs provide.
  45. The Henry J. Kaiser Family Foundation. "Distribution of Medicaid Spending on Long Term Care, FY2010" (Kaiser, Statehealthfacts.org, http://www.statehealthfacts.org/comparetable.jsp?ind=180&cat=4). Larson et al. indicate total Medicaid federal and state expenditures for ICFMR services in FY 2009 was $12.87B. Braddock estimated Medicaid spending for ICFMR facilities in 2009 to be just under $16B (Braddock, 2011). Americans with developmental disabilities and mental retardation make up approximately 1.3% of Medicaid recipients, but account for about 9.3% of Medicaid payouts. Medicaid is the primary source of funding, but other funds are available. (Highbeam Business, 2012).
  46. This amount is for total receipts in 2007. (Census Bureau, 2007)
  47. 2010 data. Public facilities housed 38% of clients and private facilities housed 62%, suggesting that public ICFs had a higher bed capacity. (AHCA, State Long-Term Health Care Sector, 2011)
  48. Includes nongovernment inpatient psychiatric hospitals (255), hospital psychiatric units (1274), state psychiatric hospitals (220) (Dobson, 2010). Avalere, in their analysis of the costs of extending EHR incentive payments to behavioral health providers, estimated 360 psychiatric hospitals, based on the number filing Medicare reports (Avalere, 2010). MedPAC counts 1536 (426 freestanding and 1100 hospital-based), a number that probably excludes state psychiatric hospitals. SAMHSA's database of mental health hospital inpatient facilities includes 1608 facilities where hospital inpatient services are available. (SAMHSA. Mental Health Treatment Facility Locator)
  49. N-SSATS data as of March 31, 2010 (http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl4.2a.htm) SAMHSA's online database of substance abuse facilities includes 588 that are hospital inpatient. (SAMHSA, data set created May 23, 2011; updated June 30, 2012.) SAMHSA's 2008 National Survey of Substance Abuse Treatment Services specified 838 substance abuse treatment facilities were hospital inpatient, with 317 having a primary focus of substance abuse, 296 focusing on a mix of substance abuse and mental health, 161 focusing on mental health care, and the rest focusing on general health care or other.
  50. "Number and percentage of persons aged 18 or older who received mental health treatment in the past year, by disorder severity, United States, 2009" (Table 24, SAMHSA, Mental Health, U.S. 2010). MedPAC counts 431,276 Medicare patients. (MedPAC, June 2012)
  51. N-SSATS data as of March 31, 2010 (http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl5.2a.htm).
  52. 2011 data. (MedPAC)
  53. There is no Medicare inpatient substance abuse treatment provider type. A very broad estimate, based on SAMHSA's estimate Medicare pays approximately 7% of substance abuse treatment costs across all settings, would be $154M. This number may be an overstatement if limits on Medicare spending for inpatient psychiatric care extend to substance abuse facilities.
  54. "Medicaid--Beneficiaries and Payments: 2000 to 2009" (U.S. Statistical Abstract 2012, http://www.census.gov/compendia/statab/2012/%20tables/12s0151.pdf.) This includes inpatient psychiatric facilities for persons under 21 and mental hospitals for the aged. Medicaid, under a restriction known as Medicaid's Institutions for Mental Disease (IMD) exclusion, does not reimburse psychiatric institutions for services provided to Medicaid enrollees aged 21-64. A review by the National Association of State Mental Health Program Directors Research Institute of state mental health agency-controlled Medicaid revenues for state psychiatric hospitals estimated $2.14B for 2009. (NASMHPD, 2012)
  55. This is a very broad estimate based on SAMHSA's estimate Medicaid paid approximately 21% of substance abuse treatment costs across all settings.
  56. 2005 data. Includes mental health treatment in specialty units of general hospitals and inpatient specialty hospitals ($11.3B). "Table A.1. Spending by Provider and Setting: Levels and Percent Distribution for Mental Health and Substance Abuse (MHSA), Mental Health (MH), Substance Abuse (SA), Alcohol Abuse (AA), Drug Abuse (DA), and All-Health, 2005." (SAMHSA, National Expenditures, 2010). SAMHSA estimates costs for all inpatient hospital (specialty and non-specialty) MH treatment to be $31.47B for 2006 and $45.45B for 2014. (Levit, 2008)
  57. Pennsylvania financial analysis showed in 2010, freestanding psychiatric hospitals had a operating margin of 5.92% and an overall margin for inpatient psychiatric facilities of 4.58% (Pennsylvania Health Care Cost Containment Council, 2011). MedPAC reports hospital-based specialty units, such as psychiatric, historically have had lower profit margins than freestanding.
  58. MedPac report (March 2012).
  59. "Table 4.2A: Type of care offered, by facility operation and primary focus of facility: 2010" (SAMHSA, N-SSATS, 2010, http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl4.2a.htm).
  60. 2010 data (1649 MH and 2843 SA). These numbers are based on SAMHSA's databases of MH and SA facilities, filtered by residential care (includes both adult and adolescent facilities)--(SAMHSA. Mental health facilities, 2010; SAMHSA. Substance Abuse Facilities, 2010) SAMHSA (Mental Health U.S., 2010) counts 551 residential treatment centers (RTCs) for children with severe emotional disturbance (2008 data) and 55 RTCs for adults (Table 116. "Number of mental health organizations, by organization type, United States and by State, 2008"). The most recently published numbers from SAMHSA's N-SSATS survey (2008) Schwalbe, who defines the RTC as an "RTC, also known as a psychiatric residential treatment facility (PRTF under the federal Medicaid laws and rules) is any non-hospital facility that holds a provider agreement with a state Medicaid agency to provide inpatient services benefit to Medicaid-eligible individuals under the age of 21" (Schwalbe, 2010).
  61. Includes 211,000 clients under the age of 18 receiving MH treatment ("Table 56. Number and percentage of persons aged 12-17 who received mental health treatment in the past year, by type of treatment, United States, 2009," SAMHSA, Mental Health U.S., 2010), and 103,692 clients (including 9302 under the age of 18) receiving SA treatment (http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl5.2a.htm, N-SSATS, 2010). Although there are numbers for adults receiving SA treatment who have co-occurring MH issues, there are no good United States data on the numbers of adults receiving only MH treatment in adult residential facilities for adults with mental illness. A study published by SAMHSA in 2006, based on September 2003 data, reported results from a survey that received responses from 34 states and the District of Columbia. 63 types of facilities were identified by the survey, with a total of 7,327 facilities with 103,393 beds. State and local MH agencies were responsible for the majority of funding for care in these facilities. Residents also used Supplemental Security Income payments and Social Security Disability insurance payments as funding sources. (Ireys, 2006)
  62. Residential care facilities are not eligible to enroll in Medicare. The U.S. Census Bureau estimates $988M in Medicare patient care revenues for residential mental retardation, MH and SA. (Census Bureau, 2010)
  63. 2008 data (Schwalbe, 2010). The MAX [Medicaid Analytic eXtract] Chartbook 2008 (Borck, 2012) indicates $488M was spent by Medicaid on residential MH treatment for adults and $2B was spent on residential MH treatment for children and adolescents. PRTF for persons under 21 is a designation for a Medicaid-certified facility. For further information about public spending for residential treatment facilities for children with emotional disturbance, see Ireys et al. (Ireys, 2006).
  64. 2005 data. "Table A.1. Spending by Provider and Setting: Levels and Percent Distribution for Mental Health and Substance Abuse (MHSA), Mental Health (MH), Substance Abuse (SA), Alcohol Abuse (AA), Drug Abuse (DA), and All-Health, 2005." (SAMHSA. National Expenditures for Mental Health Services & Substance Abuse Treatment, 1986-2005, 2010.) Dobson et al. (NAPHS) estimate $4.5B in direct expenditures for MH services in RTCs for calendar year 2008.
  65. Avalere puts the count of CMHCs at 672 (Avalere, 2010). CMS indicates in 2007 there were 224 facilities who billed Medicare for partial hospitalization services, the only treatment covered by Medicare in CHMCs. (CMS, Federal Register 76 FR 35684; June 17, 2011)
  66. Behavioral Pathway Systems. "National Council for Community Behavioral Health Care." (2005)
  67. 2010 data. HHS, OIG, August 2012.
  68. This is the amount of state MH agency-controlled funds for community MH services. ("SMHA Revenues for State Psychiatric Hospitals and Community-Based Programs: FY 2009" NASMHPD Research Institute, August 2012)
  69. Ibid. These are "community mental health revenues".
  70. This number includes psychologists who are self-employed and those who work in health care facilities. (BLS, 2012)
  71. Mental Health, U.S. (2010).
  72. U.S. Census Bureau. "Office of Mental Health Practitioners (Except Physicians) (NAICS 62133)" from Table 8.10 of the 2010 Service Annual Survey, "Selected Health Care Services (NAICS 621,622, and 623)--Estimated Revenue for Employer Firms by Source: 2006 Through 2010". [Social work services billed to Medicare for MH services in 2003 were $234M.]
  73. Ibid.
  74. Based on number practicing multiplied by median wage. SAMHSA indicates total spending for clinical social workers, clinical psychologists, and licensed counselors was $7.6B in 2005. "Spending by provider and setting." (SAMHSA, 2005)
  75. 2008 data. 46% of psychologists are in private practice; 12% work in hospital settings; 11% work in other human services setting (clinics, counseling centers, rehab facilities); 4% work in community mental health centers. (Michalski, 2010) A case study based on 2000 data indicate 1% of psychologists work in skilled nursing facilities (Penn State University, "Case Overview," http://lobby.la.psu.edu/007_Clinic_Soc/frameset_clinic_soc.html).
  76. Occupational Employment Statistics (BLS, 2011). This number includes health care social workers and MH and SA social workers. Based on estimates by NASW, SAMHSA puts the number of clinically active clinical social workers (2006 data) at 92,227 (Mental Health, U.S. 2010); Avalere puts the number at 260,000 (Avalere, 2010).
  77. Based on number practicing multiplied by median wage. (Health care labor statistics by SOC Code, May 2012)
  78. The following industries are major employers of health care social workers: Hospitals (state, local, and private)--31%; Nursing and residential care facilities--13%; Individual and family services--11%; Home health care services--10%; Local government--6%; the following industries employed the most MH/SA social workers: Outpatient MH/SA centers--17%; Individual and family services--16%; Hospitals--14%; local government--10%; psychiatric and SA hospitals--8%. (BLS, 2012) A case study based on 2000 data indicate 10% of clinical social workers work in SNFs (Penn State University, "Case Overview," http://lobby.la.psu.edu/007_Clinic_Soc/frameset_clinic_soc.html).
  79. Operating 8,147 sites. 2010 data. (GWU, 2012)
  80. 2010 data. (Kaiser Family Foundation)
  81. 2009 data. (MedPAC, June 2011)
  82. Ibid.
  83. MedPAC report, June 2011. "In 2007 FQHCs received over $1.6 billion of Section 330 Grants, $335 million of revenue from indigent care programs, and higher reimbursement rates for the $3.9 billion of Medicaid and Medicare receipts because of their FQHC status" (National Council, 2009).
  84. January 2012 data. (Muskie School of Public Service, 2012; The George Washington University, 2012)
  85. Estimate based on 2008 data. (The George Washington University, 2012)
  86. CMS figure for 2010 was $874M. Medicaid Budget and Expenditure System (MBES) CMS-64 data.
  87. Based on estimate Medicare and Medicaid provides approximately 60% of RHC funding. (GWU, 2012)
  88. Gale and Coburn, 2003.
  89. The George Washington University, 2012. "A provider-based RHC is an integral and subordinate part of a Medicare participating hospital, critical access hospital (CAH), skilled nursing facility (SNF), or home health agency (HHA), and is operated with other departments of the provider under common governance, professional supervision, and usually licensure. All other RHCs are considered to be independent" (73 FR 36696; June 27, 2008). Independent clinics are most commonly owned by physicians (49%), other individuals or corporate entities (29%), hospital corporations (15%), nurse practitioners, physician assistants, certified nurse midwives (7%), or RHC administrators (1%). Provider-based clinics are owned by hospitals of less than 50 beds (50%), hospitals of more than 50 beds (40%), and nursing homes and other owners (10%). (Gale and Coburn, 2003)
  90. 2008 data (VMG Health, 2010). According to VMG Health analysis, of the total number of freestanding ASCs, 5174 were Medicare-certified. MedPAC data for 2011 indicates there were 5344 Medicare-certified facilities.
  91. 2006 data. (Cullen et al., 2009)
  92. 2011 data. 2012 proposed rule for ASC payment systems estimates total Medicare ASC payments for CY 2013 would be approximately $4.103 billion, an increase of $211 million over CY 2012. (CMS, Proposed Rule, July 30, 2012)
  93. Based on MedPAC data for Medicare expenditures and VMG Health's estimate that Medicaid contributes approximately 5% to ASC revenues (VMG, 2010). A number of studies have shown that lower income individuals tend to receive outpatient surgery treatment in hospital outpatient departments instead of ASCs. (See, for example, Strope, et al., 2009)
  94. Based on MedPAC data for Medicare expenditures and VMG Health's estimate that Medicare contributes approximately 25% to ASC revenues. (VMG, 2010)
  95. MedPAC is unable to calculate a Medicare margin because ASCs do not submit data on the cost of services they provide to Medicare beneficiaries. Pennsylvania financial analysis of ASCs operating in their state estimated an average margin of 26.3% in 2010. (Pennsylvania Health Care Cost Containment Council, 2011)
  96. American Ambulatory Surgery Association.
  97. VMG Health, 2010.
  98. United States Renal Data System (USRDS), 2011. "Chapter 10: Providers" USRDS data is for 2009; MedPac figure for 2010 was 5500 facilities.
  99. USDRS (2011). The number of patients given in the Medicare and Medicaid Statistical Supplement 2011 is 387,000. MedPAC's number of Medicare patients in 2010 was 335,000.
  100. 2009 USRDS data. "Report by the Numbers" (Renal Business Today, 2011). Numbers vary widely by source, probably dependent upon whether drug costs are bundled into the total. MedPAC's figure is $9.5B (MedPAC, March 2012). The GAO figure is $7.9B. (GAO, ESRD, 2006)
  101. USRDS "Report by the Numbers" (Renal Business Today, 2011).
  102. Margins vary based on size and geography. (MedPAC, June 2012)
  103. GAO, 2006.
  104. MedPAC, June 2012.
  105. National Highway Traffic Safety Administration, 2011.
  106. CMS Data Compendium, December 2010.
  107. This number is for "transportation services" so probably includes more than emergency services. Medicaid Statistical Information System, 2009 data.
  108. CMS. National Health Expenditures Accounts: Definitions, Sources, and Methods, 2009.
  109. GAO, 2012.
  110. 2004 data. These numbers are based on the GAO's analysis of Medicare-certified ground ambulance services. (GAO, 2007)
  111. SK&A, 2012.
  112. CMS Data Compendium, December 2010.
  113. Ibid. A report from the OIG of HHS put Medicaid expenditures for prescription drugs in 2009 at $26B. (Levinson, 2011)
  114. "National Health Expenditures Aggregate, Per Capita Amounts, Percent Distribution, and Average Annual Percent Change, by Type of Expenditure: Selected Calendar Years 1960-2010" (CMS, National Health Expenditures Data, 2010).
  115. SK&A, 2012.
  116. Midwest Pharmacy Workforce Research Consortium, 2009.
  117. BLS, "Pharmacists", 2012.
  118. CMS CLIA Update, July 2012. The number on the CMS website is 225,000 (CMS, CLIA website).
  119. 2011 data. $4.6B Independent and physician office-based; $4.4B hospital-based. (MedPAC, June 2012)
  120. CMS-64 data. Includes radiology. (CMS, Financial Management Report, 2010)
  121. RNCOS, 2012.
  122. Ahn et al., 1997. CMS' Division of Laboratory Services provides the following breakdown of laboratories by type of facility--50.06% physician office, 6.39% nursing facility, 6.13% HHA, 3.78% hospital, 3.29% pharmacy, 2.74% community clinic, 2.28% ESRD, 2.28% ASC, 2.4% independent. The following facility types made of less than 2% of the CLIA database--ambulance, ancillary test site, assisted living facility, blood banks, comprehensive outpatient rehabilitation, FQHC, health fair, HMO, hospice, industrial, insurance, ICFMR, mobile laboratory, other practitioner, prison, public health laboratory, RHC, school/student health service, and tissue back/repository. 8.71% of laboratories were classified as other. (CMS, CLIA Update, July 2012)
  123. FDA Blood Establishment Registration Database. Filtered by an establishment status of "Active". More than one category may apply to a facility. (FDA, 2012)
  124. Number of transfusions (2008). (HHS, National Blood Collection Report, 2009)
  125. Ibid. Most Medicare reimbursement for blood is part of the diagnosis-related group (DRG) payment made for inpatient services. Other payers, besides Medicare, pay for blood using varying mechanisms.
  126. Ibid. Blood centers were responsible for 93.8% of total blood units collected, hospitals 6.2%.
  127. "Table 113: Health care employment and wages, by selected occupations: United States, selected years 2001–2010". (NCHS, 2012, http://www.cdc.gov/nchs/data/hus/2011/113.pdf)
  128. "Offices of Physical, Occupational and Speech Therapists, and Audiologists (NAICS 62134)" from Table 8.10 of the 2010 Service Annual Survey, "Selected Health Care Services (NAICS 621,622, and 623)--Estimated Revenue for Employer Firms by Source: 2006 Through 2010." (U.S. Census Bureau, 2010)
  129. Ibid.
  130. Ibid.
  131. Physical therapists typical employment affiliations: Offices of health practitioners (37%); Hospitals; state, local, and private (28%); Home health care services (10%); Nursing and residential care facilities (7%). About 7% of physical therapists were self-employed in 2010. Occupational therapists typical employment affiliations: Hospitals; state, local, and private (27%); Offices of physical, occupational and speech therapists, and audiologists (21%); Nursing care facilities (9%); Home health care services (7%); Individual and family services (3%). Speech-language pathologists typical employment affiliations: Elementary and secondary schools; state, local, and private (44%), Offices of physical, occupational and speech therapists, and audiologists (15%), Hospitals; state, local, and private (13%), Nursing care facilities (4%), Home health care services (3%). (BLS, 2012)
  132. "Table 113: Health care employment and wages, by selected occupations: United States, selected years 2001–2010". (NCHS, 2012, http://www.cdc.gov/nchs/data/hus/2011/113.pdf)
  133. $4.8M spent on diabetes self-management training by dietitians. Medicare also covers direct billing for medical nutrition therapy performed by dietitians. The regulatory impact analysis of Medicare reimbursement to dietitians and nutrition professionals providing diagnostic therapy and counseling services related to medical nutrition therapy estimated a cost of $70M in FY 2006. (CMS, 2001) 134. Figure is a broad estimate, based on the number of practitioners times the average salary. (Highbeam, SIC 8049, 2012) 135. Dietitians typical places of employment: Hospitals; state, local, and private--32%; Nursing care facilities--8%; Outpatient care centers--6%; Offices of physicians--4%. They also work in cafeterias, schools, and some are self-employed. (BLS, 2012)
Long-Term and Post-Acute Care
Nursing Homes (SNF/NF) 15,7164 1,385,9555 $31.9B6 $50B7 $143.1B8 18.5% for SNFs 60% chain-owned

93.6% freestanding

24% of the approximately 4800 hospitals surveyed by American Hospital Association (AHA) have skilled nursing care units

Inpatient Rehabilitation Facilities (IRFs) 1,17911 397,25612 $6.32B13 N/A14 $11.0B15 8.8%16 80% hospital-based;
20% freestanding17

29.3% of the approximately 4800 hospitals surveyed by AHA have inpatient physical rehabilitation units.

Long-Term Care Hospitals (LTCHs) 436 118,300 $5.2B $520M S8.0B 6.4% overall

6.7% urban facilities
-0.5% rural
5.6% free-standing
8.1% HwH
-0.6% nonprofit;
7.2% for profit

62% are freestanding (38% hospital within hospital)

Over 60% of LTCHs are co-located with acute care hospitals, but under separate ownership

Approximately 7% of almost 4800 hospitals surveyed by the AHA report having a LTCH unit.

Home Health Agencies (HHAs)25 12,02626 3,400,00027 $19.6B28 $4.8B29 $44.7B30 In 2010, HHA margins in aggregate were 19.4% for freestanding agencies31 90% freestanding32

69.7% proprietary
69.5% not part of a chain

81.6% Medicare-certified
80.7% Medicaid-certified33

27% of the approximately 4800 hospitals surveyed by AHA offer home health services

Hospice Agencies 5,15034 1,580,00035 $13.0B $2.36B36 $17.1B37 5.1%38 58% freestanding
19.2% home health based
21.3% hospital based
1.4% SNF-based39

76.3% not part of a chain
93.4% Medicare-certified
86.4% Medicaid-certified40

20.7% of the approximately 4,800 hospitals surveyed by AHA offer hospice services

Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF/IID)41 651442 87,56043 $044 $13.62B45 $18.3B46   87% private
13% public47

95% operated by nonstate agencies [67% of large (<16 residents), 95% (7-15 residents) and 99% (6 or fewer)]

Behavioral Health
Psychiatric Hospitals/Units including Substance Abuse Treatment 2497

1749 (MH)48
748 (SA)49

1,909,238

1,894,000 (MH)50
15,238 (SA)51

$4.3B (MH)52

Substance abuse--see note53

$2.96B

$2.5B (MH)54
$46M (SA)55

$23.06B

$20.18B (MH)
$2.88B (SA)56

See note.57 72% of psychiatric inpatient facilities are hospital-based units 28% are freestanding

The largest psychiatric hospital chain owns 102 of the 300 freestanding psychiatric hospitals58

87% of inpatient substance abuse facilities are private
13% government

33.6% of the approximately 4,800 hospitals surveyed by AHA report having inpatient psychiatric units
9.7% offer substance abuse treatment

Residential Treatment Centers (RTCs) (Mental Health and/or Substance Abuse) 449260 314,39361 See note.62 $2.03B63 S21.77B64    
Community Mental Health Centers 140065 6.0M66 $218.6M67 $15.8B68 $26.8B69    
Clinical Psychologists 93,96070 Private office: 7,648,000 (aged 18 and older) (includes psychiatrists)

Private office: 2,281,000 (children 12-17) (includes psychiatrists)

2,276,000 (aged 12-17) (school social worker, psychologist, or counselor)71

$387M72 $951M73 $6.45B74 N/A See note.75
Clinical Social Workers 249,28076 $10B77 N/A See note.78
Safety Net Providers
Federally Qualified Health Centers (FQHC) 1,12479 19,469,46780 $674M81 $4.25B82 $11.583   All FQHCs are freestanding
Rural Health Centers (RHC) 395084 6.5M85 $312M $800M86 1.9B87 Most operate at a deficit88 52% independent; 48% provider-based89
Other Health Care Providers
Ambulatory Surgical Centers (ASC) 597690 14.9M91 $3.5B92 612M93 $12.3B94 See note95 65% physician-owned
17% hospital/ physician-owned
20% corporate (including physician and physician-hospital)
2% hospital-owned96
22% owned by major multi-facility chains97
24.5% of hospitals replying to the 2010 AHA survey have ambulatory surgery centers
Renal Dialysis Facilities 5,76098 571,00099 $29.1B100 $13.5B101 $42.6B 2.3%102 60% of dialysis facilities in the United States are owned by two for-profit chains103

90% freestanding
10% hospital-based104

Emergency Medical Service Providers 19,971105 36.7M events
28M transports
$5.5B106 $2.1B107 $16.7B108 2%109 9% hospital-affiliated
37% fire department-affiliated
21% affiliated with another government agency
33% freestanding, for-profit or not-for-profit110
Pharmacies 62,892 3.75B prescriptions $63.53B prescription drugs $15.85B prescription drugs $259.1B prescription drugs   60% chain
36% independent/ private
2% government
2% other (franchise, HMO, university/school)

Typical Settings:
60% pharmacies and drug store
26% grocery or department store
10% hospital
4% other (medical or walk-in clinic, university/ school, nursing home, or corporate)115

Pharmacists 274,900
(249,391 in 2009)116
          Typical Provider Setting:
43% pharmacies and drug stores
23% hospitals
14% grocery or department stores
5% other general merchandise stores117
Laboratories 232,996118   $8.9B119 $1.56B120 $61B121   1995 data:
55% Hospital-based
37% Independent clinical laboratories
8% Physician office Independent clinical laboratories were the fastest growing segment of the market122
Blood Centers 2628123 15,014,000124 See note125       See note126
Physical/ Occupational/ Speech Language Therapists 393,110127   $3.83M128 $742M129 $28.3B130   See note131
Registered Dietitians/ Nutritional Professionals 53,510132   See note133   $3.42B134   See note135

Data Sources

Ahn, R., et al. Public Health Laboratories and Health System Change. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, 1997. http://aspe.hhs.gov/health/reports/phlabs/front.htm.

American Ambulatory Surgery Association. Ambulatory Surgery Centers: A Positive Trend in Health Care, 2011. http://www.ascaconnect.org/CONNECT/Communities/Resources/ViewDocument/ ?DocumentKey=7d8441a1-82dd-47b9-b626-8563dc31930c.

American Health Care Association. Research Department. LTC Stats: Intermediate Care Facilities for Individuals with Mental Retardation/Developmental Disabilities. October 2011 update. http://www.ahcancal.org/research_data/oscar_data/ Intermediate%20Care%20Facilities%20MRDD%20Survey%20Reports/mrdd_deficiency_rpt_1011%5B1%5D.pdf.

----. LTC Stats: Nursing Facility Patient Characteristics Report, June 2012 update. http://www.ahcancal.org/research_data/oscar_data/NursingFacilityPatientCharacteristics/ LTC%20STATS_HSNF_PATIENT_2012Q2_FINAL.pdf.

American Health Care Association. Reimbursement and Research Department. The State Long-Term Health Care Sector: Characteristics, Utilization, and Government Funding: 2011 Update. September 2011. http://www.ahcancal.org/research_data/trends_statistics/Documents/ST_rpt_STStats2011_20110906_FINAL_web.pdf.

American Hospital Association, Health Forum LLC. AHA Hospital Statistics, 2012 Edition.

Avalere. Federal Costs for Extending EHR Incentive Payments to Behavioral Health Providers: Memo Discussion, October 2010.

Behavioral Pathway Systems. National Council for Community Behavioral Healthcare, 2005. http://bpsys.org/nationalcouncil.html.

Borck, R., et al. Medicaid Analytic eXtract 2008 Chartbook. Mathematica Policy Research; U.S. Centers for Medicare and Medicaid Services, 2012. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MAX/ Downloads/max-chartbook-2008.pdf.

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----. "Network and Computer Systems Administrators." March 2012. http://www.bls.gov/ooh/computer-and-information-technology/network-and-computer-systems-administrators.htm.

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----. "Social Workers." March 2012. http://www.bls.gov/ooh/community-and-social-service/social-workers.htm.

----. "Speech-Language Pathologists." March 2012. http://www.bls.gov/ooh/healthcare/speech-language-pathologists.htm.

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----. Financial Management Report FY 2002 through FY 2010 (CMS-64 Quarterly Expense Report), Medicaid Budget & Expenditure System (MBES). https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidBudgetExpendSystem/Downloads/NetExpenditure02through10.zip.

----. Hospital Outpatient Prospective and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Electronic Reporting Pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; Quality Improvement Organization Regulations. Proposed Rule, 77 FR 45061, July 2012. http://www.regulations.gov/#!documentDetail;D=CMS-2012-0084-0002.

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----. Medicare Program; Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 2002. Final Rule 66 FR 55331, November 2001. http://www.gpo.gov/fdsys/pkg/FR-2001-11-01/html/01-27275.htm.

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----. National Health Expenditure Projections 2011-2021. January 2011. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf.

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----. Ambulance Providers: Costs and Medicare Margins Varied Widely; Transports of Beneficiaries Have Increased. October 2012. http://www.gao.gov/assets/650/649018.pdf.

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Notes

  1. For a full list of data resources used, see the Sources section at the end of this appendix.

[Return to the Table of Contents]

 

APPENDIX E. LONG-TERM AND POST-ACUTE CARE PROVIDER PROFILES

This appendix provides the clinical characteristics and EHR summary (EHR use, clinical utility, barriers) data for the following long-term and post-acute care providers. Definitions for the provider types are found in Appendix C.

  1. Nursing homes (SNF/NF)
  2. Inpatient rehabilitation facilities (IRF)
  3. Long-term care hospitals (LTCH)
  4. Home health agencies (HHA)
  5. Hospice
  6. Intermediate care facilities for persons with intellectual disabilities (ICF/IID)

A. Nursing Homes

A nursing home (either a skilled nursing facility (SNF) or nursing facility (NF)) is an institution or a distinct part of an institution that has in effect a transfer agreement with one or more hospitals and is primarily engaged in providing: skilled nursing care and related services for residents who require medical or nursing care; or rehabilitation of injured, disabled, or sick persons; meets detailed requirements relating to services provided, residents' rights, professional standards, health and safety standards, and notification to the state of changes in ownership and control; and is not primarily for the care and treatment of mental diseases (and in the case of NFs provides health related care and services to individuals who because of their mental and physical condition can only be made available to them through an institutional facility).1, 2 Nursing homes have a permanent core staff of registered or licensed practical nurses who, along with other staff, provide nursing, therapy, and continuous personal care services.3

Nursing Homes' Characteristics
  1. CMS. National Health Expenditures (2010).
  2. American Health Care Association (AHCA) using CMS-CASPAR data as of June 2012. (American Health Care Association. Research Department. LTC Stats: Nursing Facility Patient Characteristics Report, June 2012 update. http://www.ahcancal.org/research_data/oscar_data/NursingFacilityPatientCharacteristics/LTC%20STATS_HSNF_PATIENT_2012Q2_FINAL.pdf.)
  3. CMS 2011 Data Compendium. "Table VI.1: Medicare Hospital and SNF/NF/ICF Facility Counts, November 2011." http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/DataCompendium/2011_Data_Compendium.html.
  4. 2011 data (MedPAC, June 2012).
No. of providers 15,716 NHsa
Description Nursing homes are inpatient facilities that provide nursing services to provide for the physical, mental and psychosocial well-being of each resident through a multi-disciplinary approach via nurses, therapists and other related professionals. Many of these facilities are dually-certified under both Medicare and Medicaid (91.5%).
Other names Skilled nursing facility (SNF), nursing facility (NF), sub acute unit, transitional care unit, LTC facility.
Number of patients 1,385,955 patients.b
Description of patients Typical nursing home patients require assistance and care on a daily basis, and a large number of these patients are Medicare beneficiaries.
Revenue $143.1 Billiona
Owned by eligible provider 6.4% are hospital-basedc
Medicare profit margin 18.5%d

 

Nursing Homes' Health IT Use, Clinical Utility and Barriers
  1. Resnick, H.E., Manard, B.B., Stone, R.I., Alwan, M. "Use of Electronic Information Systems in Nursing Homes: United States, 2004." Journal of the American Medical Informatics Association (JAMIA), 2009, 16: 179-186. Abstract available online at http://jamia.bmj.com/content/16/2/179.abstract.
EHR Needed Yes
Adoption Rate 43%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange High, as patients may transition from the nursing home to primary care facilities and/or emergency care facilities several times each year.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of awareness of the need to implement an EHR
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes

Nursing Homes References

American Health Care Association. Research Department. LTC Stats: Nursing Facility Patient Characteristics Report, June 2012 update. http://www.ahcancal.org/research_data/oscar_data/NursingFacilityPatientCharacteristics/LTC%20STATS_HSNF_PATIENT_2012Q2_FINAL.pdf.

CMS. National Health Expenditures. 2010.

Government Accountability Office. Nursing Homes: Private Investment Homes Sometimes Differed from Other in Deficiencies, Staffing, and Financial Performance, July 2011, http://www.gao.gov/new.items/d11571.pdf.

Grabowski, David C. Post-Acute and Long-Term Care: A Primer on Services, Expenditures and Payment Methods. U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, June 2010. http://aspe.hhs.gov/daltcp/reports/2010/paltc.htm.

Resnick, H.E., Manard, B.B., Stone, R.I., Alwan, M. "Use of Electronic Information Systems in Nursing Homes: United States, 2004." Journal of the American Medical Informatics Association (JAMIA), 2009, 16: 179-186. Abstract available online at http://jamia.bmj.com/content/16/2/179.abstract.

B. Inpatient Rehabilitation Facilities

An inpatient rehabilitation facilities (IRF) provides intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. Though medical management can be performed in an IRF, patients must be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in IRFs in order to be transferred to an IRF.4

Inpatient Rehabilitation Facilities' Characteristics
  1. MedPAC. Report to the Congress. Medicare Payment Policy, March 2012.
  2. MedPAC, March 2012.
No. of providers 1,179a
Description An inpatient rehabilitation hospital or facility is one that provides intensive rehabilitation services to patients after injury, illness, or surgery. These facilities provide physical and occupational therapy, rehabilitation nursing, prosthetic and orthotic services, as well as speech-language pathology, and about 80% of these facilities were specialized units within hospitals.
Other names Rehab unit, inpatient rehabilitation facility
No. of patients 397,256a
Description of patients 95% of patients are transferred from acute care hospitals into these facilities, and require intensive care after injury, illness, or surgery. Medicare is the predominant payor of IRF services, accounting for about 60% of all discharges.
Revenue: $11.0 Billiona
No. owned by eligible provider 80% hospital-basedb
Medicare profit margin 8.8% (varies greatly from one facility to another)a

 

Inpatient Rehab Hospitals Health IT Use, Clinical Utility and Barriers
  1. Wolf, L., Harvell, J., and Jha, A. "Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates of Electronic Health Records." Health Affair, vol. 31 no. 3 (March 2012). http://content.healthaffairs.org/content/31/3/505.
EHR Needed Yes
Adoption Rate 4%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange High, as patients are discharged from acute care hospitals into these facilities as a result of serious injury, illness or surgery. Their clinical and medical information must travel with them to ensure adequate care.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes
  • EHRs available lack of alignment with MU criteria

Inpatient Rehabilitation Facilities' References

2010 data (MedPAC, March 2012).

Grabowski, David C. Post-Acute and Long-Term Care: A Primer on Services, Expenditures and Payment Methods. U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, June 2010. http://aspe.hhs.gov/daltcp/reports/2010/paltc.htm.

"Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Psychiatric Units; Final Rule." 76 FR 47836 (August 5, 2011). http://www.gpo.gov/fdsys/pkg/FR-2011-08-05/pdf/2011-19516.pdf.

MedPAC. Report to the Congress. Medicare Payment Policy, March 2012.

Pennsylvania Health Care Cost Containment Council. An Annual Report on the Financial Health of Pennsylvania's Non-GAC Facilities. Financial Analysis 2007 v.2: Ambulatory Surgery Center Care, Rehabilitation Care, Psychiatric Care, Long-term Acute Care, Specialty Care. November 2008. http://www.phc4.org/reports/fin/07/docs/fin2007report_volumetwo.pdf.

Wolf, L., Harvell, J., and Jha, A. "Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates of Electronic Health Records." Health Affair, vol. 31 no. 3 (March 2012). http://content.healthaffairs.org/content/31/3/505.

C. Long-Term Care Hospitals

A long-term care hospital provides inpatient services, by or under the supervision of a physician, to patients whose medically complex conditions require a long hospital stay and programs of care provided by a long-term care hospital. The average inpatient length of stay is greater than 25 days. A long-term care hospital has active physician involvement with patients during their treatment through an organized medical staff, physician-directed treatment with physician on-site availability on a daily basis to review patient progress, and consulting physicians on call and capable of being at the patient's side within a moderate period of time, and an interdisciplinary team.5

Long-Term Care Hospitals' Characteristics
  1. 2011 data (MedPAC, June 2012).
  2. MedPAC. Report to the Congress. Medicare Payment Policy, March 2012.
  3. Grabowski, 2010.
  4. CMS. Determining Medical Necessity and Appropriateness of Care for Medicare Long Term Care Hospitals, 2011.
No. of providers 436a
Description Long-term care hospitals treat medically complex patients who require hospital-level care for extended periods of time. These facilities are either freestanding or co-located with other hospitals as hospitals within hospitals or satellites.
Other names Long-Term Care Hospital
No. of patients 118,300b
Description of patients Patients treated in long-term acute care hospitals (LTACH) are typically medically complex, and require treatment for one or more serious conditions, such as life-threatening yet recoverable respiratory illnesses. About 65% of LTACH patients are Medicare beneficiaries.
Revenue $8.0 Billiona
Owned by eligible provider 62% are freestanding; (38% hospital within hospital)c
60% are co-located with acute care hospitals, but under separate ownership.d
Medicare profit margin 6.4% overallb

 

Long-Term Care Hospitals Health IT Use, Clinical Utility and Barriers
  1. Wolf, L., Harvell, J., and Jha, A. "Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates of Electronic Health Records." Health Affair, vol. 31 no. 3 (March 2012). http://content.healthaffairs.org/content/31/3/505.
EHR Needed Yes
Adoption Rate 6%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange High, as patients are admitted from a variety of settings, and may be transferred to one of several facilities for continuing or emergency care. Patients are medically-complex, with serious conditions that require complete knowledge of their medical history.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of awareness of the need to implement an EHR
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes

Long-Term Care Hospital References

2011 data (MedPAC, June 2012).

Grabowski, David C. Post-Acute and Long-Term Care: A Primer on Services, Expenditures and Payment Methods. U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, June 2010. http://aspe.hhs.gov/daltcp/reports/2010/paltc.htm.

MedPAC. Report to the Congress. Medicare Payment Policy, March 2012.

Wolf, L., Harvell, J. and Jha, A. "Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates of Electronic Health Records." Health Affair, vol. 31 no. 3 (March 2012). http://content.healthaffairs.org/content/31/3/505.

D. Home Health Agencies

A home health agency provide skilled nursing and other therapeutic services such as physical therapy, occupational therapy, or speech-language pathology, medical social services, and home health aide services. Supervision of services is provided by a physician or a registered professional nurse.6

Home Health Agencies' Characteristics
  1. National Association for Home Care and Hospice (NAHC). Basic Statistics about Home Care, Updated 2010. http://www.nahc.org/facts/10HC_Stats.pdf.
  2. National Health Expenditures Accounts. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ Proj2011PDF.pdf.
  3. MedPAC (March 2012).
  4. MedPAC (March 2012). http://www.medpac.gov/chapters/Mar12_Ch08.pdf.
No. of providers 12,026 Medicare Certifieda
Description Home health agencies provide skilled nursing, therapy, aide, and medical social work services to beneficiaries in their homes.
Other names N/A
No. of patients 3,400,000a
Description of patients Home health patients require long-term part-time or intermittent skilled care to treat illness or injuries, and Medicaid Home Health services are a mandatory Medicaid benefit for enrollees entitled to nursing facility services. However, patients must also be unable to leave their home without considerable effort.
Revenue $44.7 Billionb
Owned by eligible provider 10% (90% are freestanding)c
Medicare profit margin In 2010, HHA margins in aggregate were 19.4% for freestanding agencies.d

 

Home Health Agencies' Health IT Use, Clinical Utility and Barriers
  1. Resnick, H.E., Alwan, M. "Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007." Journal of the American Medical Informatics Association (JAMIA), 2010, 17: 389-395. Abstract available online at: http://jamia.bmj.com/content/17/4/389.abstract.
EHR Needed Yes
Adoption Rate 43%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, payroll, and HR
Clinical Utility
  •  
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  •  
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, security and Integrity features
Need for Information Exchange High, as patients are treated in their homes by several medical providers, but also require transfer to hospitals or nursing homes.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of awareness of the need to implement an EHR
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes

Home Health Agency References

Medicaid Budget & Expenditure System (MBES) data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidBudgetExpendSystem/ CMS-64-Quarterly-Expense-Report.html.

MedPAC, June 2012.

MedPAC, March 2012.

National Association for Home Care and Hospice (NAHC). Basic Statistics about Home Care, Updated 2010, http://www.nahc.org/facts/10HC_Stats.pdf.

National Health Expenditures Accounts. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf.

Resnick, H.E., Alwan, M. "Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007." Journal of the American Medical Informatics Association (JAMIA), 2010, 17: 389-395. Abstract available online at: http://jamia.bmj.com/content/17/4/389.abstract.

Selected Health Care Services (NAICS 621,622, and 623).Estimated Revenue for Employer Firms by Source: 2006 Through 2010 CMS Compendium (CMS. Data Compendium, 2011 edition, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/DataCompendium/ 2011_Data_Compendium.html.

E. Hospice

A hospice organization provides care to terminally ill individuals under a written plan established and periodically reviewed by the individual's attending physician and by the medical director and the interdisciplinary team. The care and services described in subparagraphs may be provided on a 24-hour, continuous basis only during periods of crisis and as necessary to maintain the terminally ill individual at home. Services may be provided at an inpatient facility after meeting specific conditions.7

Hospice Characteristics
  1. NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, January 2012. http://www.nhpco.org/files/public/Statistics_Research/2011_Facts_Figures.pdf.
  2. NAHC 2010 Data.
  3. Grabowski, 2010.
No. of providers 5,150a
Description Hospices provide care to terminally ill individuals, including therapy, nursing care, medical social services, physician care, or home health services.
Other names Unknown
No. of patients 1,580,000 Medicare Hospice Patientsa
Description of patients Hospice patients are terminally-ill and require palliative and supportive care for these patients and their families. About 31% of Home Health patients suffer from cancer.
Revenue $17.1 Billionb
Owned by eligible provider 21.3% are hospital-basedc
Medicare profit margin 5.1%; dependent upon geography and/or ownership

 

Hospice Health IT Use, Clinical Utility and Barriers
  1. Resnick, H.E., Alwan, M. "Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007." Journal of the American Medical Informatics Association (JAMIA), 2010, 17: 389-395. Abstract available online at: http://jamia.bmj.com/content/17/4/389.abstract.
EHR Needed Yes
Adoption Rate 43%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Low, as patients reside in hospices or receive hospice benefits for end-of-life treatment. Their conditions are terminal.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of awareness of the need to implement an EHR
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes

Hospice References

CMS Compendium, December 2011. "CMS Benefit Payments by Major Program Service Categories, fiscal year 2010."

Grabowski, David C. Post-Acute and Long-Term Care: A Primer on Services, Expenditures and Payment Methods. U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, June 2010. http://aspe.hhs.gov/daltcp/reports/2010/paltc.htm.

Medicare Program; Hospice Wage Index for Fiscal Year 2012. Final Rule 76 FR 47327, http://www.gpo.gov/fdsys/pkg/FR-2011-08-04/pdf/2011-19488.pdf.

NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, January 2012. http://www.nhpco.org/files/public/Statistics_Research/2011_Facts_Figures.pdf.

Resnick, H.E., Alwan, M. "Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007." Journal of the American Medical Informatics Association (JAMIA), 2010, 17: 389-395. Abstract available online at: http://jamia.bmj.com/content/17/4/389.abstract.

F. Intermediate Care Facility for Persons with Intellectual Disabilities

Intermediate Care Facilities for persons with intellectual disabilities (ICF/IID) provide residential care services including comprehensive and individualized health care and rehabilitation services to individuals to promote their functional status and independence. These facilities are available only for individuals in need of, and receiving, active treatment (AT) services. AT refers to aggressive, consistent implementation of a program of specialized and generic training, treatment and health services.8

Intermediate Care Facilities for Persons with Intellectual Disabilities Characteristics
  1. Larson, S.A., et al. Residential Services for Persons with Developmental Disabilities: Statues and trends through 2010. Minneapolis: University of Minnesota, Research and Training Center on Community Living, Institute on Community Integration (2012). http://rtc.umn.edu/docs/risp2010.pdf.
  2. Ibid.
  3. U.S. Census Bureau, 2007 Economic Census. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk.
No. of providers 6,514a
Description Intermediate Care Facilities for persons with intellectual disabilities provide health-related care and services above the level of custodial care to persons with mental retardation, but does not provide the level of care or treatment available in a hospital or skilled nursing facility. These facilities provide regular medical, nursing, social and rehabilitative services in addition to room and board for individuals incapable of independent living, typically from youth until old age.
Other names ICF/MR, MR-DD Facility
No. of patients 87,560b
Description of patients Patients are individuals with intellectual and developmental disabilities.
Revenue $18.3 Billionc
Owned by eligible provider Unable to determine.
Medicare profit margin Unable to determine.

 

Intermediate Care Facilities for Persons with Intellectual Disabilities Health IT Use, Clinical Utility and Barriers
EHR Needed Yes; dependent upon size
Adoption Rate Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Therapy information system
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange High, as patients require transfer and discharge to-and-from skilled nursing facilities or acute care hospitals for treatment above basic nursing care.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes

ICF/IID References

American Health Care Association. LTC Stats: Intermediate Care Facilities for Individuals with Mental Retardation/Developmental Disabilities. October 2011 Update. http://www.ahcancal.org/research_data/oscar_data/Intermediate%20Care%20Facilities%20MRDD%20Survey%20Reports/ MRDDLTCSTATSSummaryReport.pdf.

Braddock, D. Challenges in Developmental Disabilities Services in Washington State and the United States: 2011. Presentation: Washington Developmental Disabilities Council,May 2011. http://sos.arielmis.net/images/documents/2011_05_18washington stateall.pdf.

Braddock, D., et al. The State of the States in Developmental Disabilities, 2011. http://www.stateofthestates.org/documents/SOS%20FINAL%20REVISED%20EDITION2011.pdf.

CMS. ICF/MR Program Trends. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/ICFMR_Trends.pdf.

Eljay, LLC, A Report on Shortfalls in Medicaid Funding for Nursing Home Care, December 2011, http://www.ahcancal.org/research_data/funding/Documents/Eljay%20Medicaid%20Shortfalls%20Report%202011.pdf.

Henry J. Kaiser Family Foundation. "Distribution of Medicaid Spending on Long Term Care, FY2010."

Highbeam Business. http://business.highbeam.com/industry-reports/business/intermediate-care-facilities.

Table 8.E1--Number of recipients, total vendor payments, and average payment, by type of medical service, fiscal years 1985-2009. Annual Statistical Supplement to the Social Security Bulletin, 2011, p.446.

U.S. Census Bureau, 2007 Economic Census. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk.

United States Public I/DD Spending by Revenue Source: FY 2009. http://www.stateofthestates.org/documents/UnitedStates.pdf.

Notes

  1. Social Security Act. http://www.ssa.gov/OP_Home/ssact/title19/1919.htm.

  2. Social Security Act. http://www.ssa.gov/OP_Home/ssact/title18/1819.htm.

  3. U.S. Census Bureau. http://www.census.gov/econ/industry/def/d623110.htm.

  4. Centers for Medicare and Medicaid Services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf.

  5. Centers for Medicare and Medicaid Services. http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-p-4-a.

  6. Centers for Medicare and Medicaid Services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c05.pdf.

  7. Social Security Act. http://www.socialsecurity.gov/OP_Home/ssact/title18/1861.htm#act-1861-ii.

  8. Medicaid.gov. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Institutional-Care/ Intermediate-Care-Facilities-for-Individuals-with-Mental-Retardation-ICFMR.htm.

[Return to the Table of Contents]

 

APPENDIX F. BEHAVIORAL HEALTH PROVIDER PROFILES

This appendix provides the clinical characteristics and EHR summary (EHR use, clinical utility, barriers) data for the following behavioral health providers. Definitions for the provider types are found in Appendix C.

  1. Psychiatric Hospital/Unit including Substance Abuse
  2. Residential Treatment Centers/Facilities for Mental Health and/or Substance Abuse
  3. Community Mental Health Clinics
  4. Clinical Psychologists
  5. Clinical Social Workers

A. Psychiatric Hospitals/Units Including Substance Abuse

A psychiatric hospitals/units (including substance abuse) provide inpatient hospital services to patients. They are certified under Medicare as inpatient psychiatric hospitals and distinct units of acute care hospitals and critical access hospitals.1 These hospitals primarilyengaged in providing diagnostic, medical treatment, and monitoring services forinpatients who suffer from mental illness or substance abuse disorders. The treatment often requires an extended stay in the hospital. These establishments maintain inpatient beds and provide patients with food services that meet their nutritional requirements. They have an organized staff of physicians and other medical staff to provide patient care services. Psychiatric, psychological, and social work services are available at the facility. These hospitals usually provide other services, such as outpatient services, clinical laboratory services, diagnostic X-ray services, and electroencephalograph services.2

Psychiatric Hospitals/Units Including Substance Abuse Characteristics
  1. Dobson DaVanzo & Associates, LLC. The Economic Impact of Inpatient Psychiatric Facilities A National and State-level Analysis. Submitted to National Association of Psychiatric Health Systems (NAPHS), February 2010.
  2. Avalere. Federal Costs for Extending EHR Incentive Payments to Behavioral Health Providers: Memo Discussion, October 15, 2010.
  3. See http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl4.1.htm.
  4. Medicare and Your Mental Health Benefits. Medicare coverage for partial hospitalizations, page 10. http://www.medicare.gov/Publications/Pubs/pdf/10184.pdf.
  5. See http://www.nssats.com/Definitions/index.asp.
  6. Mental Health, U.S. 2010. Table 24. "Number and percentage of persons aged 18 or older who received mental health treatment in the past year, by disorder severity, United States, 2009."
  7. See http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl5.2a.htm.
  8. Substance Abuse and Mental Health Services Administration. National Expenditures for Mental Health Services and Substance Abuse Treatment, 1986-2005. DHHS Publication No. (SMA) 10-4612. Rockville, MD: Center for Mental Health Services and Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2010. http://store.samhsa.gov/shin/content//SMA10-4612/SMA10-4612.pdf.
  9. MedPac report (March 2012).
  10. Pennsylvania financial analysis showed in 2010, freestanding psychiatric hospitals had an operating margin of 5.92% and an overall margin for inpatient psychiatric facilities of 4.58%. http://www.phc4.org/reports/fin/10/docs/fin2010report_volumethree.pdf.
Number of providers 2497 (including 1749a psychiatric hospitals (non-government inpatient psychiatric hospitals (255), hospital psychiatric units (1274), and state psychiatric hospitals (220)b and 748 substance abuse inpatient facilities)c
Description A Psychiatric Hospital is a facility or distinct part of a facility that provides psychological or psychiatric services, occupational therapy, and recreational therapy, under the supervision of a physician. These facilities are staffed by specially-trained professionals for the diagnosis and treatment of mentally ill patients. Outpatient departments may provide partial day hospitalization services.d A substance abuse treatment hospital is a location that provides treatment for substance abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
Other names Mental Health Hospital; Inpatient Psychiatric/Mental Health Hospital/Unit, Detoxification Unit, Medically-Managed Intensive Inpatient Treatmente
Number of patients 1,909,238 (including 1,894,000 for mental health treatment andf 15,238 for substance abuse treatment or detoxificationg)
Description of patients Psychiatric Hospitals treat chronic, mentally ill, and typically medically stable patients. Younger patients commonly suffer from psychosis, whereas older patients commonly suffer from dementia. Patients may be served at inpatient psychiatric hospitals providing substance abuse services for intensive detoxification, acute medical care services, as well as for rehabilitation services, for treatment relating to alcohol and other drug abuse and dependency.
Revenue $23.06 Billion (including $20.18B (MH) and $2.88B (SA))h
Owned by eligible provider 72% of psychiatric units are hospital-basedi
Medicare profit margin not knownj

 

Psychiatric/Hospitals/Units Including Substance Abuse Health IT Use, Clinical Utility and Barriers
  1. Wolf, Larry, Jennie Harvell, and Ashish K. Jha. "Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates Of Adoption Of Electronic Health Records." Health Affairs 31, no. 3 (March 1, 2012): 505-513. Adoption rate for specialty substance abuse treatment hospitals is unknown. http://content.healthaffairs.org/content/31/3/505.
EHR Needed Yes
Adoption Rate 2%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Privacy, Security and Integrity Features
Need for Information Exchange Need ability to share information for coordination of care activities during stay. Access to other providers' information is crucial to care planning and post-care treatment.
Barriers to Adoption
  • Lack of capital (MH/SA)
  • Lack of a certified vendor for provider specialty (MH/SA)
  • Lack of awareness of the need to implement an EHR (SA)
  • Lack of demand for an EHR (SA)
  • EHRs available lack of alignment with MU criteria (MH/SA)
  • Workforce limitations to implement and maintain an EHR (MH/SA)
  • Limited decision support for complex clinical condition (MH/SA)
  • Lagging standards for clinical processes (MH/SA)
  • Lack of consent management (MH/SA)

Psychiatric/Hospitals/Units Including Substance Abuse References

Levit KR, Kassed CA, Coffey RM, Mark TL, McKusick DR, King E, VandivortR, Buck J, Ryan K, Stranges E. Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment, 2004-2014. SAMHSA Publication No. SMA 08-4-326. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2008.

Mental Health, U.S. 2010. Table 24. "Number and percentage of persons aged 18 or older who received mental health treatment in the past year, by disorder severity, United States, 2009."

National Council for Community Behavioral Healthcare. HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health: Report on the 2012 National Council Survey. June 2012. http://www.thenationalcouncil.org/galleries/business-practice%20files/HIT%20Survey%20Full%20Report.pdf.

"SMHA Revenues for State Psychiatric Hospitals and Community-Based Programs: FY 2009" NASMHPD Research Institute, Inc. State Mental Health Revenues and Expenditures for Mental Health Services. August 2012.

Substance Abuse and Mental Health Services Administration. "Spending by Provider and Setting" (2005) https://info.samhsa.gov/Dissemination/Substance-Abuse-Treatment-Facility-Locator/9fiu-br7a.

Substance Abuse and Mental Health Services Administration. N-SSATS, 2010 "Table 4.2A: Type of care offered, by facility operation and primary focus of facility: 2010." http://www.samhsa.gov/data/DASIS/2k10nssats/NSSATS2010Tbl4.2a.htm.

The National Survey of Substance Abuse Treatment Services (N-SSATS): 2008. Data on Substance Abuse Treatment Facilities specifies 838 are hospital inpatient, with 317 having a primary focus of substance abuse, 296 focusing on a mix of substance abuse and mental health, 161 focusing on mental health care, and the rest focusing on general health care or other. http://wwwdasis.samhsa.gov/08nssats/nssats2k8.pdf.

B. Residential Treatment Centers/Facilities for Mental Health and/or Substance Abuse

Residential treatment centers/facilities for mental health and/or substance abuse are a stand-alone entity that provides a range of comprehensive services to treat the condition of residents on an inpatient basis under the direction of a physician.3 These facilities engage in providing residential care and treatment for patients with mental health and substance abuse illnesses. These establishments provide room, board, supervision, and counseling services. Although medical services may be available at these establishments, they are incidental to the counseling, mental rehabilitation, and support services offered. These establishments generally provide a wide range of social services in addition to counseling. Illustrative examples include Alcoholism or drug addiction rehabilitation facilities (except licensed hospitals), Psychiatric convalescent homes or hospitals, mental health halfway houses, Residential group homes for the emotionally disturbed.4

Residential Treatment Centers/Facilities for Mental Health and/or Substance Abuse Characteristics
  1. See https://info.samhsa.gov/Services/Mental-Health-/z8sj-w7z2.
  2. See https://info.samhsa.gov/Dissemination/Substance-Abuse-Treatment-Facility-Locator/9fiu-br7a.
  3. SAMHSA. "Table 56. Number and percentage of persons aged 12 to 17 who received mental health treatment in the past year, by type of treatment, United States, 2009." (Mental Health U.S., 2010)
  4. The National Survey of Substance Abuse Treatment Services (N-SSATS): 2008. http://wwwdasis.samhsa.gov/08nssats/nssats2k8.pdf.
  5. Dobson, 2010.
  6. National Expenditures for Mental Health Services and Substance Abuse Treatment.
Number of providers 1649 (MH)a; 2843 (SA)b
Description Residential Treatment Facilities provide residential, non-hospital care and a safe and stable living environment to patients with mental illness and/or substance abuse disorders. Designated treatment personnel, who provide a planned regimen of care in a 24-hour setting, operate these facilities.
Other names Unknown
Number of patients 211,000 Child Patients; >103,393 adult beds (MH)c; 107,441 (SA)d
Description of patients Patients of Residential Treatment Facilities suffer from mental illness and/or substance abuse disorders. Designated treatment personnel, who provide a planned regimen of care in a 24-hour setting, operate these facilities. Most studies report that patients in mental health residential treatment programs have conduct, antisocial, delinquent or behavioral problems.
Revenue $4.5 Billion (MH)e; $4.6 Billion (SA)f
Owned by eligible provider Unknown
Medicare profit margin Unknown

 

Residential Treatment Centers/Facilities for Mental Health and/or Substance Abuse Health IT Use, Clinical Utility and Barriers
EHR Needed Yes
Adoption Rate Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records Pharmacy information system
  • Lab information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Privacy, Security and Integrity Features
Need for Information Exchange Need ability to share information for coordination of care activities during stay. Access to other providers' information is crucial to care planning and post-care treatment.
Barriers to Adoption
  • Lack of capital
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes
  • Lack of consent management (privacy concerns)

Residential Treatment Centers/Facilities for Mental Health and/or Substance Abuse References

Dobson DaVanzo & Associates, LLC. The Economic Impact of Inpatient Psychiatric Facilities ANational and State-level Analysis. (Submitted to National Association of Psychiatric Health Systems (NAPHS), February 2010). http://www.naphs.org/news/documents/NAPHSFinalReport21910.2.pdf.

Ireys, H, Achman, L, Takyi, A. State Regulation of Residential Facilities for Adults with Mental Illness. DHHS Pub. No. (SMA) 06-4166. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2006. http://www.samhsa.gov/News/NewsReleases/residfaciladultFinal.pdf.

MAX Chartbook 2008 (published 2012). Published by Medicaid.gov. http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MAX/MAX-Chartbooks.html.

National Council for Community Behavioral Healthcare. HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health: Report on the 2012 National Council Survey. June 2012. http://www.thenationalcouncil.org/galleries/business-practice%20files/HIT%20Survey%20Full%20Report.pdf.

Substance Abuse and Mental Health Services Administration, mental health facilities filtered by residential care. https://info.samhsa.gov/Services/Mental-Health-/z8sj-w7z2; https://info.samhsa.gov/Dissemination/Substance-Abuse-Treatment-Facility-Locator/9fiu-br7a.

Schwalbe, Leslie. Behavioral Health Providers: Expenditures, Methods and Sources of Payment, Electronic Health Record Incentive Payments for Certain Behavioral Health Providers Policy Descriptions. U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, June 2010. http://aspe.hhs.gov/daltcp/reports/2010/behhp.htm#inpatient.

C. Community Mental Health Center

Community mental health centers (CMHCs) came about as a result of legislation enacted in 1963 (the Mental Retardation Facilities and Community Mental Health Centers Construction Act, P.L. 88-164), to provide localities with funding for the development of CMHCs as part of the deinstitutionalization movement, and to provide services for the uninsured poor. With the passage of the 1981 Omnibus Reconciliation Act, mandatory federal funding ceased to federally qualified CMHCs (thus, eliminating the federal designation of CMHC) and funding was block granted to states for the delivery of behavioral health services to multiple provider organizations, including CMHCs and other multi-service mental health organizations. Most CMHC funds are controlled by the state mental health agency, although Medicare still recognizes CMHCs as a provider of partial hospitalization services, and in June 2011 proposed Conditions of Participation for CMHCs to ensure basic levels of quality and safety for CMHC care.5

Community Mental Health Center Characteristics
  1. 76 FR 35684; June 17, 2011. http://www.gpo.gov/fdsys/pkg/FR-2011-06-17/pdf/2011-14673.pdf.
  2. Behavioral Pathway Systems. "National Council for Community Behavioral Health Care." http://bpsys.org/nationalcouncil.html.
  3. "SMHA Revenues for State Psychiatric Hospitals and Community-Based Programs: FY 2009" NASMHPD Research Institute, Inc. State Mental Health Revenues and Expenditures for Mental Health Services (August 2012).
Number of providers 1400a
Description Community Mental Health Clinics specialize in outpatient services for mentally ill patients who have been discharged from inpatient treatment at a mental health facility. These facilities may also act as 24-hour emergency care facilities, screening facilities, or day treatment facilities (partial hospitalization) for mentally ill patients.
Other names Community Mental Health Center
Number of patients 6,000,000b
Description of patients Patients treated at CMHCs may be children, the elderly, or individuals who are chronically mentally ill or require screening for admission to state mental health facilities, consultation and/or education services.
Revenue $26.8 Billionc
Owned by eligible provider Unknown
Medicare profit margin Unknown

 

Community Mental Health Center Health IT Use, Clinical Utility and Barriers
  1. "HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health." National Council for Community Behavioral Healthcare. http://www.thenationalcouncil.org/galleries/business-practice%20files/HIT%20Survey%20Full%20Report.pdf. Community behavioral health organizations report that 21% of organizations have EHRs at all of their sites; 65% of the behavioral health organizations surveyed reported having adopted some form of an EHR at some of their sites. Only 2% of responding community behavioral health organizations reported adopting technology that could meet the base requirements of the Meaningful Use Program.
EHR Needed Yes
Adoption Rate 65%a (2% of responding organizations reported meeting the base requirements of the Meaningful Use Program)
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records Pharmacy information system
  • Lab information system
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry Privacy, Security and Integrity Features
Need for Information Exchange Need ability to share information for coordination of care activities with multiple caregivers.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition
  • Lagging standards for clinical processes
  • Lack of consent management (privacy)

Community Mental Health Center References

2010 data. U.S. Department of Health and Human Services. Office of the Inspector General. Questionable Billing by Community Mental Health Centers (August 2012) http://oig.hhs.gov/oei/reports/oei-04-11-00100.pdf.

Avalere. 76 FR 35684; June 17, 2011; http://www.gpo.gov/fdsys/pkg/FR-2011-06-17/pdf/2011-14673.pdf.

Behavioral Pathway Systems. "National Council for Community Behavioral Health Care." http://bpsys.org/nationalcouncil.html.

National Council for Community Behavioral Healthcare. "HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health." June 2012. http://www.thenationalcouncil.org/galleries/business-practice%20files/HIT%20Survey%20Full%20Report.pdf.

Sherril B. Gelmon and Oliver Droppers. Community Health Center and Electronic Health Records: Issues, Challenges, and Opportunities. Portland, OR: Northwest Health Foundation, 2008. http://nwhf.org/images/files/Electronic_Medical_Record_Handbook.pdf.

"SMHA Revenues for State Psychiatric Hospitals and Community-Based Programs: FY 2009" NASMHPD Research Institute, Inc. State Mental Health Revenues and Expenditures for Mental Health Services (August 2012).

D. Clinical Psychologists

Clinical psychologists are legally authorized to perform services under state law.6 They are mental health professionals engaged in: (1) the diagnosis and treatment of mental, emotional, and behavioral disorders; and/or (2) the diagnosis and treatment of individual or group social dysfunction brought about by such causes as mental illness, alcohol and substance abuse, physical and emotional trauma, or stress. These practitioners operate private or group practices in their own offices (e.g., centers, clinics) or in the facilities of others, such as hospitals or medical centers.7

Clinical Psychologists' Characteristics
  1. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, "Psychologists," on the Internet at http://www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm (visited September 05, 2012).
  2. Mental Health, U.S. (2010).
  3. SAMHSA indicates total spending for clinical social workers, clinical psychologists, and licensed counselors was $7.6B in 2005. "Spending by provider and setting." SAMHSA, 2005.
  4. Daniel Michalski, Tanya Mulvey, and Jessica Kohout. 2008 APA Survey of Psychology Health Service Providers. American Psychological Association, May 2010).
Number of providers 93,960a
Description Psychologists assess, diagnose, and treat mental, emotional, and behavioral disorders. Psychologists may own their own practice, or be employed by hospitals, mental health institutions or long-term care facilities as part of a team care approach.
Other names Unknown
Number of patients 7,648,000b
Description of patients Psychologists treat patients who may require mental, emotional, and behavioral support, with the population varying greatly among different provider settings. Psychologists may treat a high volume of Medicare and/or Medicaid beneficiaries depending upon service location.
Revenue $6.45 Billionc
Owned by eligible provider 16% are either employed by a hospital or CMHCd
Medicare profit margin Unknown

 

Clinical Psychologists' Health IT Use, Clinical Utility and Barrier
EHR Needed Yes
Adoption Rate Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management (small segment can prescribe)
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records Patient Portals
  • Patient eligibility determinations
  • Billing
Clinical Utility
  • Patient Demographic , Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry (small segment can prescribe)
Need for Information Exchange Need ability to share information for coordination of care activities with multiple care givers.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria Workforce limitations to implement and maintain an EHR
  • Lagging standards for clinical processes
  • Lack of consent management

E. Clinical Social Worker

A clinical social worker possesses a master’s or doctor’s degree in social work, is licensed or certified by the state in which the services are performed and has completed at least 2 years or 3,000 hours of post-master’s degree supervised clinical social work practice under the supervision of a master’s level social worker in an appropriate setting (as determined by the Secretary). Services performed include the diagnosis and treatment of mental illnesses (as legally authorized).8

Clinical Social Workers' Characteristics
  1. Occupational Employment Statistics. http://www.bls.gov/oes/current/oes211022.htm.
  2. Health care labor statistics by SOC Code, May 2012.
Number of providers 249,280a
Description Clinical Social Workers provide diagnosis and case management care to individuals suffering from a variety of conditions and illnesses. They perform social care services in several in-patient and out-patient care settings, and in certain states, may operate a private practice.
Other names Unknown
Number of patients Unknown
Description of patients Patients may be of all life-cycle ages, and suffering from a broad spectrum of illness or condition. The patient demographic is heavily dependent upon the practice site, and patients may be Medicare and/or Medicaid beneficiaries with volumes varying across service location.
Revenue $10 Billionb
Owned by eligible provider Unknown
Medicare profit margin Unknown

 

Clinical Social Workers' Health IT Use, Clinical Utility and Barriers
EHR Needed Yes
Adoption Rate Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records Patient Portals
  • Patient eligibility determinations
  • Billing
Clinical Utility
  • Patient Demographic , Health Information and Problem Lists
  • Clinical Decision Support
  • Privacy, Security and Integrity Features
Need for Information Exchange Need ability to share information for coordination of care activities with multiple care givers.
Barriers to Adoption
  • Lack of capital
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • EHRs available lack of alignment with MU criteria
  • Workforce limitations to implement and maintain an EHR
  • Lagging standards for clinical processes
  • Lack of consent management

Clinical Psychologists and Clinical Social Workers References

2009 data. The Medicare Payment Advisory Commission. Report to Congress: Medicare and the Health Care Delivery System, Chapter 6. June 2011. http://www.medpac.gov/documents/Jun11_EntireReport.pdf.

Clinically active clinical social workers (2006 data) at 92,227 (Mental Health, U.S. 2010); Avalere puts the number at 260,000 (Avalere. Federal Costs for Extending EHR Incentive Payments to Behavioral Health Providers: Memo Discussion, October 15, 2010).

National Council for Community Behavioral Healthcare. "HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health." June 2012. http://www.thenationalcouncil.org/galleries/business-practice%20files/HIT%20Survey%20Full%20Report.pdf.

Occupational Employment Statistics. This number includes health care social workers and mental health and substance abuse social workers. http://www.bls.gov/oes/current/oes211022.htm.

Sherril B. Gelmon and Oliver Droppers. Community Health Center and Electronic Health Records: Issues, Challenges, and Opportunities. Portland, OR: Northwest Health Foundation, 2008. http://nwhf.org/images/files/Electronic_Medical_Record_Handbook.pdf.

Notes

  1. Medicare Benefit Policy Manual. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c02.pdf.

  2. U.S. Census Bureau. http://www.census.gov/econ/industry/def/d622210.htm.

  3. Centers for Medicare and Medicaid Services. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter07-15.pdf.

  4. U.S. Census Bureau. http://www.census.gov/econ/industry/def/d623220/htm.

  5. Medicare Program; Conditions of Participation (CoPs) for Community Mental Health Centers. Proposed Rule (76 FR 35684). https://www.federalregister.gov/articles/2011/06/17/2011-14673/medicare-program-conditions-of-participation-cops- for-community-mental-health-centers.

  6. Social Security Act. http://www.socialsecurity.gov/OP_Home/ssact/title18/1861.htm#act-1861-ii.

  7. U.S. Census Bureau. http://www.census.gov/econ/industry/def/d621330.htm.

  8. Social Security Act. http://www.socialsecurity.gov/OP_Home/ssact/title18/1861.htm#act-1861.ii.

[Return to the Table of Contents]

 

APPENDIX G. SAFETY NET PROVIDER PROFILES

This appendix provides the clinical characteristics and EHR summary (EHR use, clinical utility, barriers) data for the following safety net providers. Definitions for the provider types are found in Appendix C.

  1. Federally Qualified Health Center
  2. Rural Health Clinic

A. Federally Qualified Health Centers

A Federally Qualified Health Center (FQHC) is a facility receiving a grant under Section 330 of the Public Health Service Act, a look-alike health center organization that meets the requirements of Section 330 but does not receive grant funding, and outpatient health programs/facilities operated by tribal organizations (under the Indian Self Determination Act, P.L. 96-638) or urban Indian organizations (under the Indian Health Care Improvement Act, P.L. 94-437).1 They are located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician. FQHCs are located in areas where private health providers lack financial incentives to operate, including sparsely populated rural locations with fewer patients or highly populated urban centers where there are high rates of publicly insured or uninsured patients.2 An FQHC provides primary health care services in the same scope as would be provided by a physician, dentist or podiatrist in the clinic or office setting. Services and supplies incident to these services are covered as well.

Federally Qualified Health Centers' Characteristics
  1. The George Washington University Department of Health Policy. Quality Incentives for Federally Qualified Health Centers, Rural Health Clinics and Free Clinics: A Report to Congress. (January 2012)
  2. The Henry J. Kaiser Family Foundation. "Patients Served by Federally-Funded Federally Qualified Health Centers, 2010." http://www.statehealthfacts.org//comparebar.jsp?ind=426&yr=138&typ=1&sort=a&rgnhl=15.
  3. MedPAC report, June 2011. http://www.medpac.gov/documents/Jun11_EntireReport.pdf.
Number of providers 1,124a (clinics)
Description Federally Qualified Health Centers are primary care clinics operating under funding provided by Section 330 of the Public Health Act, and are a required Medicaid benefit through CMS. These facilities provide on-site or contracted services typically provided by hospitals, to provide primary and preventative care for underserved populations.
Other names Unknown
Number of patients 19,469,467b
Description of patients Patients of FQHCs are of all ages that typically live in medically-underserved and economically depressed locations. 63% of patients were of racial or ethnic minority, and 70% have an income below the poverty line.
Revenue $11.5 Billionc
Owned by eligible provider 0
Medicare profit margin Unknown

 

Federally Qualified Health Centers' Health IT Use, Clinical Utility and Barriers
  1. RCHN Community Health Foundation Research Collaboration. Policy Research Brief #27: Results from the 2010-11 Readiness for Meaningful Use of HIT and Patient Centered Medical Home Recognition Survey. (November 2011).
EHR Needed Yes
Adoption Rate 68.5%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Coordinate care with a wide range of providers and specialists.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Workforce limitations to implement and maintain an EHR

B. Rural Health Clinic

A Rural Health Clinic (RHC) is primarily engaged in furnishing to outpatients services a certified facility located in a rural medically underserved area that provides ambulatory primary medical care. Rural health clinics utilize physician assistants and nurse practitioners by providing reimbursement for services these health professionals provided to Medicare and Medicaid patients even in the absence of a full-time physician.3 Rural health clinic services are a mandatory Medicaid benefit.

Rural Health Clinics' Characteristics
  1. Muskie School of Public Service. Maine Rural Health Research Center. RHCs at the Crossroad (presentation, National Rural Health Association Annual Meeting, Denver, CO, April 18, 2012. http://muskie.usm.maine.edu/Publications/rural/RHCs-at-the-crossroads_Gale-NRHA-2012.pdf.
  2. See http://www.healthit.gov/system/files/pdf/quality-incentives-final-report-1-23-12.pdf.
  3. Estimate, based on 2008 data. The George Washington University (2012).
  4. Based on estimate Medicare and Medicaid provides approximately 60% of RHC funding. (GWU, 2012)
  5. The George Washington University, 2012. ("A provider-based RHC is an integral and subordinate part of a Medicare participating hospital, critical access hospital (CAH), skilled nursing facility (SNF), or home health agency (HHA), and is operated with other departments of the provider under common governance, professional supervision, and usually licensure. All other RHCs are considered to be independent." (73 FR 36696; June 27, 2008). Independent clinics are most commonly owned by physicians (49%), other individuals or corporate entities (29%), hospital corporations (15%), nurse practitioners, physician assistants, certified nurse midwives (7%), or RHC administrators (1%). Provider-based clinics are owned by hospitals of less than 50 beds (50%), hospitals of more than 50 beds (40%), and nursing homes and other owners (10%). (Gale and Coburn, 2003)
  6. Gale and Coburn, 2003.
Number of providers 3,950 Medicare-certifieda (clinics)
Description Rural Health Clinics may be stand-alone facilities, facilities within hospitals, or mobile units that must be staffed by a physician and have at least one other certified practitioner on staff at least 50% of the time to provide primary care in medically underserved or non-urbanized areas.
Other names Unknown
Number of patients An estimate of number of patients seen in 2008 is 5-8 million patients.b For purposes of this study we use the average of this range: 6,500,000.c
Description of patients Patients of RHCs reside in medically-underserved, non-urbanized areas, and may rely on Medicare and Medicaid services. About one-third of RHC patients are Medicaid or Medicare beneficiaries.
Revenue $1.9 Billiond
Owned by eligible provider 52% independent; 48% provider-basede
Medicare profit margin Unknown; most operate at a deficitf

 

Rural Health Clinics' Health IT Use, Clinical Utility and Barriers
  1. RCHN Community Health Foundation Research Collaboration. Policy Research Brief #27: Results from the 2010-11 Readiness for Meaningful Use of HIT and Patient Centered Medical Home Recognition Survey. (November 2011).
EHR Needed Yes
Adoption Rate 42%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Coordinate care with multiple providers, professionals and specialists.
Barriers to Adoption
  • Cost to adopt/lack of capital/lack of incentives
  • Workforce limitations to implement and maintain an EHR

References

Gale, John A., and Andrew F. Coburn. The Characteristics and Roles of Rural Health Clinics in the United States: A Chartbook. Portland, ME: Edmund S. Muskie School of Public Service, January 2003. http://muskie.usm.maine.edu/Publications/rural/RHChartbook03.pdf.

Medicare Learning Network. Centers for Medicare and Medicaid Services. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf.

Muskie School of Public Service. Maine Rural Health Research Center. RHCs at the Crossroad presentation, National Rural Health Association Annual Meeting, Denver, CO, April 18, 2012 http://muskie.usm.maine.edu/Publications/rural/RHCs-at-the-crossroads_Gale-NRHA-2012.pdf; https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ MedicaidBudgetExpendSystem/CMS-64-Quarterly-Expense-Report.html.

RCHN Community Health Foundation Research Collaboration.Policy Research Brief #27: Results from the 2010-11 Readiness for Meaningful Use of HIT and Patient Centered Medical Home Recognition Survey. November 2011.

The George Washington University Department of Health Policy.Quality Incentives for Federally Qualified Health Centers, Rural Health Clinics and Free Clinics: A Report to Congress. January 2012. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_4383_1239_15610_43/http%3B/wci-pubcontent/publish/ onc/public_communities/p_t/resources_and_public_affairs/reports/reports_portlet/files/quality_incentives_final_report_1_23_12.pdf.

The Henry J. Kaiser Family Foundation. "Patients Served by Federally-Funded Federally Qualified Health Centers, 2010." http://www.statehealthfacts.org/comparebar.jsp?ind=426&yr=138&typ=1&sort=a&rgnhl=15.

The Medicare Payment Advisory Commission. Report to Congress: Medicare and the Health Care Delivery System, Chapter 6. June 2011. http://www.medpac.gov/documents/Jun11_EntireReport.pdf; http://www.thenationalcouncil.org/galleries/policy-file/Healthcare%20Payment%20Reform%20Full%20Report.pdf.

Notes

  1. Social Security Act. http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-aa-4.

  2. Health Resources and Services Administration. http://bphc.hrsa.gov/about/.

  3. Comparison of the Rural Health Clinic and Federally Qualified Health Center Programs. HRSA. June 2006. http://www.ask.hrsa.gov/downloads/fqhc-rhccomparison.pdf.

[Return to the Table of Contents]

 

APPENDIX H. OTHER HEALTH CARE PROVIDER PROFILES

This appendix provides the clinical characteristics and EHR summary (EHR use, clinical utility, barriers) data for the following other health care providers. Definitions for the provider types are found in Appendix C.

  1. Ambulatory Surgical Centers
  2. Renal Dialysis Facilities
  3. Registered Dietician/Nutritional Professionals
  4. Therapists (Physical, Occupational and Speech Pathologists)
  5. Pharmacists and Pharmacies
  6. Laboratories
  7. Emergency Medical Service Providers
  8. Blood Centers

Information on health IT/EHR use was often very limited for these health care providers. Inferences were made by the study team based on review of literature available and/or review of products that may serve the market.

A. Ambulatory Surgical Centers

Ambulatory Surgical Center provide outpatient surgical services (e.g., orthoscopic and cataract surgery). They have specialized facilities, such as operating and recovery rooms, and specialized equipment, such as anesthetic or X-ray equipment.1 The ASCs must be certified as meeting the requirements for an ASC and must enter into an agreement with the Centers for Medicare and Medicaid Services (CMS).2

Ambulatory Surgical Centers' Characteristics
  1. 2008 data. (VMG Health, 2010). According to VMG Health analysis, of the total number of freestanding ASCs, 5174 were Medicare-certified.
  2. See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/Downloads/C_ASC_RTC-2011.pdf.
  3. Cullen et al., 2009.
  4. See http://www.medpac.gov/documents/MedPAC_Payment_Basics_11_ASC.pdf.
  5. Based on MedPAC data for Medicare expenditures and VMG Health's estimate that Medicare contributes approximately 25% to ASC revenues. (VMG, 2010)
  6. American Ambulatory Surgery Association. Ambulatory Surgery Centers: A Positive Trend in Health Care, 2011. http://www.ascaconnect.org/CONNECT/Communities/Resources/ViewDocument/ ?DocumentKey=7d8441a1-82dd-47b9-b626-8563dc31930c.
Number of providers 5,976a
Description Ambulatory Surgical Centers are hospital-based or free-standing facilities that provide outpatient surgical services to patients. Patients do not require hospitalization and the duration of the services they receive is unlikely to exceed 24 hours.b
Other names Surgicenters
Number of patients 14,900,000 totalc
Description of patients Patients of ASCs receive a variety of ambulatory surgeries. The most common procedures in 2009 were cataract removal with lens insertion, upper gastrointestinal endoscopy, colonoscopy, and other eye procedures.d
Revenue $12.3 Billione
Owned by eligible provider 94% are owned by physicians or hospitals (65% physician-owned; 17% hospital/physician-owned; 8% Corporation-Physician-owned; 6% Corporation-Hospital-Physician)f
Medicare profit margin 26.3% (estimated, based on Pennsylvania data); MedPAC unable to estimate due to lack of reporting by ASCs

 

Ambulatory Surgical Centers' Health IT Use, Clinical Utility and Barriers
  1. Pizzi, Richard. "Ambulatory Surgery Centers Short on IT." Healthcare IT News. http://www.healthcareitnews.com/news/ambulatory-surgery-centers-short-it?page=0,0.
EHR Needed Yes
Adoption Rate 18%a
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records Pharmacy information system
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Care coordination to ensure a complete understanding of patient histories to adequately perform surgical operations.
Barriers to Adoption
  • Lack of capital
  • Lack of awareness of the need to implement an EHR
  • Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition

Ambulatory Surgical Center References

Medicare Payment Advisory Commission (MedPAC). A Data Book: Health Care Spending and the Medicare Program, June 2012. http://www.medpac.gov/documents/Jun12DataBookEntireReport.pdf.

National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012.

Pennsylvania Health Care Cost Containment Council. An Annual Report on the Financial Health of Pennsylvania's Non-GAC Facilities. Financial Analysis 2007 v.2: Ambulatory Surgery Center Care, Rehabilitation Care, Psychiatric Care, Long-term Acute Care, Specialty Care. November 2008. http://www.phc4.org/reports/fin/07/docs/fin2007report_volumetwo.pdf.

Pizzi, Richard. "Ambulatory Surgery Centers Short on IT." Healthcare IT News. http://www.healthcareitnews.com/news/ambulatory-surgery-centers-short-it?page=0,0.

Strope, Seth A, et al. "Disparities in the Use of Ambulatory Surgical Centers: A Cross Sectional Study." BMC Health Services Research 9 (July 21, 2009): 121. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725040/.

VMG Health. 2010 Intellimarker: Ambulatory Surgical Center Financial and Operational Benchmarking Study. http://www.vmghealth.com/Downloads/VMG_Intellimarker10.pdf.

B. Renal Dialysis Facilities

Renal Dialysis Facilities is an independent unit that is approved to furnish dialysis service(s) directly to end stage renal disease patients.3 They have medical staff primarily engaged in providing outpatient kidney or renal dialysis services.4

Renal Dialysis Facilities' Characteristics
  1. United States Renal Data System (USRDS), 2011. "Chapter 10: Providers" USRDS data is for 2009.
  2. Kidney Dialysis Centers (NAICS# 621492). http://www.census.gov/econ/industry/def/d621492.htm.
  3. USDRS (2011).
  4. "Report by the Numbers" (Renal Business Today, 2011).
  5. MedPAC, June 2012.
  6. GAO, 2006.
  7. MedPAC, June 2012.
Number of providers 5,760a
Description End Stage Renal Dialysis Facilities are facilities other than hospitals that provide dialysis treatment via hemodialysis, maintenance and/or training services to patients and caregivers on an ambulatory or home-care basis.b
Other names Unknown
Number of patients 571,000c
Description of patients Patients suffer from End Stage Renal Disease, or the final stage of chronic renal disease, characterized by kidney failure. Patients who do not receive transplants must receive treatment either via in-home peritoneal dialysis (8% of patients) or in-facility hemodialysis (64%) several times each week.
Revenue $42.6 Billiond
Owned by eligible provider 10% are hospital-based;e 60% of ESRD facilities are owned by two for-profit chainsf
Medicare profit margin 2.3%g

 

Renal Dialysis Facilities' Health IT Use, Clinical Utility and Barriers
EHR Needed Yes
Adoption Rate Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Order entry and management
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Pharmacy information system
  • Lab information system
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Physician Order Entry
  • Privacy, Security and Integrity Features
Need for Information Exchange Care coordination with other providers and professionals.
Barriers to Adoption
  • Lack of capital
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR
  • Limited decision support for complex clinical condition

Renal Dialysis Facility References

"2011 USRDS Report By the Numbers" (2011 USRDS Annual Report. 2009 Service Costs). Renal Business Today. http://www.renalbusiness.com/galleries/2011/10/2011-usrds-report.aspx?pg=5.

Medicare Payment Advisory Commission (MedPAC). A Data Book: Health Care Spending and the Medicare Program, June 2012. http://www.medpac.gov/documents/Jun12DataBookEntireReport.pdf.

"RPA Comments on Meaningful Use Stage 2 Rule." Renal Physicians Association. May 7, 2012. http://www.renalmd.org/legis.aspx?id=4153.

United States Renal Data System (USRDS). 2011 Annual Data Report. "Chapter 10: Providers." http://www.usrds.org/2011/pdf/v2_ch10_11.pdf.

United States Renal Data System (USRDS). 2011 Annual Data Report. "Chapter 11: Costs of ESRD." http://www.usrds.org/2011/pdf/v2_ch011_11.pdf.

C. Registered Dietician/Nutritional Professionals

Dietitians and nutritionists are experts in food and nutrition. They advise people on what to eat in order to lead a healthy lifestyle or achieve a specific health-related goal. Dietitians and nutritionists work in many settings, including hospitals, cafeterias, nursing homes, and schools. Some are self-employed with their own practice.5

Registered Dietician/Nutritional Professionals Characteristics
  1. "Table 113: Health care employment and wages, by selected occupations: United States, selected years 2001-2010." (NCHS, 2012) http://www.cdc.gov/nchs/data/hus/2011/113.pdf.
  2. Figure is a broad estimate, based on the number of practitioners times the average salary. (Highbeam, SIC 8049, 2012)
  3. BLS, 2012.
Number of providers 53,510a
Description Dietitians are experts in food and nutrition, who educate patients about their dietary needs in order to manage their conditions or illnesses via medical nutrition therapy and nutritional plans. Dietitians work in many settings, including hospitals and medical centers, corporate wellness programs, nursing homes, and several other public and private health settings.
Other names Nutritionist
Number of patients Unknown
Description of patients Dieticians provide nutrition counseling services to patients of all ages and health conditions such as diabetes self-management.
Revenue $3.42 Billionb
Owned by eligible provider 32% work in hospitals; 4% work in physician officesc
Medicare profit margin Unknown

 

Registered Dietician/Nutritional Professionals Health IT Use, Clinical Utility and Barriers
EHR Needed Yes
Adoption Rate Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Clinical notes
  • Medication and treatment records
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Lab information system
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Privacy, Security and Integrity Features
Need for Information Exchange Care coordination to understand patient diagnosis to adequately supply nutritional information and dietary guidelines related.
Barriers to Adoption
  • Lack of capital/lack
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR
  • Lagging standards for clinical processes

Registered Dietician/Nutritional Professional References

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Dietitians and Nutritionists. http://www.bls.gov/ooh/healthcare/dietitians-and-nutritionists.htm.

Electronic Medical Records and Personal Health Records: A Call for the Creation and Inclusion of a Nutrition Dataset. Academy of Nutrition and Dietetics. http://www.eatright.org/search.aspx?search=EHR+Nutrient+dataset.

Health, United States, 2012. "Table 113: Health care employment and wages, by selected occupations: United States, selected years 2001-2010". http://www.cdc.gov/nchs/data/hus/2011/113.pdf.

Highbeam Business. http://business.highbeam.com/industry-reports/business/offices-clinics-of-health-practitioners-not-elsewhere-classified.

D. Therapist (Physical, Occupational and Speech Language)

Therapists are classified as one of the following:6

  • Physical therapists provide services to patients who have impairments, functional limitations, disabilities, or changes in physical functions and health status resulting from injury, disease or other causes, or who require prevention, wellness or fitness services.

  • Occupational therapists provide services to patients forplanning and administering educational, recreational, and social activities designed to help patients or individuals with disabilities, regain physical or mental functioning or to adapt to their disabilities.

  • Speech language therapists diagnose and treat speech, language, or hearing problems. The term "speech-language pathology services" means such speech, language, and related function assessment and rehabilitation services furnished by a qualified speech-language pathologist as the speech-language pathologist is legally authorized to perform under state law (or the state regulatory mechanism provided by the state law) as would otherwise be covered if furnished by a physician.7

CMS has requirements for education and licensure for therapists. They may operate private or group practices in their own offices (e.g., centers, clinics), practice in an outpatient rehabilitation facility, or work the facilities of others, such as hospital, rehab facilities, nursing homes, home health agencies, or HMO medical centers.8

Therapists' Characteristics
  1. "Table 113: Health care employment and wages, by selected occupations: United States, selected years 2001-2010." (NCHS, 2012) http://www.cdc.gov/nchs/data/hus/2011/113.pdf.
  2. "Offices of Physical, Occupational and Speech Therapists, and Audiologists (NAICS 62134)" from Table 8.10 of the 2010 Service Annual Survey, "Selected Health Care Services (NAICS 621,622, and 623) -- Estimated Revenue for Employer Firms by Source: 2006 Through 2010" (U.S. Census Bureau, 2010).
Number of providers 393,110a
Description Therapists include: physical therapists, who assist patients in gaining mobility after illness or injury; occupational therapists, who help patients regain or learn day-to-day life skill; and speech-language pathologists, who help patients recovering from illness or injury to properly and effectively communicate. These professionals treat patients in a wide variety of settings, including private practices, hospitals and nursing homes.
Other names Physical Therapist, Occupational Therapist, Speech Therapist
Number of patients 5,400,000 outpatient Medicare patients (3.9M PT, 1M OT, 0.5M SLP)
Description of patients Patients come from all life-cycle ages, and may be treated for a wide variety of illness, injury, or condition.
Revenue $28.3 Billionb
Owned by eligible provider 37% of PTs work in offices of health practitioners, 28% in hospitals; 27% of OTs work in hospitals; 13% of SLP therapists work in hospitals.
Medicare profit margin Unknown

 

Therapists' Health IT Use, Clinical Utility and Barriers
EHR Needed Yes
Adoption Rate PT=28%; OT, SLP=Unknown
Use in Practice
  • Admission, discharge and transfer (ADT)
  • Appointments
  • Clinical notes
  • Assessments
  • Care Plan
  • Condition specific documentation
  • Medication and treatment records
  • Therapy information system
  • Patient Portals
  • Patient eligibility determinations
  • Billing
  • Staffing, Payroll, and HR
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Clinical Decision Support
  • Privacy, Security and Integrity Features
Need for Information Exchange Therapists coordinate care, obtain orders, report progress with physicians and other care givers.
Barriers to Adoption
  • Lack of capital
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria Workforce limitations to implement and maintain an EHR
  • Lagging standards for clinical processes

Therapist References

Bassett, J. "Wired for Success." Advance for Physical Therapy and Rehab Medicine. http://physical-therapy.advanceweb.com/Archives/Article-Archives/Wired-for-Success.aspx.

Health, United States, 2012. "Table 113: Health care employment and wages, by selected occupations: United States, selected years 2001-2010." http://www.cdc.gov/nchs/data/hus/2011/113.pdf.

U.S. Census Bureau. "Offices of Physical, Occupational and Speech Therapists, and Audiologists (NAICS 62134)" from Table 8.10 of the 2010 Service Annual Survey, "Selected Health Care Services (NAICS 621,622, and 623) -- Estimated Revenue for Employer Firms by Source: 2006 Through 2010."

E. Pharmacists and Pharmacies

A pharmacist dispenses prescription medications to patients and offer advice on the safe use of medications. Pharmacists work in pharmacies, including those in grocery and drug stores. They also work in hospitals, clinics and specialty pharmacies.9

Pharmacies are establishment licensed by states and engaged in retailing prescription or nonprescription drugs and medicines.10

Pharmacists' Characteristics
  1. Midwest Pharmacy Workforce Research Consortium, 2009.
Number of providers 274,900a
Description Pharmacists are professionals who dispense medication to patients, and may provide input based on patient case on safe use. They can perform in private, customer-facing pharmacies or behind the scenes in hospitals.
Other names Unknown
Number of patients Unknown
Description of patients Pharmacists do not have direct clinical contact with patients, however, their services touch patients of all ages and conditions.
Revenue $259.1 Billion spent on prescription drugs annually
Owned by eligible provider 23% work in hospital pharmacies
Medicare profit margin Unknown

 

Pharmacies' Characteristics
  1. SK&A, 2012.
  2. "National Health Expenditures Aggregate, Per Capita Amounts, Percent Distribution, and Average Annual Percent Change, by Type of Expenditure: Selected Calendar Years 1960-2010" (CMS, National Health Expenditures Data, 2010).
  3. SK&A, 2012.
Number of providers 62,892a
Description Pharmacies dispense and sell prescription drugs.
Other names  
Number of patients  
Description of patients Patients belong to all age groups as well as all socioeconomic backgrounds. 90% of elderly individuals rely on prescription medication on a daily basis, as do 58% of individuals aged 18-64.
Revenue $259.1 Billion -- Prescription drugsb
Owned by eligible provider Unknown; 23% hospital-basedc
Medicare profit margin Unknown

 

Pharmacists' Health IT Use, Clinical Utility and Barriers
  1. Fuji, K., Galt, K., Siracuse, M., and Christofferson, J.S. "Electronic Health Record Adoption and Use by Nebraska Pharmacists." Perspectives in Health Information Management (Summer 2011): 1-11. http://perspectives.ahima.org/index.php?option=com_content&view=article&id=218:electronic-health-record-adoption-and- use-by-nebraska-pharmacists&catid=42:electronic-records&Itemid=88.
EHR Needed Yes
Adoption Rate 12a
Use in Practice
  • Order entry and management
  • Pharmacy information system
  • Patient eligibility determinations
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists (do not contribute)
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Information exchange needed for e-prescribing, medication management and sharing clinical data.
Barriers to Adoption
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an HER
  • Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR

 

Pharmacies' Health IT Use, Clinical Utility and Barriers
EHR Needed No (health IT needed to interface with EHR)
Adoption Rate N/A
Use in Practice
  • Order entry and management
  • Pharmacy information system
  • Patient eligibility determinations
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists (Do Not Contribute)
  • Clinical Decision Support
  • Physician Order Entry
  • Support Clinical Quality Measures
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Information exchange needed for e-prescribing, medication management and sharing clinical data.
Barriers to Adoption
  • Lack of awareness of the need to implement an EHR
  • Lack of a certified vendor for provider specialty
  • Workforce limitations to implement and maintain an EHR

Pharmacist and Pharmacy References

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Pharmacists, on the Internet at http://www.bls.gov/ooh/healthcare/pharmacists.htm (visited September 07, 2012).

Fuji, K., Galt, K., Siracuse, M., and Christofferson, J.S. "Electronic Health Record Adoption and Use by Nebraska Pharmacists." Perspectives in Health Information Management (Summer 2011): 1-11. http://perspectives.ahima.org/index.php?option=com_content&view=article&id=218:electronic-health-record-adoption-and-use- by-nebraska-pharmacists&catid=42:electronic-records&Itemid=88.

Midwest Pharmacy Workforce Research Consortium. 2009 National Pharmacist Workforce Survey: Final Report of the 2009 National Sample Survey of the Pharmacist Workforce to Determine Contemporary Demographic and Practice Characteristics. Pharmacy Manpower Project, Inc. http://www.aacp.org/resources/research/pharmacymanpower/Documents/2009%20National%20Pharmacist%20Workforce%20 Survey%20-%20FINAL%20REPORT.pdf.

"National Health Expenditures Aggregate, Per Capita Amounts, Percent Distribution, and Average Annual Percent Change, by Type of Expenditure: Selected Calendar Years 1960-2010" CMS, National Health Expenditure Data, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/ Downloads/tables.pdf.

SK&A. National Pharmacy Market Summary (June 2012). http://www.skainfo.com/health_care_market_reports/pharmacy_list_national_summary.pdf.

F. Laboratories

Laboratories provide biological, microbiological, serological, chemical, immuno-hematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for analytic or diagnostic services to the medical profession or to the patient on referral from a health practitioner.11, 12 State law defines who can request a lab service and some states allow direct consumer access to testing (no provider referral or requisition required) for at least some testing.

Laboratories' Characteristics
  1. CMS CLIA Update, July 2012. The number on the CMS website is 225,000 (CMS, CLIA website).
  2. RNCOS, 2012.
  3. Ahn et al., 1997.
Number of providers 232,996a
Description A facility that provides biological, microbiological, serological, chemical, immune-hematological, hematological, biophysical, cytological, pathological, or other examination of materials for the purpose of providing information for the diagnosis, prevention, or treatment of injury or illness. These facilities are typically independent of an institution or physician's office.
Other names Clinical Laboratory
Number of patients Unknown
Description of patients Patients utilize laboratory services under a variety of circumstances, and may come from all age groups and with a variety of conditions.
Revenue $61 Billionb
Owned by eligible provider 55% Hospital-based in 1995c
Medicare profit margin Unknown

 

Laboratories' Health IT Use, Clinical Utility and Barriers
  1. Winsten, D. and Weiner, H. "Improve Outreach Performance by Leveraging the Internet." CLMA Thinklab '10 Session 504 (May 2010). http://www.clma.org/resource/resmgr/Professional_Development_-_Past_ThinkLabs/ 504_Dennis_Winsten___Hal_Wei.pdf?hhSearchTerms=emr.
EHR Needed No (health IT applications needed to interface with an EHR)
Adoption Rate 24.2% can post to an EHR via interfacea
Use in Practice
  • Order entry and management
  • Lab information system
  • Patient eligibility determinations
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Exchange health information (send, receive and integrate)
  • Privacy, Security and Integrity Features
Need for Information Exchange Lab orders and results require sharing with hospitals, other providers, professionals and specialists.
Barriers to Adoption
  • Lack of awareness of the need to implement an EHR
  • Lack of demand for an EHR
  • Lack of a certified vendor for provider specialty

Laboratory References

CMS CLIA Database, July 2012. The number on the CMS website is 225,000. (Centers for Medicare and Medicaid Services.Clinical Laboratory Improvement Amendments (CLIA) [website]) https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads//factype.pdf; http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html?redirect=/CLIA/; http://www.rncos.com/Report/IM442.htm.

"Electronic Health Records Now Permitted by CLIA." U.S. Department of Health and Human Services, Health IT Buzz. http://www.healthit.gov/buzz-blog/privacy-and-security-of-ehrs/electronic-health-records-ehrs-permitted-clia/.

ELINCS: The National Lab Data Standard for Electronic Health Records, California Health Care Foundation. http://www.chcf.org/projects/2009/elincs-the-national-lab-data-standard-for-electronic-health-records.

Winsten, D. and Weiner, H. "Improve Outreach Performance by Leveraging the Internet."CLMA Thinklab '10 Session 504 (May 2010). http://www.clma.org/resource/resmgr/Professional_Development_-_Past_ThinkLabs/ 504_Dennis_Winsten___Hal_Wei.pdf?hhSearchTerms=emr.

G. Emergency Medical Service Providers

Emergency medical service providers primarily engaged in providing transportation of patients by ground or air, along with medical care. These services are often provided during a medical emergency but are not restricted to emergencies. The vehicles are equipped with lifesaving equipment operated by medically trained personnel.13

Emergency Medical Service Providers' Characteristics
  1. National Highway Traffic Safety Administration, 2011.
  2. CMS. National Health Expenditures Accounts: Definitions, Sources, and Methods, 2009.
Number of providers 19,971a
Description Emergency Medical Services provide first-response care to individuals to evaluate and manage acute traumatic and medical conditions in a pre-hospital setting. Emergency Medical Services is the intersection of public health, public safety, and acute patient care.
Other names Ambulance
Number of patients 36,700,000 events; 28,000,000 transports
Description of patients Patients utilizing Emergency Medical Services are of all age groups, and may suffer from a variety of illnesses or conditions
Revenue $16.7 Billionb
Owned by eligible provider 9% hospital-based
Medicare profit margin 2%

 

Emergency Medical Service Providers' Health IT Use, Clinical Utility and Barriers
EHR Needed No (require health IT to exchange information with EHR)
Adoption Rate Unknown
Use in Practice
  • Clinical notes
 
Clinical Utility
  • Patient Demographic, Health Information and Problem Lists
  • Support Clinical Quality Measures
  • Privacy, Security and Integrity Features
Need for Information Exchange Access past medical history and exchange information with emergency department or other care giver.
Barriers to Adoption
  • Lack of capital
  • Lack of a certified vendor for provider specialty
  • EHRs available lack of alignment with MU criteria
  • Limited decision support for complex clinical condition
  • Lack of consent management

Laboratory References

CMS Data Compendium, December 2010.

Grant to Enhance EMS/Hospital Data Exchange. Journal of Emergency Medical Services. http://www.jems.com/article/technology/grant-enhance-emshospital-data.

National Health Expenditures Accounts: Definitions, Sources, and Methods, 2009.

National Highway Traffic Safety Administration (NHTSA). 2011 National EMS Assessment. http://www.ems.gov/pdf/2011/National_EMS_Assessment_Final_Draft_12202011.pdf.

H. Blood Centers

Blood centers primarily engaged in collecting, storing, and distributing blood and blood products.14

Blood Centers' Characteristics
  1. FDA Blood Establishment Registration Database.
Number of providers 2628
Description Blood Centers include manufacturers of blood and blood components, blood banks, blood product testing laboratories, transfusion services, and plasmapheresis centers. These facilities are subject to FDA compliance measures under Section 510 of the Food, Drug, and Cosmetic Act.
Other names Unknown
Number of patients 15,014,000
Description of patients Patients are of all ages and may require blood or blood products as a result of illness or injury.
Revenue Unknown
Owned by eligible provider 34% hospital-baseda
Medicare profit margin Unknown

 

Blood Centers' Health IT Use, Clinical Utility and Barriers
EHR Needed No
Adoption Rate Unknown
Use in Practice Unable to determine
Clinical Utility
  • Patient Demographic , Health Information and Problem Lists
  • Support Clinical Quality Measures
  • Privacy, Security and Integrity Features
Need for Information Exchange  
Barriers to Adoption
  • Lack of a certified vendor for provider specialty
 

Blood Center References

FDA Blood Establishment Registration Database. Filtered by an establishment status of "Active." More than one category may apply to a facility. http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/EstablishmentRegistration/ BloodEstablishmentRegistration/default.htm.

Number of Transfusions (2008). U.S. Department of Health and Human Services. The 2009 National Blood Collection and Utilization Survey Report. http://www.aabb.org/programs/biovigilance/nbcus/Documents/09-nbcus-report.pdf.

Notes

  1. U.S. Census Bureau. http://www.census.gov/epcd/ec97/def/621493.HTM.

  2. Centers for Medicare and Medicaid Services. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ AmbSurgCtrFeepymtfctsht508-09.pdf.

  3. Centers for Medicare and Medicaid Services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf.

  4. U.S. Census Bureau, North American Industry Classification System (NAICS). http://www.census.gov/epcd/ec97/def/621492.HTM.

  5. See http://www.bls.gov/ooh/Healthcare/Dietitians-and-nutritionists.htm.

  6. Offices of Physical, Occupational and Speech Therapists, and Audiologists (NAICS# 621340). http://www.census.gov/econ/industry/def/d621340.htm.

  7. Social Security Act. http://www.socialsecurity.gov/OP_Home/ssact/title18/1861.htm#act-1861-ii.

  8. Ibid.

  9. See http://www.bls.gov/ooh/Healthcare/Pharmacists.htm.

  10. U.S. Census Bureau, North American Industry Classification System (NAICS). http://www.bls.gov/oes/current/naics5_446110.htm.

  11. U.S. Census Bureau, North American Industry Classification System (NAICS). http://stds.statcan.gc.ca/naics-scian/2007/cs-rc-eng.asp?criteria=62151.

  12. Definition Laboratories. 42 U.S.C. 263a Section 353.

  13. U.S. Census Bureau, North American Industry Classification System (NAICS). http://www.bls.gov/oes/current/naics5_621910.htm.

  14. U.S. Census Bureau, North American Industry Classification System (NAICS). http://www.census.gov/epcd/ec97/def/621991.HTM.

[Return to the Table of Contents]

 

APPENDIX I. TABLE SUMMARY OF PATIENT PROTECTION AND AFFORDABLE CARE ACT PROVISIONS WITH RELATIONSHIP TO INELIGIBLE PROVIDERS AND HEALTH IT USE

This table provides a summary of the Patient Protection and Affordable Care Act (Affordable Care Act) provisions that potentially:

  • impact the ineligible provides who are the focus of this study; and
  • require or could leverage the use of health IT to support health information exchange.

The summary was compiled from the law and/or from implementing guidance by the authorized agency during the implementation of the provision. It should be noted that the summary is not intended to express Departmental views on statutory interpretation of provisions in the Affordable Care Act. Rather, the table highlights provisions in the Affordable Care Act that either: (i) required or could support the use of health IT, or (ii) required or imply the exchange of health information. Some of the health information exchange provisions in the Affordable Care Act require electronic health information exchange, while other provisions do not specify the method of exchange (e.g., information exchange could be electronic or manual).

Abbreviations used in the table are at the end of this Appendix.

PPACA Section Program Health IT Required/ Could Be Used HIE Required/ Could Be Used Eligible Provider LTPAC BH Safety Net Other Ineligible Provider Notes
  1. See https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-10294.pdf.
  2. See http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/ Balancing/Money-Follows-the-Person.html.
  3. See http://www.mathematica-mpr.com/health/moneyfollowsperson.asp.
  4. See http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10022.pdf.
  5. See http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf.
  6. See https://docs.google.com/viewer?a=v&pid=sites&srcid=bWFjcGFjLmdvdnxtYWNwYWN8Z3g6MzM2ZWM3Zjlh MDI1ZGFhNw.
  7. See http://www.qualitynet.org/dcs/ContentServer?cid=1219069855273&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page.
  8. See http://www.promotingexcellence.org/finance/pe3692.html.
  9. See http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/11-010.pdf.
1104 Administrative simplification               Sets forth provisions governing electronic health care transactions, with penalties for health plans failing to comply; review committee to ensure coordination with the standards that support the C-EHR technology approved by ONC.
2401 Community first choice option     X
Hospital
X
NF
ICF/IID
X
IMDs Institutions for Mental Disease
    HCBS/S to persons under a plan of services based on functional assessment. Includes assistance w/ADLs, IADLs, and health related tasks. Includes establishing a QA system that includes:
feedback from consumers/others, monitors health and well-being, a process for the mandatory reporting, investigation, and resolution of allegations; and provides information about the QA provisions; and collects and report information. State are required to provide the Secretary with information regarding the provision of home and community-based attendant services and supports, including:
"The specific number of individuals served by type of disability, age, gender, education level, and employment status."

HCBS (based on a functional assessment);final rule1 states can cover attendant care as optional state plan benefit, 6% increase from Federal Government to cover these services.

2402 Removal of barriers to providing HCBS       X X     HHS shall promulgate regulations to ensure that all states develop service systems designed to--(1) allocate resources for services that is responsive to the changing needs and choices of beneficiaries receiving non-institutionally-based long-term services and supports (including such services and supports provided under programs other the state Medicaid program), and that provides strategies for beneficiaries receiving such services to maximize their independence, including through the use of client-employed providers; (2) provide the support and coordination needed for a beneficiary in need of such services (and their family caregivers or representative, if applicable) to design an individualized, self-directed, community-supported life; and (3) improve coordination among, and the regulation of, all providers of such services under federally and state-funded programs.
2403 MFP rebalancing demonstration       X X     Extends the demonstration and excludes days of Medicare covered short-term rehabilitation.

MFP makes grants to states to develop systems and services to help transition institutionalized persons who want to move back to HCB settings.

Transition Medicaid clients from institutions to community. 43 states and DC implementedMFP programs.2 Strengthens and expands to more states until 2016 grants to help move persons from institution to community-based settings.Mathematica Policy Research report.3

2601 Improved coordination for dual eligible beneficiaries       X X     This new authority enhances existing tools to improve care and services for this vulnerable group. Must include a focus on the dual-eligible population and provide delivery system options or services that could not typically be provided to dually eligible individuals under the state plan.

Makes available an array of services to dually eligible persons such as: case management services, homemaker/HH aide services and personal care services, adult day health services, respite care, and other medical and social services that can contribute to the health and well-being of individuals and their ability to reside in a community-based care setting.

Medicaid Director letter.4
Creates Sec. 1915(h) dual eligible demonstrations.

2602 Providing federal coverage and payment coordination for dual eligible beneficiaries     X
Acute care
X       Improve care continuity and ensure safe and effective care transitions.

Federal Coordinated Health Care Office is to--(1) more effectively integrate benefits under the Medicare and Medicaid programs; and (2) improve the coordination between the federal and state governments for dually eligible individuals to ensure that such individuals get full access to the items and services.

Goals: Simplify access the covered items and services; Improve quality of health care and long-term services; Increase dual eligible individuals' understanding and satisfaction with coverage under the Medicare and Medicaid; Eliminate regulatory conflicts between Medicare and Medicaid programs; Improve care continuity and ensuring safe and effective care transitions for dual eligible individuals; Eliminate cost-shifting between the Medicare and Medicaid program and among related health care providers; Improve the quality of performance of providers

2701 Adult health quality measures for Medicaid eligible adults       X       Provision applies to all Medicaid eligible adults.

Secretary, in consultation with states, shall develop a standardized format for reporting information based on the initial core set of adult health quality measures and create procedures to encourage states to use such measures to voluntarily report information regarding the quality of health care for Medicaid eligible adults.

2703 State option to provide health homes for enrollees with chronic conditions.       X X
BH
CMHC
X
FQHC
RHC
X
Nutritionist
Social Worker
Allow states to operate a Medicaid Health Home using person-centered care. Identify a team of health professionals.

Participating states must demonstrate a capacity to use HIT to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate.

Provider shall report to the state on all applicable measures for determining the quality and when appropriate and feasible, shall use HIT.

Services include: (i) comprehensive care management; (ii) care coordination and health promotion; (iii) comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; (iv) patient and family support (including authorized representatives); (v) referral to community and social support services, if relevant; and (vi) use of HIT to link services, as feasible and appropriate.
Medicaid letter.5

2704 Evaluate integrated care around a hospitalization     X
Hospital
X       Bundled payments for provision of integrated care for a Medicaid beneficiary; Robust discharge planning programs to ensure Medicaid beneficiaries requiring PAC are appropriately placed in, or have ready access to, PAC settings.
2801 MACPAC assessment of policies affecting all Medicaid beneficiaries       X
LTC
X X
FQHC
RHC
  Clarifies topics to be reviewed by MACPAC.Includes residential, LTC, HCBS, FQHCs, RHCs.

MACPAC shall: review Medicaid and CHIP regulations and may comment through submission of a report to the appropriate committees of Congress and the Secretary, on any such regulations that affect access, quality, or efficiency of health care; and coordinate and consult with the Federal Coordinated Health Care Office established under section 2081 of the ACA before making any recommendations regarding dual eligible individuals.

Members shall include persons w/experience/ expertise in: health plans and integrated delivery systems, HIT.

Secretary and states should accelerate development of innovations that support high quality, cost-effective care for persons w/ disabilities….Priority should be give to innovations that promote coordination of physical, behavioral, and community support services…[March 2012 Report to Congress6]

2952 Support, education, and research for PPD         X     Improved screening and diagnostic techniques; coordination of services to individuals and their families with or at risk for PPD.

Funds projects to include: delivering or enhancing outpatient and home-based health and support services, including case management and comprehensive treatment services; delivering or enhancing inpatient care management services that ensure the well-being of the mother and family and the future development of the infant; improving the quality, availability, and organization of health care and support services (including transportation services, attendant care, homemaker services, day or respite care, and providing counseling on financial assistance and insurance); and providing education about postpartum conditions to promote earlier diagnosis and treatment.

3004 Quality reporting for LTCH, inpatient rehabilitation hospitals, and hospice programs       X
LTCH
IRF
Hospice
      LTCHs, IRFs, and hospice providers shall submit data (beginning in 2014) on quality measures in a form and manner, and at a time, specified by the Secretary; or be subject to payment reductions. Secretary shall post information regarding quality measure performance on a website.

Reimbursement reduced for LTCHs, IRFs, hospice programs that fail to report quality measures.

3006 Value-based purchasing programs for SNFs, HHAs       X       Includes development, selection, and modification of quality measures.

Secretary shall develop a plan for value-based purchasing for SNFs and HHAs that considers measures of all dimensions of quality and efficiency.

3008 Payment adjustment for HACs     Hospital excluded from IPPS Physicians X
IRF
LTCH
SNF
  X X
ASC
Applies to hospitals. Secretary to make available HAC information via a website.

Study and report on expansion of HAC policy to other providers.

3013 Quality measurement improvement       X X X   Identify gaps in quality measures. In prioritizing measures, priorities include: the management and coordination of health care across episodes of care and care transitions for patients across the continuum of providers, health care settings, and health plans; the experience, quality, and use of information provided to and used by patients, caregivers, and authorized representatives to inform decision making about treatment options, including the use of shared decision making tools and preference sensitive care; and the MU of HIT.

Secretary to award grants to develop QMs and to the extent practicable, data on such quality measures is able to be collected using HI and quality measures are to be publicly available on an Internet website.

3021 Establishment of Center for Medicare and Medicaid Innovation within CMS       X X X   Test and demonstrate new payment and delivery models; preference given to models that improve coordination, quality, efficiency of health care (e.g. utilizing geriatric assessments and comprehensive care plans); Improving PAC through continuing care hospitals that offer inpatient rehab, LTCHs, and HH or skilled nursing care during an inpatient stay and the 30 days following discharge; funding HH providers who offer chronic care management services to applicable individuals as part of an interdisciplinary team; considerations include whether the model uses EHRs and remote monitoring systems to coordinate care over time and across settings.

In selecting models considerations include: Whether the model uses technology, such as EHRs and patient-based remote monitoring systems, to coordinate care over time and across settings.

3022 Medicare shared savings program     X
Hospital
Physician group
X       Establishes a shared savings program that promotes accountability for a patient population and coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery.

ACOs shall have a leadership and management structure that includes clinical and administrative systems, shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.

Encourages investment in infrastructure; must demonstrate patient-centeredness such as the use of patient assessments; reporting requirements may include care transitions across settings, including hospital discharge planning and post-hospital discharge follow-up. Other reporting requirements may include electronic prescribing, use of EHRs as required in the Incentive programs.

3023 National Pilot Program on Payment Bundling     X
Hospital
Physician group
X
SNF
HHA
      The Secretary shall establish a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health care services.

Applicable conditions include whether a condition has significant variation in the amount of expenditures for PAC spending, whether a condition is high volume and has high PAC expenditures.

Applicable services include acute care inpatient, physician services in and outside of acute care hospital, outpatient hospital services including emergency dept, PAC services including HH services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services furnished by a LTCH. Episodes of care include 30 days following discharge from hospital.

Payment model to include payment for appropriate services such as care coordination, medication reconciliation, discharge planning, transitional care services, patient-centered activities.

To the extent practicable, quality measures should be submitted through the use of a qualified EHR.

3024 Independence at home demonstration program     X
Hospitals
Physicians
NPs
X X X   Test a payment incentive and service delivery model that uses physician and NP directed home-based primary care teams designed to reduce Medicare expenditures and improve health outcomes.

Demonstration will test whether model, accountable for providing comprehensive, coordinated, continuous, and accessible care to high-need populations at home and coordinating health care across all treatment settings results in improvements in quality of care and reduced hospital/ ER use, and other efficiency gains.

The term "independence at home medical practice" means a legal entity that (among other things): uses electronic HI systems, remote monitoring, and mobile diagnostic technology.

Applicable beneficiaries include individuals with 2 or more chronic conditions, such as CHF, diabetes, dementia, COPD, ischemic heart disease, stroke, Alzheimer's, etc. Preference given to practices located in high-cost areas, have experience in furnishing HH services, and use EHRs, HIT, and individualized plans of care.

3025 Hospital readmission reduction program     X
Hospitals
X
SNF
HHA
IRF
LTAC
      CMS Guidance: The 30-day readmission measures provide consumers with important information to complement other quality measures reported on Hospital Compare, such as the process-of-care quality measures and other outcome measures including the mortality and complication measures. Measuring and reporting hospital readmission measures encourages hospitals to evaluate the entire spectrum of care they deliver to patients and more carefully transition patients to outpatient care or other institutional care.

See FAQ.7

3026 Community-based care transitions program     X
Hospitals
X
SNF
HHA
IRF
LTAC
X X   Funding provided for Community-based care transitions program (CCTP): eligible entities include hospitals or community-based orgs providing care transition services across the continuum through arrangements with hospitals; focus on high-risk beneficiaries with multiple chronic conditions or other risk factors associated with hospital readmission or substandard transition to post-hospital care; preference given to entities participating in an AoA program to provide concurrent care transition intervention.

Interventions may include:
Arranging timely post-discharge follow-up services to the high-risk Medicare beneficiary to provide the beneficiary with information regarding responding to symptoms that may indicate additional health problems or a deteriorating condition; Providing the beneficiary with assistance to ensure productive and timely interactions between patients and post-acute and outpatient providers; and Conducting comprehensive medication review and management

3108 Permitting PAs to order post-hospital extended care services     X X
SNF
    X Allows a PA working in collaboration with a physician, who does not have an employment relationship with SNF, to certify need for PAC.
3140 Medicare hospice concurrent care demonstration program       X       Furnish hospice care concurrently with other items or services covered by Medicare.

New models for delivering palliative care include: Ongoing communication among patients, families and providers.8

Parallels in Sec. 2302.

3201 Medicare Advantage payment       X X     Care coordination and management performance bonus; foster patient and provider collaboration in terms of transitional care interventions, including programs targeting post-discharge patient care; HIT programs, including CDS and other tools to facilitate data collection and ensure patient-centered, appropriate care.
3310 Reducing wasteful dispensing of outpatient prescription drugs in LTCFs under prescription drug plans and MA-PD plans       X     X
Pharmacies
Requires sponsors of PDPs to use uniform techniques for dispensing part D drugs to enrollees residing in a LTCF. Techniques include: such as weekly, daily, or automated dose dispensing, when dispensing covered part D drugs to enrollees who reside in a LTCF to reduce waste associated with 30-day fills.
3502 Community health teams to support the patient-centered medical home     X
Physicians
X X X X Community-based interdisciplinary, inter-professional teams to support primary care practices within a hospital service area. The health team includes an interdisciplinary, interprofessional team of health care providers may include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians' assistants.

Health teams support patient-centered medical homes, that includes--(A) personal physicians; (B) whole person orientation; (C) coordinated and integrated care; (D) safe and high-quality care through evidence informed medicine, appropriate use of HIT, and continuous quality improvements…

Health teams support: transitioning between health care providers and settings and case management; develop and implement interdisciplinary, interprofessional care plans that integrate clinical and community preventive and health promotion services for patients; promote effective strategies for treatment planning, monitoring health outcomes and resource use, sharing information, treatment decision support, and organizing care to avoid duplication of service and other medical management approaches intended to improve quality and value of health care services; establish a coordinated system of early identification and referral for children at risk for developmental or behavioral problems such as through the use of infolines, HIT, or other means as determined by the Secretary; provide 24-hour care management and support during transitions in care settings including--(A) a transitional care program that provides onsite visits from the care coordinator, assists with the development of discharge plans and medication reconciliation upon admission to and discharge from the hospitals, nursing home, or other institution setting; (B) discharge planning and counseling support to providers, patients, caregivers, and authorized representatives; (C) assuring that post-discharge care plans include medication management, as appropriate; (D) referrals for mental and BH services; and demonstrate a capacity to implement and maintain HIT that meets the requirements of C-EHR technology (as defined in section 3000 of HITECH to facilitate coordination among members of the applicable care team and affiliated primary care practices.

5309 Nurse Education, Practice, and Retention Grants             X Grants may be awarded to licensed practical nurses, licensed vocational nurses, certified nurse assistants, HH aides, diploma degree or associate degree nurses, to become baccalaureate prepared RNs or advanced education nurses.

Grants may support: to improve the retention of nurses and enhance patient care that is directly related to nursing activities by enhancing collaboration and communication among nurses and other health care professionals, and by promoting nurse involvement in the organizational and clinical decision-making processes of a health care facility.

5315 U.S. public health sciences track     X   X X X To award degrees in public health, epidemiology, emergency preparedness and response. Training demonstration program for family nurse practitioners serving as primary care providers in FQHCs or nurse-managed health centers.

Training under such plan shall emphasize patient-centered, interdisciplinary, and care coordination skills.

5604 Co-locating primary and specialty care in community-based mental health settings     X   X     SAMHSA grants for demonstration projects for provision of coordinated and integrated services through the co-location of primary and specialty care services in community-based and BH settings.

Grant funds awarded under this section shall be used for--(A) provision, by qualified primary care professionals, of onsite primary care services; (B) reasonable costs associated with medically necessary referrals to qualified specialty care professionals, other coordinators of care or, if permitted by the grant or cooperative agreement, by qualified specialty care professionals on a reasonable cost basis on site at the eligible entity; (C) information technology required to accommodate the clinical needs of primary and specialty care professionals; or (D) facility modifications needed to bring primary and specialty care professionals on site at the eligible entity.

6103 Nursing home compare Medicare website       X
SNF/NF
      Requires SNFs/NFs to make available for and HHS to post on NH Compare the following information: Staffing data including information on staffing turnover and tenure, links to state Internet websites with information regarding state survey and certification programs, links to Form 2567 state inspection reports, standardized complaint form, Summary information on substantiated complaints, criminal violations of staff.
6106 Ensuring staffing accountability       X
SNF/NF
      Program for facilities to report direct care staffing information in a uniform format the Secretary shall require a facility to electronically submit to the Secretary direct care staffing information including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Information to include resident census data and information on resident case mix.
6114 National demonstration projects on culture change and use of information technology in nursing homes       X
SNF/NF
      Two SNF/NF demonstration projects to develop best practices for: (1) culture change; and (2) use of information technology to improve resident care.
6406 Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse     X
Physicians
X
HHA
      The Secretary may revoke enrollment for a physician or supplier if such physician or supplier fails to maintain and provide access to documentation relating to written orders or requests for payment for durable medical equipment, certifications for HH services, or referrals for other items or services.
6407 Face to face encounter with patient required before physicians may certify eligibility for HH services  or durable medical equipment under Medicare     X
Physicians
X
HHA
    x Requires face-to-face encounter (including through the use of telehealth) with individual before approving HH services.

Also as (modified by Sec. 10605): Allows nurse practitioner or clinical nurse specialist working in collaboration with a physician to certify.

6703 Grant program for adoption and use of C-EHRs by LTCFs (e.g., nursing homes)

Participation of LTCFs and state HIE program

Adoption and implementation of messaging standards for clinical data exchange by LTCFs

      X       Secretary to develop grant program for LTCFs to offset costs related to purchasing, leasing, developing, and implementing C-EHR technology designed to improve patient safety and reduce adverse events and health care complications resulting from medication errors. LTCFs receiving grants to participate in state HIE activities. Secretary to adopt electronic standards for the exchange of clinical data by LTCFs and, within 10 years of enactment, to have in place procedures to accept the optional electronic submission of clinical data by LTCFs pursuant to such standards. Standards adopted must be compatible with standards established under current law and with general HIT standards.

Authorized funds: $20 million for FY2011, $17.5 million for FY2012, and $15 million for each of FY2013 and FY2014. Funds not appropriated.

10202 Incentives for states to offer HCBS as a LTC alternative to nursing homes       X       Provision focuses on Medicaid LTSS: Certain states may receive an enhanced FMAP for establishing a: single point of entry,  case management services to develop a service plan, arrange for services and supports, support the beneficiary (and, if appropriate, the beneficiary's caregivers) in directing the provision of services and supports for the beneficiary, and conduct ongoing monitoring are required, and use of core standardized assessment instruments for determining eligibility to determine a beneficiary's needs for training, support services, medical care, transportation, and other services, and develop an individual service plan to address such needs.

State agrees to collect from providers of services and through such other means as the state determines appropriate.

Offer states ability to move spending to non-institutional services more easily.
BIP Program9

10330 Modernizing computer and data systems of CMS to support improvements in care delivery.               Requires HHS Secretary to develop a plan and budget to modernize CMS computer and data systems to support improvements in care delivery, and consider how such modernized system could make available data in a reliable and timely manner to providers of services and suppliers to support their efforts to better manage and coordinate care furnished to beneficiaries of CMS programs; and support consistent evaluations of payment and delivery system reforms under CMS programs.
10333 Community-based collaborative care networks       X X X   Consortium of health care providers with a joint governance structure (including providers within a single entity) that provides comprehensive coordinated and integrated health care services. Grant funds to be used (in part) for case management and care management.
10410 Centers of Excellence for Depression         X     Requires Secretary, acting through SAMHSA to award grants to establish national centers of excellence for depression and designate one center as a coordinating center. Requires coordinating center to establish and maintain a national, publicly available database to improve prevention programs, evidence-based interventions, and disease management programs for depressive disorders using data collected from the national centers.

The Centers shall coordinate on the use of EHRs and telehealth technology to better coordinate and manage, and improve access to, care, as determined by the coordinating center

10605 Certain other providers permitted to conduct face to face encounter for HH services       X
HHA
      Amends section 6407 requiring a face to face visit with a physician to certify HH or DME. Allow nurse practitioner or clinical nurse specialist working in collaboration with a physician to certify.

 

List of report acronyms
ACA   Patient Protection and Affordable Care Act (same as PPACA) 
 
BH Behavioral Health
BIP   Balancing Incentives Program 
 
CARE Continuity Assessment Record and Evaluation  
CDS Clinical Decision Support
C-EHR   Certified Electronic Health Record
CHF Congestive Heart Failure
CHIP Children's Health Insurance Program
CMCS Center for Medicaid and CHIP Services
CMHC Community Mental Health Center
CMS Centers for Medicare and Medicaid Services
CNA Certified Nursing Assistant
COPD Chronic Obstructive Pulmonary Disease
 
EHR Electronic Health Record
ESRD   End-Stage Renal Disease  
 
FQHC   Federally-Qualified Health Center  
 
GAO   Government Accountability Office  
 
HAC Hospital-Acquired Condition
HCBS Home and Community-Based Services
HCBW   Home and Community-Based Waivers
HH Home Health
HHA Home Health Agency
HHS U.S. Department of Health and Human Services  
HI Health Information
HIE Health Information Exchange
HIT Health Information Technology
HRSA Health Resources and Services Administration
 
IHS Indian Health Service
IPPS   Inpatient Prospective Payment System  
IRF Inpatient Rehabilitation Facility
 
LPN Licensed Professional Nurse
LTAC Long-Term Acute Care Hospital (same As LTCH)  
LTC Long-Term Care
LTCF Long-Term Care Facility
LTCH Long-Term Care Hospital (same as LTAC)
LTPAC   Long-Term Post-Acute Care
LTSS Long-Term Care, Supports and Services
 
MACPAC   Medicaid and CHIP Payment and Access Commission
MA-PD Medicare Advantage Prescription Drug Program
MDS Minimum Data Set
MedPac Medicare Payment Advisory Commission
MFP Money Follows the Person
MIPPA Medicare Improvements for Patients and Providers Act  
MU Meaningful Use
 
NF   Nursing Facility  
 
OASIS   Outcome and Assessment Information Set
ONC Office of the National Coordinator for Health Information Technology  
OOP Out-Of-Pocket
 
PA Physician Assistant
PAC Post-Acute Care
Part D Medicare Part D (Prescription Drug Program)  
PBM Pharmacy Benefit Manager
PHSA Public Health Services Act
PPACA   Patient Protection and Affordable Care Act
PPD Post-Partum Depression
PPS Prospective Payment System
 
RHC   Rural Health Center  
RN Registered Nurse
 
SAMHSA   Substance Abuse and Mental Health Services Administration  
SNF Skilled Nursing Facility
 
TRICARE   U.S. Department of Defense Health Care Program (Provides Health Care for the Seven Uniformed Services: Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, and the National Oceanic and Atmospheric Administration)

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APPENDIX J. BEHAVIORAL HEALTH PROVIDER ANALYSIS

This study identified ineligible providers based on: (i) the definition in HITECH §3000(3); and (ii) those HITECH identified providers that could participate in the Medicare or Medicaid Programs. The definition of health care provider in HITECH does not include certain healthcare providers that are key for delivering behavioral health services. Identifying the behavioral health provider types included in the behavioral health cluster in this report was particularly challenging in large part due to the historic blurring of behavioral health providers and the services provided by these entities. This appendix identifies the behavioral health providers included in the study and describes the services these types of providers can deliver. In addition, this appendix identified those behavioral health provider types evaluated, but not included in this study.

TABLE J1. Providers Identified in HITECH and Included in This Study
Provider Type Services Include
Psychiatric Hospital/Units including those psychiatric hospitals/units specializing in substance abuse Diagnostic, medical treatment, and monitoring services for inpatients who suffer from mental illness. (May also include substance abuse hospitals and units that provide treatment for patients who suffer from substance abuse disorders.)
Residential Treatment Center/Facility for mental health and/or substance abuse These establishments provide room, board, supervision, and counseling services. Although medical services may be available at these establishments, they are incidental to the counseling, mental rehabilitation, and support services offered.
Community Mental Health Center Multi-service organization for mentally ill patients who have been discharged from inpatient treatment at a mental health facility. These facilities may also act as 24-hour emergency care facilities, screening facilities, or day treatment facilities (partial hospitalization) for mentally ill patients.
Clinical Psychologist Psychologists assess, diagnose, and treat mental, emotional, and behavioral disorders. Psychologists may own their own practice, or be employed by hospitals, mental health institutions or long-term care facilities as part of a team care approach.
Clinical Social Worker Clinical Social Workers provide diagnosis and case management care to individuals suffering from a variety of conditions and illnesses. They perform social care services in several in-patient and out-patient care settings, and in certain states, may operate a private practice.

 

TABLE J2. Providers Evaluated, but Did Not Meet Study Criteria to be Included in This Study
Provider Type Services Include
  1. Bureau of Labor Statistics, Occupational Handbook. http://www.bls.gov/ooh/community-and-social-service/substance-abuse-and-behavioral-disorder-counselors.htm accessed November 20, 2012.
  2. See http://www.medicare.gov/coverage/partial-hospitalization-mental-health-care.html accessed November 20, 2012.
Substance abuse hospital/unit Diagnostic, medical treatment and monitoring services for inpatients who suffer from substance abuse disorders.
Outpatient mental health and/or substance abuse clinic No definitive definition -- may provide multiple services, partial hospitalization.

The Medicare program does not have an outpatient mental health or substance abuse provider type. State Medicaid programs may chose to elect to have outpatient mental health and/or substance abuse clinics as a designated Medicaid provider type. However, for purposes of this study:

  • Some of the clinicians who practice in this optional category may be presently eligible for incentives (i.e., psychiatrists).
  • Other clinicians who practice in this clinic may be ineligible and are otherwise included in this report (i.e., clinical psychologist and social workers).

Given the lack of data on expenditures on health IT adoption on these clinics, this report does not include a specific focus on these clinics.

Licensed Counselor Substance abuse and behavioral disorder counselors advise people who have alcoholism or other types of addiction, eating disorders, or other behavioral problems. They provide treatment and support to help the client recover from addiction or modify problem behaviors.a

HITECH 3000(3) does not include the health care provider type of licensed counselor. We note that Medicare and Medicaid may cover various categories of professionals considered to be licensed counselors.

Psychiatric Advanced Practice Nurse Nurse practitioners (NP) or clinical nurse specialists (CNS) in psychiatric mental health nursing. States and place of service often title Advanced Practice Psychiatric Nurse (APPN) differently. For example, in New Jersey APPNs with CNS or NP credentials in psychiatric mental health nurse are titled by the state as nurse practitioners. Standardizing the titling among states and places is a goal of American Psychiatric Nurse Association. From a national perspective, little difference exists between APPN roles except that nurse practitioners may provide primary health care for patients and in all states they have prescriptive authority.

Psychiatric advanced practice nurses are not identified in HITECH Section 3000(3). However, some psychiatric practice nurses may also be clinical nurse specialists or nurse practitioners. Clinical nurse specialists and nurse practitioners subject to volume thresholds are eligible for Medicaid EHR incentives. This study does not include a study of these providers.

Partial Day Treatment Center/ Hospitalization Partial hospitalization is a type of treatment program that is used to treat behavioral health conditions. An individual who is being treated in a partial hospitalization program is living at home, but commutes to treatment center up to 7 days a week. Partial hospitalization services are affiliated with a hospital and may be licensed as part of the hospital or a separate free standing program. Group therapy, individual therapy, medication management and other services are provided in the partial hospitalization setting.

HITECH 3000(3) does not include the health care provider type of "partial day treatment center/hospitalization." We note that Medicare covers these services.b

Opioid (Methadone) Treatment Programs One type of therapy used in the treatment of heroin or other opiate (narcotic) addiction is medication-assisted opioid therapy with medications such as methadone1 or buprenorphine. In order for a facility to use medication-assisted opioid therapies, it must be certified as an opioid treatment program (OTP) through the Center for Substance Abuse Treatment (CSAT) within the Substance Abuse and Mental Health Services Administration (SAMHSA).

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APPENDIX K. GRANT, DEMONSTRATIONS, AND COOPERATIVE AGREEMENT PROGRAMS

This appendix provides a program summary of the grants, demonstrations and cooperative agreement programs that have a focus on HIT and ineligible providers. Program highlights are presented in table format followed by a narrative description.

The last section of the appendix includes a summary of the proposals advanced by various stakeholder groups to extend grants, demonstrations and cooperative agreement programs that have a focus on HIT to some ineligible health providers.

A. Program Highlights

Authority and Funder Description Recipient: State or Provider Geographic Location Provider Type Impacted Amount
(if known)
  1. ONC, http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__hitech_programs/1487 accessed May 19, 2012.
  2. CMS, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.htm accessed May 19, 2012.
  3. See http://bphc.hrsa.gov/recovery/capitalimprovement.html.
  4. See http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/OpportunitiesCollaboration/controlnetworks.html.
  5. See http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc_beacon_community_program__improving_health_through_health_it/1805.
  6. See http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3378.
  7. See http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3869 accessed May 12, 2012.
  8. See http://www.samhsa.gov/healthreform/healthHomes/index.aspx access May 15, 2012.
ONC: ARRA/HITECH State Health Information Exchange Cooperative Agreement Program Authority1 State or State Designated Entity Nationwide All State Specific
Medicaid Grant/CMS Medicaid Health Home State Plan Option2 90% Federal match for 8 quarters. Health Home Providers State Determined -- Less than Statewide Health Home Providers State Determined
HRSA Capital Improvement Projects (CIP)3 ARRA Funding opportunity for existing health center grantees for capital improvement and employment opportunities in underserved communities. Health IT projects included the enhancement or the purchase of new EHR systems. Providers   Safety Net Providers $183,101,679
HRSA Health Center Controlled Network (HCCN)4 Grants support the creation, development, and operation of networks of safety net providers through the enhancement of health center operations, including health information technology Providers   Safety Net Providers  
SAMHSA Grants to use web-based services, smart phones and behavioral health electronic applications to enhance communication between patients and providers and to better manage patients' health. Provider Awardee Geographic areas   Awardees may receive up to $280,000 annually over 3 years
ONC: ARRA/HITECH Beacon Community Grants5 Grant program for communities to build and strengthen their health IT infrastructure and exchange capabilities. Some communities are addressing include engagement of LTPAC, BH, or Safety Net providers and/or the patients they serve. Providers Those BCPs that include a focus on ineligible providers:
  • Danville, PA
  • Tulsa, OK
  • RI
  • Southeast MN
  • HI
  • S. Piedmont, NC
  • Brewer, ME
  • Western NY
LTPAC Behavioral Health
  • PA: $15,914,787
  • OK: $12,043,948
  • RI: $15,914,787
  • MN: $12,284,770
  • HI: $16,091,390
  • NC: $15,907,622
  • ME: $12,749,740
  • NY: $16,092,485
ONC: ARRA/HITECH Challenge Grants6 Challenge Grants have been awarded to state health IT programs to focus on health information exchange involving LTPAC providers. States Challenge Grants that focus on LTPAC providers:
  • CO
  • MA
  • MD
  • OK
LPTAC

CO extending grants for LTPAC organizations to connect to HIE

2011:
  • MA: $1,717,610
  • CO: $1,718,783
  • MD: $1,683,171
  • OK: $1,719,086
ONC: ARRA/HIECH Technical Assistance to States through the State Health Policy Consortium (SMPC) Help states resolve policy issues to enable electronic exchange health information across state lines (builds on the work of the HISPC project).

Funding to "Pursue Initiatives to Encourage the Adoption of Certified EHR Technology to Promote Health Care Quality and the Exchange of Health Care Information". Examples: OR, VT, IA, AL

States
  • Upper Midwest (ND, SD, MN, WI, IL, IA)
  • Southeast Regional (AR, LA, TX, FL, GA, AL)
  • Behavioral Health Data Exchange (FL, MI, KY, AL, NM)
  • Western States (OR, CA, AZ, HI, UT, NV, AK, NM)
  • Interface Library Project (TX, GA, VT, PR)
  • Consumer Innovations Challenge (GA, IL, IN, MD, MT, and NE)
All, but Behavioral Health is a focus for one of the consortia (FL, MI, KY, AL, NM)  
SAMHSA: ARRA/HITECH This feasibility pilot program funds the effective interstate exchange of behavioral health data including substance abuse treatment records using the NwHIN DIRECT. The states of Alabama One Health Record®, a health information service provider (HISP), and FL HIE, a HISP, are interstate partners. April 2012 to July 2012.7 State
  • AL
  • FL
  • KY
  • MI
  • NM
SAMHSA/ONC Federal Grant Behavioral Health and non-behavioral health providers.  
SAMHSA: Affordable Care Act Grants to 64 community-based health agencies. One of the services provided at the various sites is the development and implementation of a registry/tracking system to follow primary health care needs and outcomes.8 Community-based health agencies 64 Community-based health agencies Community-based health agencies Community Specific
AHRQ Grant to Geisinger Health System of Danville, PA to extend the KeyHIE Connected Community to behavioral health providers. Provider (Geisinger Health System) Pennsylvania Behavioral Health Providers $2.3 M over 5 years
SAMHSA Community Mental Health Services Block Grant (MHBG) MHBG distributes funds to eligible States and territories for a variety of services and for planning, administration and educational activities under the state plan for comprehensive community-based mental health services for children with serious emotional disturbance and adults with serious mental illness.

OH Department of Mental Health (ODMH) to Community Mental Health Centers to Fund Projects to Support Adoption of Health IT and Behavioral/Physical Health Care.

MI Department of Community Health to PHIPs for 4 areas, one of which is promotion of EHRs.

States to fund Provider 59 eligible states and territories
  • OH: Community MH Centers
  • MI: PHIP
  • OH: Up to $50,000 per Community MH Center
  • MI: $130,000 per PHIP
Affordable Care Act

Sec. 6114. National Demonstration Projects on Culture Change and Use of Information Technology in Nursing Homes

Development of best practices in skilled nursing facilities for the use of information technology to improve resident care. The demonstration project conducted under this section shall take into consideration the special needs of residents of skilled nursing facilities and nursing facilities who have cognitive impairment, including dementia. The duration is not to exceed 3 years. Within 9 months of completing project, a report shall be submitted to Congress on the project including recommendations for legislative and administrative action.       Unfunded
2041(b) of the Social Security Act, as added by section 6703 of the Affordable Care Act

Programs to Promote Elder Justice SEC. 2041. Enhancement of Long-Term Care.

Certified EHR Technology Grant

The Secretary is authorized to make grants to long-term care facilities for the purpose of assisting such entities in offsetting the costs related to purchasing, leasing, developing, and implementing certified EHR technology (as defined in section 1848(o)(4)) designed to improve patient safety and reduce adverse events and health care complications resulting from medication errors.

      Funds were authorized but not appropriated

B. Program Summary

ONC HITECH State Health Information Exchange Cooperative Agreement Program for State and/or State Designated Entity1

Some states have used funding through their State Health Information Exchange (SHIE) Cooperative Agreement with ONC. The SHIE Cooperative Agreement is a grant program to support states or State Designated Entities (SDEs) as they establish health information exchange (HIE) capabilities for eligible and ineligible providers.

The SHIE Cooperative Agreement requires states seeking funding to advance the electronic exchange and use of health information technology to develop an infrastructure that addresses the following domains: technical, technical and business operations, financial, policy and legal (e.g., privacy/security including access, authentication, and authorization), and governance. Some of the health IT infrastructure enhancements eligible for funding through a SHIE Cooperative Agreement (dependent on what the state submitted and ONC approved) are provided in Table K1.

TABLE K1. Potential Health IT Enhancements Eligible for ONC HIE Cooperative Agreement Funding
  1. National e-Health Initiative DURSA Data Use and Reciprocal Support Agreement. http://www.nationalehealth.org/dursa, accessed May 19, 2012.
  2. SAMHSA. "Confidentiality of Alcohol and Other Drug Treatment Records and Communicable Disease: Options for Successful Communication and Collaboration," Confidentiality of Patient Records for Alcohol and Other Drug Treatment Technical Assistance Publication (TAP) Series 13, http://kap.samhsa.gov/products/manuals/taps/13b.htm accessed May 29, 2012.
Secure Messaging
Record Locator Service
Provider Directories
Development of Privacy and Governance Policies and Procedures
Identify Management as a Common Service.
Shared Common Business Intelligence, Rules Engines and Reporting Functionality.
Supporting DIRECT Provider-to-Provider Communication
Establishment of Rules of Engagement related to Privacy and Security through Nationwide Health Information Network Data Use and Reciprocal Support Agreement (DURSA)a and SAMHSA Qualified Service Organization Agreement (QOSA)b

State awardees have flexibility to use funds for activities identified and agreed to under their cooperative agreement with ONC, including funding the infrastructure to support connectivity between all providers whether they are EPs, EHs or non-eligible EHR providers. For example, Alabama is considering as an HIE enhancement the capacity for EHR support for Community Mental Health Centers that will be participating in the state's Medicaid Health Home Initiative through the development of a web-based CCD. In FFY 2011, funding for the SHIE was 100% federal. In FFY 2012 the match rate is $7 federal to $1 state and in FFY 2013, the last year of the grant, the federal grant is $3 to $1 state.

Medicaid Health Home State Plan Option2

Section 1945 of the Social Security Act, along with the guidance provided in Center for Medicaid and CHIP Services (CMCS) Informational Bulletins and CMS State Medicaid Director Letter #10-024 of November 16, 2010,3 provides parameters for the State Plan Option for Health Homes for Enrollees with Chronic Conditions. It gives authority to State Medicaid Agencies to receive a 90 percent match for eight quarters to provide enhanced reimbursement for health home providers.

As defined by the state, health home providers may include designated providers, a team of health care professionals (physicians, nurse care coordinators, dieticians/nutritionists, social workers, behavioral health professionals and other professionals) or an interdisciplinary, inter-professional health team. Inter-professional health teams must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers (including mental health providers, and substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians' assistants.

The Medicaid health home benefit is targeted to Medicaid enrollees with at least two chronic conditions or one chronic condition and at risk for another, and/or individuals with a serious and persistent mental health condition. Medicaid health home providers must have the ability to use health IT, including an EHR, to link services and facilitate communication among team members and between the health team and individual and family caregivers. Health home providers must provide comprehensive transitional care, including appropriate follow-up from inpatient to other settings. The Health Home State Plan can be a mechanism for accommodating some of the health IT expenses of those providers. The state must define in its State Plan Amendment (Attachment 4.19B, Methods and Standards for Establishing Payment Rates) the parameters of the payment to assure efficiency, economy and quality of care.

Some state approaches to leveraging the Medicaid Health Home benefit as a vehicle to extend the use of Health IT/EHRs to support the exchange of health information on half of the persons who receive LTPAC or BH services follow. These examples are not a comprehensive list of all state approaches in this area.

  • Alabama: Alabama submitted a State Plan Amendment for the Health Home benefit relates to improved care coordination through timely transmission of transition records through the use of interoperable EHRs and Alabama's HIE, One Health Record®.

  • Colorado: Officials from the State of Colorado indicated that they expect to submit a State Plan Amendment for the Health Home benefit to support improved care coordination on behalf of persons receiving LTPAC services. Prior to submitting the State Plan Amendment, Colorado officials are conducting a strategic review of the various health IT and HIE activities underway and needed in their State so that when the amendment is submitted Colorado will positioned to most effectively use the time-limited enhanced federal match (available for eight quarters).

  • New York: One of New York's first health home initiatives will focus on enrollees with behavioral health and/or chronic medical conditions.4 New York anticipates targeting persons who receive long-term care services in a subsequent phase of their Health Home Program. To facilitate the use of health IT by health homes to improve service delivery and coordination across the care continuum, New York has developed initial and final health IT standards for health homes that are consistent with New York State's Operational Plan for Health IT and Exchange.5 Providers must meet initial health IT standards to implement a health home and must provide a plan to achieve the final standards within 18 months of program acceptance.

    Since New York anticipates a portion of health home providers may not utilize health IT in their current programs, health home providers must commit to utilizing regional health information organizations or qualified entities to the extent feasible and to develop partnerships that maximize the use of health IT across providers (EPs, EHs and non-eligible providers).6 New York Medicaid Health Home providers must use or have a plan for when and how they will implement an EHR that qualifies under MU.7

    The New York Digital Health Accelerator (NTDHA), a joint program by the New York State Department of Health (DOH), New York eHealthCollaborative (NYeHC) and the New York City Investment Fund, is a program for 12 information technology startups or growth companies to develop products for "care coordination, patient engagement, analytics and message alerts for healthcare providers".8 In addition to a $300,000 monetary award, the companies will collaborate with senior level managers at leading participating hospitals and leading digital entrepreneurs for mentorship and will have access to the digital technology that is connecting EHRs among providers throughout the state through the Statewide Health Information Network of New York (SHIN-NY). The accelerator program has already secured an initial investment of $4.2 million from backers including Aetna, Milestone Venture Partners, New Leaf Venture Partners, New York City Investment Fund, Quaker Partners, Safeguard Scientifics, and UnitedHealth Group. Applications are due June 1, 2012 with a program start date of September 10, 2012.9 Ineligible providers including the Visiting Nurse Services in two counties are participating.

  • West Virginia: West Virginia, like Alabama, is in the process of implementing a statewide HIEthrough their ONC Cooperative Agreement that will facilitate the sharing of information across various care delivery settings. All health home providers will be expected to participate in the HIE as it is implemented across the state.10 West Virginia has received a planning grant from CMS11 to develop the State Plan amendment (SPA) and the state is working closely with the West Virginia Health Improvement Institute on the development of the SPA.12 Eligibility criteria to quality for the program include for individuals with chronic conditions residence in a long-term care facility.

Beacon Community Program Grants that Support Behavioral Health, Long-Term Post-Acute Care and Other Non-Eligible Providers

ONC awarded grants to 17 "Beacon Community Programs" (BCPs) to support innovative interoperable HIE activities. Several BCPs focus on HIE with BH, LTPAC and other providers non-eligible for the MU EHR Incentive programs. BCPs that include a focus on these non-eligible providers are described below:

  • Rhode Island's Beacon Community Program: Spearheaded by the Rhode Island Quality Institute (RIQI), the Rhode Island BCP received $15,914,787, to build upon existing strengths in developing Patient Centered Medical Homes (PCMHs) by enriching them with greater health IT to support registered, clinical decision support tools, and health care quality reporting to drive improvements. Rhode Island, which has implemented a HIE system called current care, seeks to reduce the impact of undiagnosed, untreated depression through increased screening.13

  • Southeastern Minnesota Beacon Community: The 11-county Southeastern Minnesota Beacon Community, which received $12,284,770, has been identified as one of the most advanced communities in terms of health IT. Virtually 100 percent of primary care providers in the area have EHRs, and Winona County has a decade of experience with "wired" connectivity of health information among health care and community partners. This Beacon Community seeks to facilitate better care coordination and clinical transformation among clinics, hospitals, the public health department, and schools in the community. In Olmsted County, it has been shown that sharing action plans for children with asthma across primary care clinics, schools, and the public health department reduces health care utilization and improves school attendance.14

  • Southern Piedmont Beacon Community (SPBC): The SPBC received $15,907,622 to serve a three-county area in North Carolina that has extensive EHR adoption, including all three nonprofit hospitals and the VA hospital, and close to 60 percent of the ambulatory care physicians in the area. SPBC is expanding the benefits of the care management model to other chronic diseases as well as increasing effective use of technologies to support early detection services, such as mammograms and colorectal cancer screenings. The goal of the SPBC is to use health IT to support increased communication and collaboration among members of the care team, including care managers, pharmacists, and mental health counselors, through specialized software notification to care managers when patients are due to be discharged so that plans can be made for a smooth transition from hospital to home or other health care settings.

    Care managers and nurse practitioners, armed with laptops and access to EHRs and other information; provide home visits to patients within three days following hospital discharge. Computer software allows care managers and other clinicians to identify patients with ischemic vascular disease (clogging of the arteries) to ensure patients receive evidence-based interventions and appropriate monitoring of blood pressure and cholesterol levels. School nurses monitor students who have asthma and send updates to the child's primary care providers through a secure portal that will be available to their primary care pediatricians. Inhalers with GPS tracking capabilities, coupled with smart phone and web-based applications, are helping approximately 2,000 asthma patients manage their condition better.15 To improve care coordination, care managers, mental health counselors and pharmacists are being added to the health team for individuals with certain chronic diseases.

  • Keystone Beacon Community Program (BCP): The Keystone BCP will extend the health infrastructure used in this Pennsylvania community by enabling LTPAC providers (even those without EHRs) to make available in their data repository clinically-useful assessment data. Assessment data will be summarized, transformed, and made interoperable by software running at the repository. Assessment Summary Documents and other clinical information are made available at the repository to authorized users using a patient identifier. Keystone is presently piloting the use of a document exchange standard previously endorsed by ONC. In December 2012, Keystone will conduct a Phase 2 pilot using the refined C-CDA.16

  • Bangor Beacon Community: The Bangor BCP focuses on improving the health of patients with diabetes, lung disease, heart disease, and asthma by enhancing care management; improving access to, and use of, adult immunization data; preventing unnecessary ED visits and re-admissions to hospitals; and facilitating access to patient records using health information technology. To achieve their goals they are using information technology to enhance coordinated care management, improving access to adult immunization data, reducing unnecessary emergency department visits and readmissions through health IT, and facilitating patient access to their records.17

  • Hawaii County Beacon Community: The Hawaii County BCP is improving the health of the Hawaii Island residents through health care system improvements and interventions across independent hospitals, physicians, and physician groups and in partnership with public and private health insurers. Engaging patients in their own health care is also a primary focus. This will be accomplished by implementing a patient-centered medical home and telemedicine to improve primary, specialty and behavioral health care; monitor patients more closely to avert onset and advancement of diabetes, high blood pressure, and cholesterol; reduce health disparities for Native Hawaiians; and assist physicians in achieving meaningful use of electronic health records.18

  • Western New York Beacon Community: The Western New York BCP is working to close gaps in service, and improve health outcomes for patients with diabetes by reducing emergency room visits, hospitalizations and readmissions; increasing control of their condition, improving smoking cessation, increasing flu immunizations, reducing disparities especially in urban and rural underserved areas through health IT to facilitate patient monitoring and treatment; and by expanding patient access to their health information.19

Infrastructure: ONC Challenge Grants for LTPAC

ONC awarded LTPAC Challenge Grants to four states to extend their state health IT infrastructure to include LTPAC providers. The focus of these challenge grants is described below.

  • Massachusetts Technology Park Challenge Grant: Massachusetts Technology Park was awarded two HIE Challenge Grants ($1.7 million for improving long-term and post-acute care transitions and $1.6 million for fostering distributed population-level analytics).20 The Massachusetts Challenge grant will extend the State health infrastructure by deploying software (and perhaps hardware) to enable the interoperable exchange of: (i) data from LTPAC providers (even if they do not have EHRs); and (ii) inclusion of functional status, cognitive status, and pressure ulcers data from other health care providers (e.g., EPs and EHs). Massachusetts will pilot this exchange in late 2012, and expects later to extend this technology statewide.21

  • Colorado Challenge Grant: As the state designated HIE, Colorado Regional Health Information Organization (CORHIO) was awarded a grant of $1,718,783 in 2011 to facilitate adoption of EHRs and measure the impact of HIE on LTPAC transitions.22 CORHIO is working with LTPAC organizations, including home health, hospice, skilled nursing, assisted living, long-term acute care hospitals and residential care facilities for the developmentally disabled to improve care transitions to and from acute care settings through the HIE. The goals of the program are to facilitate adoption of HIE by the LTPAC community, develop community protocol for information sharing across care transitions, and measure the impact of HIE on quality of patient care and rates of hospital readmissions.

    In four diverse Colorado communities (Boulder County, Colorado Springs, Pueblo, and the San Luis Valley), CORHIO is working with LTPAC organizations to demonstrate the value of participating with the rest of the local and statewide health care community in improving information sharing and care coordination through HIE. CORHIO has identified 320 LTPAC providers in the targeted communities, with a goal of 50 percent (160) participating in HIE by January 2014.23

    The first tier of qualified LTPAC applicants will receive funding from the Challenge Grant sufficient to cover: (i) the cost of their one-time set up fee of $2000; and (ii) the cost of two-years of monthly subscription fees for use of CORHIO's HIE. The second tier of qualified applicants will receive funding sufficient to cover: (i) the cost of a one-time set up fee of $2000; and (ii) the cost of one-year of monthly subscription fees for use of CORHIO's PatientCare.24

  • Oklahoma Challenge Grant:25 The Oklahoma Health Care Authority received $1,719,086 to implement processes that optimize efficient and well-orchestrated patient transitions, including implementation of a Clinical Documentation Tool (CDT).26 The Oklahoma Health Information Exchange (OHIET) is focusing on improving transitions of care between hospitals and LTC facilities by implementing electronic information exchange to support patient care during and after patient transfers. In addition to the implementation of the technology to support electronic exchange of patient-specific information, they are focusing on improving workflow and processes associated with care transitions to ensure effective use of information to improve patient care.

    Selected pilot nursing homes will access the regional HIE via a lightweight-hosted ambulatory EHR installed as a CDT. In addition, a continuity of care document (CCD) would be available for any transfer in or out of a long-term care facility in the Norman Regional Health System pilot region.

  • Maryland Challenge Grant:27 The goal of the Maryland Department of Health and Mental Hygiene, who received $1,683,171 in 2011, is to pilot the electronic exchange of clinical documents between pairs of long-term care centers and proximate hospital emergency departments (EDs). The pilot will center on six large long-term care facilities across Maryland, with some services being offered to every facility in the state. Each participating long-term care facility is paired with a hospital in its immediate medical service area. The state will analyze the reduction in average time to transmit such information compared to the status quo, and the effect on hospital readmission rates for patients participating in the pilot versus a control group.28

The technology solutions under development and piloting in the four states could be re-used by other states and communities to engage LTPAC providers in HIE activities. For example, representatives in Colorado and Oklahoma have expressed an interest in potentially leveraging the tools created by Massachusetts.

Technical Assistance to States through the State Health Policy Consortium (SMPC)

SMPC, established through a HHS contract with RTI in March 2010, facilitates groups of states in resolving policy issues at a concrete level to enable electronically-exchanged health information across state lines. Building on previous work of the Health Information Security and Privacy Collaboration (HISPC) project, this effort seeks to pursue development of template language for interstate agreements or other similar mechanisms that will enable interstate HIE despite differences in individual state consent laws. The Upper Midwest (UM-HIE) Consortium convened representatives from six states, Illinois, Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin, to work together to create concrete regional solutions to barriers affecting HIE for treatment purposes.29

Infrastructure: Behavioral Health Data Exchange Consortium

Created to pilot the interstate exchange of BH treatment records among treating health care providers using the Nationwide Health Information Direct protocols, this project involves the creation of draft Policies and Procedures (P&P) for exchange of BH records. The pilot is intent on meeting the requirements of federal regulations at 42 CFR Part 2 and participating state mental health laws. To achieve this, the group of states (Alabama, Florida, Kentucky, New Mexico, Nebraska and Michigan) has created sample Part 2 compliant consent forms (one for universal disclosure of health information and one for more limited disclosure).

SAMHSA Health IT Grants: Increase Access to Behavioral Health Services30

  • Community Health Centers: In September 2011, SAMHSA awarded 47 community health centers serving people with mental and substance use disorders $200,000 each to develop health IT and expand the use of EHRs.31

  • National Council on Community Behavioral Health Care: The council received $3.8 million to help community health centers and state-designated agencies implement EHRs.

AHRQ Grant: Geisinger to Extend the KeyHIE Connected Community

This grant will provide additional expansion of the KeyHIE (part of the Keystone Beacon) connected community (see to additional regional hospitals, long-term care facilities, home health organizations, and physician practices). In addition to expanding participation across the community, KeyHIE will use the five-year AHRQ grant of $2.3 million to make new clinical applications and document types available within the HIE.32

Federal Mental Health Block Grants to Fund Projects to Support Adoption of Health IT and Behavioral/Physical Health Care

  • Health Information Technology (Health IT)/Health Integration Innovation Mini-Grant through the Ohio Department of Mental Health (ODMH) to Community Mental Health Centers: ODMH will make available a maximum award of up to $50,000 per applicant for selected activities or work completed between March 1, 2012 and June 30, 2012 by community behavioral health centers that are in the process of moving towards becoming a Community Behavioral Health Center (CBHC) Medicaid health home. Activities that may be supported or enhanced include but are not limited to technical assistance, needs assessments, e-prescribing, data management, certified EHR, and information exchange interfaces which will also include intake from other data sources for utilization review activities, billing interfaces, tele-health innovations and implementation of patient registries.33

  • Michigan Prepaid Inpatient Health Plans through Michigan Department of Community Health (MDCH) FY13 Mental Health Block Grants: Support of $130,000 to each Prepaid Inpatient Health Plan (PIHP), for the purpose of funding systems-level Integrated Healthcare (IH) services enhancement, in one or more domains, of which continuation of promotion of adoption of EHRs is one.34

Patient Protection and Affordable Care Act

The Affordable Care Act includes several provisions that support/advance the use of health IT/EHRs including on behalf of providers ineligible for the EHR Incentive Programs. In addition to the Medicaid Health Home optional benefit described above that would extend the use of health IT to support care coordination on behalf of persons with mental illness, and persons with chronic conditions including persons who receive long-term care services, the Affordable Care Act also includes provisions that would:

  • Sec. 6114. National Demonstration Projects on Culture Change and Use of Information Technology in Nursing Homes. The Secretary is authorized to make grants under the demonstration to facility-based settings for the development of best practices in skilled nursing facilities and nursing facilities for the use of information technology to improve resident care. Funds were authorized but not appropriated.

  • Programs to Promote Elder Justice SEC. 2041. Enhancement of Long-Term Care. Secretary is authorized to make grants to long-term care facilities for the purpose of assisting such entities in offsetting the costs related to purchasing, leasing, developing, and implementing certified EHR technology. Funds were authorized but not appropriated. Additionally, Section 2041(c) of the Act requires the Secretary to adopt standards for the electronic exchange of clinical data by long-term care facilities. While funds were authorized but not appropriated, ONC is supporting work to advance health IT standards for LTPAC and is seeking feedback on the need for EHR certification criteria for LTPAC providers.

C. Proposals to Extend Health IT Grants, Demonstrations and Cooperative Agreement Programs EHR Incentives to Ineligible Provider35

The following table identifies some of the actions that some stakeholders have advanced to extend grants, demonstrations and cooperative agreement programs that have a focus on health IT for some ineligible health providers, such as long-term and post-acute, and behavioral health providers. This summary is not intended to be a complete list of proposals to extend these grant, demonstration, and cooperative agreement programs. Rather the list serves to highlights some of the suggestions by some stakeholders of extending these programs. Further, this list is not intended as endorsement of any one of these options. Instead, the summary serves only to list some of the actions that have been proposed that could support the use of EHR technology by ineligible providers. The text in the table below quotes from the referenced documents.

Stakeholder Group Source and Statement of Proposed Action
  1. See http://www.ltpachealthit.org/system/files/MU%20Comments%20March%202010%20v4%205%20%284%29.pdf.
  2. See http://www.ltpachealthit.org/system/files/LTPAC%20HIT%20Collaborative%20Comments%20on%20ONC%20 Federal%20HIT%20Strategic%20Plan%205_9_11_FINALv2.pdf.
Leading Age (formerly known as AAHSA (American Association for Homes and Services for the Aging))

Leading Age 5,800 member organizations, many of which have served their communities for generations, offer the continuum of aging services: adult day services, home health, community services, senior housing, assisted living residences, continuing care retirement communities and nursing homes.

AAHSA Public Policy Priorities 2011 (p.8):
The Affordable Care Act provides for a number of exciting opportunities to better integrate acute and post-acute care services through collaboration among a variety of health care providers. This kind of collaboration will require extensive data sharing to ensure continuity and quality of services. Data collection and sharing, in turn, will absolutely depend on the use of health IT.

A report by the LeadingAge Center for Aging Services Technology (CAST) discusses the ways in which technology can change the culture, delivery options and financing of health care and long-term services and supports. We support incorporating aging services technologies into accountable care organizations, medical homes and other innovative service delivery systems to help realize cost savings and quality improvements.

LeadingAge supports:
A pilot program to provide incentives for home health agencies across the country to use home monitoring and communications technologies, giving seniors greater access to the care they need.

National Association of Home Care (NAHC)

Home Care Technology Association of America (HCTAA)

HCTAA is a wholly-owned affiliate of the NAHC, and is organized to advance the accessibility and use of technology in home care and hospice settings. HCTAA was established to unite the home care technology industry into a stronger, more effective voice to Congress, the Administration, state legislatures, the home care industry, consumers, and the media. HCTAA believes that home care and hospice providers that are properly equipped with technological solutions will serve a central role in the delivery of health care by ensuring quality, efficiency, and patient care coordination.

NAHC and HCTAA: comments on the definition of "Meaningful Use" of Electronic Health Records (EHR), as required by the American Recovery and Reinvestment Act of 2009" (June 25, 2009) (pp.2-3):
We specifically would urge the ONCHIT to ensure that:
  • HIE grant funding be made to RHIOs/HIEs emphasize the need to include and support home health care providers to effectively facilitate the electronic exchange of health information across different care settings;
  • Grants and loans be made available to home health care providers to plan for and implement certified, interoperable health IT solutions.

…as we have stated, the goal of care coordination requires the exchange of timely health information among all care providers. This goal cannot be achieved unless it is inclusive of home health care and hospice providers. With appropriate resources for implementation and standardization of EHRs, further steps can be taken by the home care and hospice community to meet the objectives of the meaningful use of EHRs and care coordination.

NAHC/HCTAA is also exploring strategies to obtain incentives such as small business loans, tax incentives and grants that could be available to LTPAC providers for the adoption of EHRs.

NAHC and HCTAA comments on the proposed rule to define the "meaningful use" of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs (March 15, 2010) (pp.1-2):

  • Encourage stakeholders to conduct demonstration projects that test the exchange of meaningful clinical information between EPs, eligible hospitals and home health care and hospice providers and provide data on the outcomes and cost effectiveness of care coordination and the sharing of clinical data amongst a broad scope of health care providers.
  • Encourage EPs (physicians) and hospitals in future rulemaking to partner with other health care providers, as defined by Section 3000(3) of the HITECH Act, by directly linking the formation of collaborative partnerships with home health care and hospice providers with the demonstration of meaningful use or by some other incentivizing means.
LTPAC Health IT Collaborative

Collaborative of associations representing health IT issues for LTPAC providers, professionals, and support services in skilled nursing facilities, nursing facilities, assisted living, home health agencies, etc.

Members include:
American Health Care Association, American Health Information Management Association, Home Care Technology Association of America, American Society of Consultant Pharmacists, Center for Aging Services Technology, Leading Age, National Association of Home Care and Hospice, National Association for the Support of Long-Term Care, National Center for Assisted Living, Program for All Inclusive Care for the Elderly

April 16, 2009. Inclusion of Long-Term Care Settings in ARRA Funded Projects. Letter to the David Blumenthal (the National HIT Coordinator) (pp.1-2):
We are also aware of the ARRA-required investments in grants and loans programs that will be administered through your office to drive the adoption of interoperable health IT nationally. We are contacting you today to provide two recommendations designed to maximize the return on this significant one time investment in the national health IT infrastructure:
  1. We recommend that ONC include language in the ARRA requests for HIT grant and loan proposals advising applicants of the benefits of and need to seek partners from different care settings, including long-term care and providing such help as may be necessary to help identify potential partners (such as providing lists of federally certified providers in various areas).
  2. In addition, we recommend that ONC specify that one of the evaluation criteria for selecting grant/loan recipients will be a preference for those who do partner with long-term care providers (and other health care providers who will not receive financial incentives).

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules.
This rule proposes to define the "meaningful use" of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs.a

LTPAC Recommendations on "Meaningful Use" (pp.1-2):

  • Encourage EPs (physicians) and hospitals in future rulemaking to partner with other providers, as defined by Section 3000(3) of the HITECH Act, by directly linking the formation of partnerships with LTPAC providers with the demonstration of meaningful use or by some other incentivizing means…
  • Recognize that improved care coordination and the exchange of meaningful clinical information among the professional health care team should involve all health care provider types and that demonstration projects should be devised to demonstrate the exchange of meaningful clinical information between EPs, eligible hospitals and LTPAC providers.

January 18, 2011. President's Council of Advisors on Science and Technology "Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward" Letter to ONC. (pp.1-2):
The report urges the Centers for Medicare and Medicaid Services (CMS) to focus on increasing health information exchange and to exercise its' influence as a major payer to drive health information exchange. While currently long-term care providers are not eligible for Meaningful Use incentives for adoption of a certified electronic health record under ARRA-HITECH, CMS could leverage federally mandated LTPAC functional status assessments (such as MDS, OASIS and IRF-PAI) to accelerate the adoption of interoperable EHRs in this sector and increase the exchange of health information across health care provider settings. ONC should also support the creation of health data exchange programs that target and engage LTPAC providers.

May 6, 2011. LTPAC HIT Collaborative Public Comments on ONC Federal HIT Strategic Plan 2011-2015.b
OBJECTIVE I.C: Support health information technology adoption and information exchange for public health and populations with unique needs.
STRATEGY I.C.3: Support health IT adoption and information exchange in long-term/post-acute, behavioral health, and emergency care settings.

The Federal HIT Strategic Plan notes ONC is working with SAMHSA and HRSA to address the policies and standards concerning the unique needs of behavioral health IT adoption and information exchange. The LTPAC Health IT Collaborative supports the inclusion of the unique needs of behavioral health identified in the strategic plan and offers these recommendations below supporting the unique needs of the LTPAC community:

  • Support for effective care delivery which maintains health care quality outside of the hospital and acute care setting where most of the elder population--both Medicare and Medicaid beneficiaries as well as "dual eligibles" reside.

Notes

  1. Office of the National Coordinator for Health Information Technology. HITECH Programs. http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__hitech_programs/1487, accessed May 19, 2012.

  2. Centers for Medicare and Medicaid Services. Health Homes. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html accessed May 19, 2012.

  3. Centers for Medicare and Medicaid Services. Letter to State Medicaid Directors re: Health Homes for Enrollees with Chronic Conditions. (November 16, 2010) http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf accessed May 12, 2012.

  4. New York Department of Health. NYS Implementation of Health Homes. (April 26, 2012) http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/nys_implementation.htm, access May 20, 2012.

  5. NYS Health Home State Plan Amendment for Individuals with Chronic Behavioral and Medical Health Conditions -- SPA# 11-56. Phase 1 (January 27, 2012) http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/chronic_conditions_spa_11-56_phase.pdf, accessed May 20, 2012.

  6. Ibid., accessed May 20, 2012.

  7. Ibid., accessed May 20, 2012.

  8. Digital Health Program Seeks Startup, Dolan, Brian (May 1, 2012) http://mobihealthnews.com/17179/digital-health-program-seeks-startups-to-redesign-medicaid-care/, accessed May 2, 2012.

  9. Brian Dolan. Digital Health Program Seeks Startup (mobihealth news May 1, 2012) http://mobihealthnews.com/17179/digital-health-program-seeks-startups-to-redesign-medicaid-care/ accessed May 2, 2012.

  10. West Virginia Health Home State Plan Amendment template (February 15, 2012 draft) http://www.wvahc.org/downloads/Draft_SPA_re_health_homes.pdf accessed May 15, 2012.

  11. Substance Abuse and Mental Health Services Administration. Medicaid State Plan Amendment for Health Homes Planning Grants, http://www.samhsa.gov/healthreform/docs/Health_Homes_Planning_Grants_for_Medicaid_508.pdf accessed May 15, 2012.

  12. National Academy for State Health Policy. "West Virginia" (updated June 2011), http://www.nashp.org/med-home-states/west-virginia accessed June 1, 2012.

  13. Office of the National Coordinator for Health Information Technology. Rhode Island Beacon Community. http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__rhode_island_beacon_community/3330 accessed May 25, 2012.

  14. Office of the National Coordinator for Health Information Technology. Southeastern Minnesota Beacon Community. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_7982_3324_21241_43/http%3B/ wci-pubcontent/publish/onc/public_communities/_content/files/se_minnesota_beacon_summary.pdf accessed May 24, 2012.

  15. Office of the National Coordinator for Health Information Technology. Southern Piedmont Beacon Community. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_7985_3327_21244_43/http%3B/wci-pubcontent/publish/onc/ public_communities/_content/files/southern_piedmont_beacon_summary.pdf accessed May 23, 2012.

  16. Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving Health through Health Information Technology, http://healthit.hhs.gov/portal/server.pt?open=512&objID=1805&parentname=CommunityPage&parentid=2&mode=2&cached=true accessed June 1, 2012.

  17. Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving Health through Health Information Technology. http://www.healthit.gov/policy-researchers-implementers/beacon-community-program accessed November 20, 2012.

  18. Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving Health through Health Information Technology. http://www.healthit.gov/policy-researchers-implementers/hawaii-county-beacon-community accessed November 20, 2012.

  19. Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving Health through Health Information Technology. http://www.healthit.gov/policy-researchers-implementers/hawaii-county-beacon-community accessed November 20, 2012.

  20. Office of the National Coordinator for Health Information Technology. Health Information Exchange Challenge Grant Program. http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3378 accessed May 15, 2011.

  21. Ibid., accessed June 2, 2012.

  22. Colorado Regional Health Information Organization (CORHIO) LTPAC Transitions Program. http://www.corhio.org/for-providers/long-term-care/ltpac-transitions-program.aspx accessed May 22, 2012.

  23. Office of the National Coordinator for Health Information Technology. Health Information Exchange Challenge Program: Colorado Regional Health Information Organization (CORHIO). April 2012. http://statehieresources.org/wp-content/uploads/2012/05/CORHIO-Challenge-Grant-Summary-Report-April-2012.pdf accessed June 1, 2012.

  24. Ibid., accessed June 1, 2012.

  25. Office of the National Coordinator for Health Information Technology. Health Information Exchange Challenge Program: Oklahoma Health Information Exchange (March 2012). http://statehieresources.org/wp-content/uploads/2012/05/Challenge-Grantee-Summary-Oklahoma_V4-2.pdf accessed June 2, 2012.

  26. Melanie Lawrence and Brian Yeaman. Oklahoma's Challenge Grant Care Transitions. http://www.nga.org/files/live/sites/NGA/files/pdf/1105HIEMELANIE1.PDF accessed May 25, 2012.

  27. Chesapeake Regional Information Systems for Our Patients (CRISP). Briefing: Maryland Statewide Health Information Exchange Challenge Grant Application (March 2011). http://mhcc.dhmh.maryland.gov/hit/hiePolicyBoard/Documents/hie_pb/Resources/MdChallengeGrantBriefing030411.pdf accessed June 1, 2012.

  28. Ibid., accessed May 22, 2012.

  29. Office of the National Coordinator for Health Information Technology. State Health Policy Consortium. http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__state_health_policy_consortium/3035 accessed June 2, 2012.

  30. SAMHSA Awards Health IT Grants. AHA News Now (September 26, 2011). http://www.ahanews.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_092611_SAMHSA&domain=AHANEWS accessed June 1, 2012.

  31. Substance Abuse and Mental Health Services Administration. AMHSA announces grants awards totaling up to $13.2 million to build on Health Information Technology investments (SAMHSA News Release, September 23, 2011. http://www.samhsa.gov/newsroom/advisories/1109231204.aspx accessed June 1, 2012.

  32. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Appendix J: Overview of Patient Assessment Summary (December 2011). http://aspe.hhs.gov/daltcp/reports/2011/StratEng-J.htm accessed May 22, 2012.

  33. Ohio Department of Mental Health. Request for Application: Health Information Technology (HIT)/Health Integration Innovation Mini-Grant (Federal Fiscal Year 2012). http://mentalhealth.ohio.gov/assets/numbered-advisories/fy2012/integration-block-grant-rfa-final-2.1.12_4_1.pdf accessed May 31, 2012.

  34. Michigan Department of Community Health FY13 Adult Mental Health Block Grant. Request for Applications. https://www.michigan.gov/documents/mdch/Block_Grant_RFA_31511_348001_7.doc accessed June 1, 2012.

  35. It should be noted the description of these proposals should not be construed as an endorsement of the proposals.

[Return to the Table of Contents]

 

APPENDIX L. LOAN PROGRAMS

This appendix provides a summary of loan programs which are available to ineligible providers. Program highlights are presented in table format followed by a narrative description of the programs offered in North Dakota and Minnesota. The last section includes a summary of proposals advanced by various stakeholders to make available various loan programs to support the use of EHRs by ineligible health providers.

A. Program Highlights

Authority and Funder Description Recipient: State Provider Geographic Location Provider Type Impacted Amount
(if known)
  1. See http://www.healthit.nd.gov/loan-program/.
  2. See http://www.mainelegislature.org/legis/bills/bills_124th/billpdfs/SP067501.pdf.
  3. See http://www.health.state.mn.us/divs/orhpc/funding/index.html#ehrloan.
State Revolving Loan
  • North Dakota
  • Maine
  • Minnesota
ND: Low-interest loans to health care entities to build their health IT infrastructure available to both eligible and ineligible providers.a Provider ND Standalone individual practitioner including long-term care facilities

Hospital and multi-professional entities

Entities with 3 or more commonly owned facilities

$125,000

$625,000

$1,250,000

ME: Bond funding for the purchase of software and the hardware necessary for health care providers to exchange patients' health care records electronically.b ME Health Care Providers $10,000,000 bond available
MN: Loan program to help finance the implementation or support of interoperable EHR systems. Loan funds are primarily intended for EHR software, hardware, training and support expenses. Six year, no-interest loans available.c MN Priority to:
  • Critical access hospitals;
  • Federally qualified health centers;
  • Skilled nursing facilities;
  • Entities that serve uninsured, underinsured and medically underserved individuals;
  • Individual or small group practices that are primarily focused on primary care.
 

B. Program Summary

North Dakota: North Dakota provides an example of a state offering low-interest loans to health care entities to build their health IT infrastructure.1 Ineligible providers may apply for the loan program including but not limited to:2 rural health clinics, long-term care facilities, emergency medical services/ambulance providers, pharmacies and others.

Eligible projects for the loan program include:3

  • Purchase, installation and/or support of software and hardware required to implement a fully functional, standards-based, interoperable electronic health records systems certified (if available for your provider type) by the Office of National Coordinator's Authorized Certification Bodies (ONC-ACBs).4

  • Electronic medication history and electronic patient medical history information system.

  • Electronic personal health records for persons with chronic diseases and for prevention services.

  • Electronic prescribing, including pharmacy systems.

  • Other electronic systems needed to meet "meaningful use".

Minnesota: The Minnesota Department of Health-Office of Rural Health and Primary Care administers an electronic health record (EHR) loan program to help finance the implementation or support of interoperable EHR systems. Loan funds are primarily intended for EHR software, hardware, training and support expenses.

Loans are six-year, no-interest with the first year's repayment deferred. Eligible entities: federally qualified health centers; community clinics; nonprofit or local units of government hospitals; individual or small group physician practices that are primarily focused on primary care; nursing facilities and local public health departments.

Note: Priority will be given to the following applicants: critical access hospitals; federally qualified health centers; skilled nursing facilities; entities that serve uninsured, underinsured and medically underserved individuals (urban or rural); and individual or small group practices that are primarily focused on primary care. The commissioner has the authority to approve other providers of health or health care services when interoperable electronic health record capability would improve quality of care, patient safety or community health.5

C. Proposals to Make Available Loans for EHRs for Ineligible Providers

The following table identifies some proposals from some stakeholders to make available loans to support the costs related to EHRs for ineligible provider types, such as long-term and post-acute, and behavioral health providers. This summary is not intended to be a complete list of options that have been proposed. Rather the list serves to highlights some of the suggestions by some stakeholders regarding the use of loans for costs related to EHRs. Further, this list is not intended as endorsement of any one of these options. Instead, the summary serves only to list some of the actions that have been proposed that could support the use of EHR technology by ineligible providers. The text in the table below quotes from the referenced documents.

Stakeholder Group Source and Statement of Proposed Action
State Medicaid Directors Association (NASMD)

NASMD a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories).

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules, published in the January 13, 2010 Federal Register.
"State Match Requirements" (p.7)
:
The states request that CMS allow in-kind contributions--such as state staff "on loan" to the Medicaid program for the provider incentive program--as part of the 10% state match. In today's economic reality of severe state deficits, states may otherwise not be able to secure the funding needed to participate in this program.
Centers for Aging Services Technology, Homecare Technology Association of America (CAST)

CAST is leading the charge to expedite the development, evaluation and adoption of emerging technologies that can improve the aging experience. CAST has become an international coalition of more than 400 technology companies, aging services organizations, research universities, and government representatives.

IMPEDIMENTS TO THE ROLL-OUT OF IT HEALTHCARE STRATEGIES (pp.1-2):
More incentives, in the form of grants, tax-credits and low-interest loans, are needed to enable long-term providers to prepare their information and communications infrastructure and deploy new technologies, including health IT and interoperable EHR systems, and other technologies including technologies for care documentation by direct care workers that improve the quality of care. Such health IT infrastructure and EHR systems, that are interoperable across provider settings, ensure the continuity of information, and thus the continuity of care, and can lead to reducing medical errors, duplicative procedures and expenditures, while improving care quality, especially for the aging population.
National Association of Home Care (NAHC)

Home Care Technology Association of America (HCTAA)

HCTAA is a wholly-owned affiliate of the NAHC, and is organized to advance the accessibility and use of technology in home care and hospice settings. HCTAA was established to unite the home care technology industry into a stronger, more effective voice to Congress, the Administration, state legislatures, the home care industry, consumers, and the media. HCTAA believes that home care and hospice providers that are properly equipped with technological solutions will serve a central role in the delivery of healthcare by ensuring quality, efficiency, and patient care coordination.

NAHC and HCTAA: comments on the definition of "Meaningful Use" of Electronic Health Records (EHR), as required by the American Recovery and Reinvestment Act of 2009" (June 25, 2009):
NAHC/HCTAA is also exploring strategies to obtain incentives such as small business loans, tax incentives and grants that could be available to LTPAC providers for the adoption of EHRs.
LTPAC Health IT Collaborative

Collaborative of associations representing health IT issues for LTPAC providers, professionals, and support services in skilled nursing facilities, nursing facilities, assisted living, home health agencies, etc.

Members include:
American Health Care Association, American Health Information Management Association, Home Care Technology Association of America, American Society of Consultant Pharmacists, Center for Aging Services Technology, Leading Age, National Association of Home Care and Hospice, National Association for the Support of Long-Term Care, National Center for Assisted Living, Program for All Inclusive Care for the Elderly

April 16, 2009. Inclusion of Long-Term Care Settings in ARRA Funded Projects Letter to the David Blumenthal (the National HIT Coordinator) (pp.1-2):
We are also aware of the ARRA-required investments in grants and loans programs that will be administered through your office to drive the adoption of interoperable health IT nationally. We are contacting you today to provide two recommendations designed to maximize the return on this significant one time investment in the national health IT infrastructure:
  1. We recommend that ONC include language in the ARRA requests for health IT grant and loan proposals advising applicants of the benefits of and need to seek partners from different care settings, including long-term care and providing such help as may be necessary to help identify potential partners (such as providing lists of federally certified providers in various areas).
  2. In addition, we recommend that ONC specify that one of the evaluation criteria for selecting grant/loan recipients will be a preference for those who do partner with long-term care providers (and other health care providers who will not receive financial incentives).

Notes

  1. North Dakota Health Information Technology. North Dakota HIT Planning Loan Program: Program Guidance. http://www.healthit.nd.gov/files/2011/07/ND2012-Planning-Loan-Program-June-2012.pdf accessed June 1, 2012.

  2. Ibid. (North Dakota HIT Planning Loan Program)

  3. Ibid. (North Dakota HIT Planning Loan Program)

  4. The Office of the National Coordinator Certified Health IT Product List webpage. http://oncchpl.force.com/ehrcert.

  5. Minnesota Department of Health. Grants and Loans webpage: http://www.health.state.mn.us/divs/orhpc/funding/index.html#ehrloan.

[Return to the Table of Contents]

 

APPENDIX M. TECHNICAL ASSISTANCE PROGRAMS

This appendix provides a program summary of the technical assistance programs. Program highlights are presented in table format followed by a narrative description. Programs that are pending or under development have been listed. This appendix captures the programs identified, but should not be considered exhaustive since a comprehensive review of every state was not conducted. The last section includes a summary of proposals advanced by various stakeholders regarding the need for technical assistance to support the use of EHRs by ineligible health providers.

A. Program Highlights

Authority and Funder Description Recipient: State or Provider Geographic Location Provider Type Impacted Amount
(if known)
  1. See http://www.stratishealth.org/expertise/healthit/nursinghomes/nhtoolkit.html.
  2. See http://www.stratishealth.org/expertise/healthit/homehealth/index.html.
  3. See http://www.hrsa.gov/healthit/toolbox.
  4. See http://statehieresources.org/wp-content/uploads/2010/12/Vulnerable_Populations_and_HIE.pdf.
  5. See http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048433.pdf.
  6. See http://www.ahima.org/downloads/pdfs/advocacy/VulnerablePopulationsModule-HIEToolkit-ONCFinalWithStateInfo_2010_11_16(2).pdf.
CMS Medicare Technical Assistance through Medicare Quality Improvement Organizations (QIOs) 10th Scope of Work to non-eligible Medicare providers, specifically long-term care providers, in 3 states to support coordination of care, facilitate HIE, and reduce medical errors by improving the medication management process.

MN's QIO (Stratis Health) developed and health IT toolkits for EHR implementation for nursing homesa and home health agenciesb with the support of local trade associations.

Medicare Ineligible Providers MN, PA, CO Long-term care providers  
SAMHSA EHRs Acquisition Guide for State and Territorial behavioral health agencies State Agencies working with BH Providers Nationwide BH Providers  
SAMHSA: HRSA Behavioral Health Integration Project (BHIP) to promote the exchange of health information among BH and medical care providers State for BH Providers IL (1 of 5 grantees) BH and Medical Providers $600,000
HRSA: Health IT Toolboxesc Planning, implementation and evaluation resources to help Safety Net providers implement health IT.
  • Health IT Adoption Toolbox
  • Kids Health IT Toolbox
  • Rural Health IT Toolbox
  • HRSA Health IT and Quality Webinars

Future Toolboxes:

  • Quality Improvement
  • Meaningful Use
  • Oral Health IT
  • Rural Health IT
Providers   Safety Net Providers  
ASPE (in collaboration with members of the LTPAC HIT Collaborative, and behavioral health reps)d Vulnerable Populations Toolkit:
Provides guidance to State HIE Programs and LTPAC and Behavioral Health Provider on how to integrate these providers and their vulnerable populations into the State HIE Program and with meaningful use requirements.

ONC posted to the toolkit on their State HIE website.

AHIMA also posted a briefing and the toolkit.e,f

    State HIE Programs LTPAC and BH Providers  

B. Program Summaries

Quality Improvement Organization (QIO) Technical Assistance: LTPAC Providers

Quality Improvement Organizations (QIOs) are helping doctors, hospitals, and home health agencies across the country harness the power of the latest information technologies such as EHRs, registries, e-prescribing, and telemedicine.1 QIOs will partner with Beacon Communities and RECs to integrate with state and local HIE efforts to encourage reporting via EHRs to state Immunization Information Systems (state registry). As directed by CMS, QIOs may perform onsite teaching or mentoring including training on evidence based interventions.2 For example, StratisHealth, Minnesota and North Dakota's QIO, provides actionable tools and resources to assist health care organizations in planning for and optimizing use of health IT, including a toolkit specifically for home health and another for nursing homes.3 In addition, the QIO program in the 10thSOW has a directed special innovation project in Minnesota, Pennsylvania, and Colorado focusing on providing technical assistance to long-term care providers and acute care hospitals to assist in the following key areas:

  1. Improve quality and coordination of care through the effective use of health IT during care transitions.
  2. Leverage standardized patient assessment content to facilitate health information exchange (HIE).
  3. Reduce medical errors by improving the medication management process through the use of EHR functionality.

State Agencies Working with Behavioral Health Providers through SAMHSA

SAMHSA developed an EHRs Acquisition Guide for state and territorial behavioral health agencies. SAMHSA also collaborated with CMS to develop behavioral health components within the Medicaid Information Technology Architecture (MITA) framework. SAMHSA developed a guide to assist mental health and substance use state agencies in obtaining assistance through CMS for information technology initiatives to integrate mental health, substance use, and Medicaid data systems.4

Behavioral Health Community Connection to Illinois Health Information Exchange using SAMHSA/HRSA Funded Cooperative Agreement5

Illinois received $600,000 in federal funding to support their Behavioral Health Integration Project (BHIP), whose goal is to promote the exchange of health information among behavioral health and medical care providers to achieve better care. Grant activities will help licensed substance abuse and mental health practitioners' better coordinate patient care with their clients' primary care providers through a secure electronic HIE. Illinois is one of five (Kentucky, Maine, Oklahoma, Rhode Island and Illinois) State Designated Entities (SDEs) that received funds (through the Center for Integrated Health Solutions (CIHS)/SAMHSA-HRSA funded cooperative agreement) for the development of infrastructure supporting HIE between behavioral health and physical health providers.

Vulnerable Populations Toolkit

This module was designed to help guide HIE activities in planning to support inclusion of vulnerable populations with LTPAC and BH needs. State health IT Coordinators and LTPAC and BH providers were the two audiences targeted for this Toolkit Module. The toolkit describes how inclusion of these vulnerable populations relates to:

  • Meaningful Use (MU) criteria for eligible hospitals (EHs) and eligible professionals (EPs); and
  • Quality measures for EHs and EPs.

The toolkit:

  • Describes: frequency of transitions in care; instances of "shared care" (multiple service providers) over time and during single episodes; opportunities for poor quality/poor coordination of care, costs of care…).

  • Provides: data on numbers of individuals receiving and providers of LTPAC and BH services; and expenditures for these services.

  • Identifies: types of state agencies engaged with LTPAC and BH, and types of providers/links to national/local provider groups.

  • Describes what is known about adoption of health IT/HER technology by:

    • NHs, HHAs, and BH service providers.
  • Describes the low hanging fruit "touchpoints" between the:

    • CMS Final Rule on EHR Incentives and ONC Rules on standards and certification; and
    • HIE needs of persons receiving LTPAC and BH services.

The Toolkit identifies several recommended practices, including:

  1. States/State Designated Entities should identify and implement actions needed to:

    • Ensure inclusion of "vulnerable populations" in planning/implementing information exchange; and
    • Provide technical assistance to providers serving "vulnerable populations" to enable development/dissemination of solutions that promote information exchange.
  2. It is incumbent upon States/State Designated Entities to define the scope of "vulnerable populations" for purposes of planning and implementing HIE activities.

  3. States/State Designated Entities should support the exchange of clinical information to be transmitted by eligible professionals (EPs) or eligible hospitals (EHs) that is also of high value to LTPAC and BH service providers including:

    • Patient summary documents;
    • Advance Directive information;
    • Medication information; and
    • Test results.
  4. State/State Designated Entity planning and implementation activities should recognize and include participation by state and local agencies engaged with LTPAC and BH providers.

  5. State health IT coordinators should coordinate with regional extension centers to consider the need for technical assistance to EPs to ensure proper construction and calculation of the EHR Incentive Program QMs.

  6. States/State Designated Entities should consider steps to advance the use of adopted standards by providers serving vulnerable populations.

C. Proposals for Technical Assistance to Support EHRs for Ineligible Providers6

The following table identifies some proposals from some stakeholders regarding the need for technical assistance to support the use of EHRs by ineligible provider types, such as LTPAC, and behavioral health providers. This summary is not intended to be a complete list of options that have been proposed. Rather the list serves to highlights some of the suggestions by some stakeholders regarding the need for technical assistance related to EHRs. Further, this list is not intended as endorsement of any one of these options. Instead, the summary serves only to list some of the proposals regarding technical assistance that could support the use of EHR technology by ineligible providers. The text in the table below quotes from the referenced documents.

Stakeholder Group Source and Statement of Proposed Action
  1. See http://www.ltpachealthit.org/system/files/LTPAC%20HIT%20Collaborative%20Comments%20on%20ONC%20 Federal%20HIT%20Strategic%20Plan%205_9_11_FINALv2.pdf.
State Medicaid Directors Association (NASMD)

NASMD a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories).

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules, published in the January 13, 2010 Federal Register. "Eligible Medicaid Providers" (p.9):
The states request that CMS recognize that the Act excludes many relevant and key providers from participating in the incentive program. Specifically, the states argue that community mental health centers and other behavioral health providers, nursing homes, community long-term care providers, and home health care providers should be eligible for incentive payments as they are critical partners in improving the quality and coordination of care for the Medicaid population. The states recognize that this is a statutory issue, but feel strongly that exclusion of these critical providers impacts Medicaid's ability to improve the quality and efficiency of care. The states recommend that CMS allow states and the regional extension centers (RECs) to provide education and training, technical assistance, and infrastructure as relevant to support these excluded providers pursuant to the 90/10 funding. By including these excluded providers in education and training, the states can set the stage for eventually achieving the long-term goal of helping all providers serving Medicaid exchanging data and be meaningful users of EHRs.
Leading Age (formerly known as AAHSA (American Association for Homes and Services for the Aging))

Leading Age 5,800 member organizations, many of which have served their communities for generations, offer the continuum of aging services: adult day services, home health, community services, senior housing, assisted living residences, continuing care retirement communities and nursing homes.

Statement for the Record. Investing in Health IT: A Stimulus for a Healthier America. January 15, 2009 (p.3):
We therefore urge you to include long-term care providers in any incentives you adopt, including direct bonuses, so as to enable long-term providers to prepare their information and communications infrastructure and deploy new technologies, including health IT and interoperable EHR systems, as well as other technologies enabling direct care workers to document their patients' care.

AAHSA Public Policy Priorities 2011 (p.4):
Leading Age supports:

  • Advancement of technology applications in long-term services and supports; and
  • Inclusion of this sector in federal programs to encourage broad use of health information technology.
National Association of Home Care (NAHC)

Home Care Technology Association of America (HCTAA)

HCTAA is a wholly-owned affiliate of the NAHC, and is organized to advance the accessibility and use of technology in home care and hospice settings. HCTAA was established to unite the home care technology industry into a stronger, more effective voice to Congress, the Administration, state legislatures, the home care industry, consumers, and the media. HCTAA believes that home care and hospice providers that are properly equipped with technological solutions will serve a central role in the delivery of health care by ensuring quality, efficiency, and patient care coordination.

NAHC and HCTAA: comments on the definition of "Meaningful Use" of Electronic Health Records (EHR), as required by the American Recovery and Reinvestment Act of 2009" (June 25, 2009):
We specifically would urge the ONCHIT to ensure that:
  • HIE grant funding be made to RHIOs/HIEs emphasize the need to include and support home health care providers to effectively facilitate the electronic exchange of health information across different care settings;
  • Grants and loans be made available to home health care providers to plan for and implement certified, interoperable health IT solutions;
  • Regional Extension Centers provide technical assistance for home health care providers seeking integration into the health information network, in addition to other acute care providers in their regions….

…as we have stated, the goal of care coordination requires the exchange of timely health information among all care providers. This goal cannot be achieved unless it is inclusive of home health care and hospice providers. With appropriate resources for implementation and standardization of EHRs, further steps can be taken by the home care and hospice community to meet the objectives of the meaningful use of EHRs and care coordination.

NAHC/HCTAA comments on the 2011-2015 Federal Health Information Technology Strategic Plan (May 6, 2011):
(p.2)
: It is promising that the RECs will work with the community-based organizations and we hope that if this partnership extends to home care and hospice agencies that we will be able to help the RECs better serve not only underserved and communities of color but also disabled persons. The ONC should advise the 62 Regional Extension Centers across the country to extend their guidance and technical assistance on certified EHR adoption and utilization to ineligible providers, including home care and hospice providers. This strategy would foster a business model for RECs that supports all health care providers and will enable them to operate without federal grant funds beyond 2015.

(p.3): It would also be helpful if the ONC would help educate incentivized providers and hospitals about the benefits of accepting clinical information from home care and hospice providers so that the information they receive from the community is not devalued because it is not ONC Certified. Facilitating the exchange and receipt of health information between physicians, hospitals, and other clinical professionals within the care continuum will help to improve patient care coordination especially for those who are chronically ill.

LTPAC Health IT Collaborative

Collaborative of associations representing health IT issues for LTPAC providers, professionals, and support services in skilled nursing facilities, nursing facilities, assisted living, home health agencies, etc.

Members include:
American Health Care Association, American Health Information Management Association, Home Care Technology Association of America, American Society of Consultant Pharmacists, Center for Aging Services Technology, Leading Age, National Association of Home Care and Hospice, National Association for the Support of Long-Term Care, National Center for Assisted Living, Program for All Inclusive Care for the Elderly

April 16, 2009. Inclusion of Long-Term Care Settings in ARRA Funded Projects Letter to the David Blumenthal (the National HIT Coordinator) (p.2):
We believe that implementing our ARRA recommendations would substantially help ensure that organizations likely to be primary drivers of adoption of standards-based EHRs and facilitators of health information exchange, such as Health Information Exchanges (HIEs), Regional Health Information Organizations (RHIOs) and Regional Health Information Technology Extensions Centers, are inclusive of all provider settings and serve broad and diverse populations, including persons requiring long-term care. Advancing policies that extend interoperable health information exchange and use to support the needs of persons requiring long-term care (including the use of standards for patient assessments) will be necessary to meet the ARRA goal that each person in the U.S. use an EHR by 2014.

June 11, 2009 Health IT Extension Program Comments. Letter to the David Blumenthal (the National HIT Coordinator) (p.1):
Our collaborative has worked to ensure that long-term care is included in the health IT provisions in the American Recovery and Reinvestment Act (ARRA) of 2009 and Health Information technology for Economic and Clinical Health (HITECH) Act. Fully including this substantial sector of the health care community in interoperable electronic health records (EHRs) is critical to reforming the health care system.

The Extension Program includes provisions addressing the unique needs of providers of historically underserved populations including long-term care. In order to achieve the goals of HITECH, Regional Health IT Extension Centers must offer technical assistance to long-term care providers (nursing homes, assisted-living, home health, PACE providers, etc) as a priority group. This technical assistance is essential so that the health care community (both acute and post-cute) become "meaningful users", have the training and support necessary to create and implement the EHR infrastructure and exchange health information across care settings. Technical assistance to achieve meaningful user status will give acute care providers the opportunity to receive incentive payments under Medicare and Medicaid. Technical assistance will enhance long-term care providers' ability to further improve the quality of care for residents. Furthermore, we request that the scope of work for the Regional Health IT Extension Centers require specific inclusion of long-term care providers as stakeholders, partners and an important priority group for receiving direct technical assistance.

Excluding long-term care will slow down the adoption of interoperable EHRs for each person in the U.S. and cause harm to our most vulnerable citizens as they migrate through the health care system with numerous providers during single episodes of care and overtime across multiple episodes of care.

May 6, 2011. LTPAC Health IT Collaborative Public Comments on ONC Federal HIT Strategic Plan 2011-2015.:a
(p.1)
: The LTPAC Health IT Collaborative is very supportive of the goals of this comprehensive strategic plan, and certainly applauds the ONC creating Strategy I.C.3. to support health IT adoption and information exchange in LTPAC, behavioral health, and emergency care settings.

(p.1): … the Collaborative broadly recommends full inclusion of the LTPAC health sector in the Federal Health Information Technology Strategic Plan to improve quality and reduce care disparities through meaningful use and systematic exchange of health information among all providers in all settings."

(pp.2-5): The following comments build on what is contained in the Strategic Plan and further extend it to better meet the needs of the large population that LTPAC serves….

OBJECTIVE I.A: Accelerate adoption of Electronic Health Records (EHR)
STRATEGY I.A.7: Align federal programs and services with the adoption and meaningful use of certified EHR

We applaud the ONC for planning to include methods to encourage providers that are not eligible for the incentive programs such as LTPAC to achieve meaningful use of information technology as well.

OBJECTIVE I.B: Facilitate information exchange to support meaningful use of EHR
Suggest including LTPAC settings with any example of provider settings.

OBJECTIVE I.C: Support health IT adoption and information exchange for public health and populations with unique needs.
STRATEGY I.C.3: Support health IT adoption and information exchange in LTPAC, behavioral health, and emergency care settings.

The Federal Health IT Strategic Plan notes ONC is working with SAMHSA and HRSA to address the policies and standards concerning the unique needs of behavioral health IT adoption and information exchange. The LTPAC Health IT Collaborative supports the inclusion of the unique needs of behavioral health identified in the strategic plan and offers these recommendations below supporting the unique needs of the LTPAC community:

  • Support for effective electronic health information exchange with ALL health professionals involved in delivering LTPAC needs of the consumer including include Home Care services such as Care Management, Private Duty, and Skilled Nursing - and also the personal care needs, infusion, nutrition, rehabilitation, PT, OT, Speech therapy as well as durable medical equipment providers.

OBJECTIVE II.A: Support more sophisticated uses of EHRs and other health IT to improve health system performance.
STRATEGY II.A.1: Identify and implement best practices that use EHRs and other health IT to improve care, efficiency, and population health.

  • Consider enhancing current language to "Clinical decision support (CDS) systems are tools that leverage EHRs to improve clinical processes--ADD NEW--"across ALL venues of care including LTPAC, behavioral health, and emergency care settings".
  • Usability is a critical issue that needs to be addressed in this GOAL so that systems providing clinical decision support provide consistent messaging and alerting across the continuum from acute care to LTPAC.

Notes

  1. American Health Quality Association. Promoting Health Information Technology: the QIO Role (Fact Sheet). http://www.ahqa.org/pub/uploads/FS_HIT.pdf accessed June 1, 2012.

  2. Centers for Medicare and Medicaid Services. Office of Clinical Standards and Quality. 10th SOW Town Hall Meeting (March 28, 2011). http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/Downloads/ 10thSOWSlides.pdf accessed May 14, 2012.

  3. StratisHealth. Health IT. http://www.stratishealth.org/expertise/healthit/index.html accessed June 2, 2012.

  4. H. Westley Clark. SAMHSA Strategic Initiative #6: Health Information Technology, Electronic Health Records and Behavioral Health (draft, October 1, 2010). http://www.samhsa.gov/about/siDocs/healthIT.pdf accessed May 23, 2012.

  5. Illinois Office of Health Information Technology. "Illinois Receives $600,000 to Connect Behavioral Health Community to Illinois Health Information Exchange " (Press release, March 2, 2012). http://www2.illinois.gov/gov/HIE/Documents/BHIP%20News%20Release%203-2-12%20FINAL.pdf access May 25, 2012.

  6. It should be noted the description of these proposals should not be construed as an endorsement of the proposals.

[Return to the Table of Contents]

 

APPENDIX N. ADMINISTRATIVE INFRASTRUCTURE BUILDING PROGRAMS

This appendix provides a program summary of the administrative infrastructure development initiatives. Program highlights are presented in table format followed by a narrative description. During the environmental scan of federal and state initiatives to advance certified EHR technology, a number of programs were funded by government agencies identified that seek to build administrative infrastructure.

A. Program Highlights

Authority and Funder Description Recipient: State Provider Geographic Location Provider Type Impacted Amount
(if known)
  1. See http://www.healthit.gov/system/files/bh-roundtable-findings-report_0.pdf.
  2. See http://www.fcc.gov/encyclopedia/rural-health-care.
  3. See 47 U.S.C. §254(h)(7)(B), available at http://www.gpo.gov/fdsys/pkg/USCODE-2011-title47/pdf/USCODE-2011-title47-chap5-subchapII-partII-sec254.pdf. ("The term ‘health care provider' means: (i) post-secondary educational institutions offering health care instruction, teaching hospitals, and medical schools; (ii) community health centers or health centers providing health care to migrants; (iii) local health departments or agencies; (iv) community mental health centers; (v) not-for-profit hospitals; (vi) rural health clinics; and (vii) consortia of health care providers consisting of one or more entities described in clauses (i) through (vi).")
  4. FCC Rural Health Care, http://www.fcc.gov/encyclopedia/rural-health-care.
ONC Standards & Inter-operability Framework The Standards and Interoperability (S&I) Framework is an ONC-sponsored public-private collaborative. The primary focus of the S&I Framework has been to identify interoperable health IT standards for the EHR MU Programs for EPs and EHs.     Longitudinal Coordination of Care Initiatives support LTPAC use cases.

Data Segmentation Initiative supports Behavioral Health use cases

 
SAMHSA $3.2-million per year, 5-year contract to develop BH clinical data standards and to develop and pilot test advanced functionality for behavioral health related health IT. States, Territories & other government jurisdictions   Providers that treat safety net populations

All providers

Nationwide
2041 of the Social Security Act, as added by section 6703 of the Affordable Care Act

Sec. 2041(c) Enhancements of Long-Term Care: Adoption of Standards for Transactions Involving Clinical Data by Long-Term Care Facilities

The Secretary shall adopt electronic standards for the exchange of clinical data by long-term care facilities, including, where available, standards for messaging and nomenclature. Standards adopted by the Secretary shall be compatible with standards established under Part C of Title XI, standards established under subsections (b)(2)(B)(i) and (e)(4) of section 1860D-4, standards adopted under section 3004 of the Public Health Service Act, and general health information technology standards.       Funds were authorized but not appropriated
LTPAC Stakeholder Roundtablea An ONC contractor hosted an LTPAC Stakeholder Roundtable on Voluntary Certification Program and health IT standards.     LTPAC Providers  
SAMHSA, HRSA, ONC Behavioral Health Data Exchange Consortium The Behavioral Health Data Exchange Consortium was created to pilot the interstate exchange of behavioral health treatment records among treating health care providers using the Nationwide Health Information Direct protocols. The project involves the creation of draft Policies and Procedures (P&P) for exchange of behavioral health treatment records. The pilot is intent on meeting the requirements of federal regulations at 42 CFR Part 2 and participating state mental health laws. State Participating States:
  • AL
  • FL
  • KY
  • NM
  • NE
  • MI
Behavioral Providers $600,000
FCC Healthcare Connect Fund, and Skilled Nursing Facility Pilot Programb The FCC provides support for broadband connectivity to certain qualifying health care providersc,d (such as community mental health centers) in rural areas, and in some cases urban areas. The FCC's Rural Health Care (RHC) Programs include the Healthcare Connect Fund and the Skilled Nursing Facilities Pilot Program. Through these programs, the FCC makes available broadband connectivity at highly discounted rates. Certain health care providers. Health care providers in rural areas, and in some cases urban areas. BH (CMHCs) LTPAC (SNFs) Broadband connectivity at highly discounted rates.

B. Program Summaries

ONC Standards & Interoperability (S&I) Framework

ONC is sponsoring work to extend the interoperable health IT infrastructure to support the exchange and re-use of health information needed to provide services to medically complex and functionally impaired individuals, including persons who receive services by EPs, EHs, and non-eligible providers (such as LTPAC and BH providers). The CMS EHR Incentive Program -- Stage 21 final rule includes requirements to provide a summary care record at transitions in care, including when such transitions are to providers who are not eligible for EHR incentives. To address the need for standards to support sharing of information between eligible and ineligible providers, the ONC rule on Standards, Implementation Specification, and Certification Criteria for EHR Technology, 2014 Edition2 provides a perspective on the priority areas for standards pertaining to ineligible providers:

"We agree that it makes good policy sense to support interoperability and the secure electronic exchange of health information between all health care settings. We believe the adoption of EHR technology certified to a minimal amount of certification criteria adopted by the Secretary can support this goal. To this end, we encourage EHR technology developers to certify EHR Modules to the transitions of care certification criteria (§170.314(b)(1) and (2)) as well as any other certification criteria that may make it more effective and efficient for EPs, EHs, and CAHs to electronically exchange health information with health care providers in other health care settings. The adoption of EHR technology certified to these certification criteria can facilitate the secure electronic exchange of health information."

The Standards and Interoperability (S&I) Framework is an ONC sponsored public-private collaborative. The primary focus of the S&I Framework has been to identify interoperable health IT standards for the EHR MU Programs for EPs and EHs. Working in collaboration with HL7, the S&I Framework advanced health IT standards that were named in the final ONC and CMS Stage 2 EHR MU rule, including standards for functional and cognitive status and pressure ulcer (these data element standards are included in the HL7 Consolidated CDA (C-CDA) which supports interoperable exchange of Summary of Care Records).

The S&I Longitudinal Coordination of Care (LCC) Workgroup (WG), in collaboration with HL7, has advanced standards to support the interoperable exchange of functional and cognitive status, and pressure ulcer content, LTPAC summary documents and patient assessment documents. The C-CDA (referenced in the EHR certification criteria and standards for the Stage 2 EHR Incentive program) includes standards for functional and cognitive status, and the LTPAC Summary Documents.

In addition, the S&I LCC WG is working to identify concepts and standards that could be included in Stage 3 of the EHR Incentive Program to enable the exchange of more comprehensive summary documents to support transitions of care and shared cared on behalf of medically complex and functionally impaired persons. In addition, the S&I LCC WG is also working to advance standards that could be included in Stage 3 of the EHR Incentive Program for the interoperable exchange of care plans, including the home health plan of care.

S&I Framework activities are also addressing an issue of critical importance to the behavioral health community for the secure exchange of health information -- specifically, data segmentation for privacy. Consensus use cases involve patients in inpatient Alcohol and Drug Abuse Treatment Programs (ADATP) to focus on patient information covered by 42 CFR Part 2 that cannot be disclosed without patient consent. The initiative is expected to be completed September 2012.3

SAMHSA/CSAT Open Behavioral Health Information Technology Architecture (OBHITA)

The OBHITA contract supports the development of both data standards for behavioral health and HIT tools for advanced behavioral health care. The Reference Electronic Health Record Model (REM) EHR application is a sub-project of OBHITA that provides a platform to develop and pilot test advanced functionality for behavioral health care needs. The intent of this project is to develop standards based, open source modules, components and services that can be reused by existing EHRs and other health IT systems. These open source tools will then be made available for use and adaptation by the entire behavioral health and health care communities. Our current efforts are focused on developing an access control service tool that will support data segmentation and granular consent management for electronic health information exchange compliant with federal health information privacy regulations (42 CFR Part 2). SAMHSA is partnering with ONC and the Veterans Administration (VA) in this effort. SAMSHA's investment in the REM system provides a unique platform for quickly and agilely developing and testing functionality to support new models of health care including health homes.

Federal Communications Commission

Healthcare Connect Fund4

In December 2012, the Federal Communications Commission (Commission or FCC) created the Healthcare Connect Fund to support state or regional broadband health care networks designed to bring the benefits of telehealth and telemedicine services to areas of the country where the need for those benefits is most acute.

The program provides a 65 percent discount on high-capacity broadband connectivity to both individual rural health care providers (HCPs) and to consortia of HCPs that have a majority of rural sites. Consortia may also obtain support for upfront charges under the Healthcare Connect Fund, which may include support for service provider deployment of new or upgraded facilities or for HCP-owned network facilities, if shown to be the most cost-effective option. Funding under the Healthcare Connect Fund will be available to all qualifying applicants starting January 1, 2014.

The Commission designed the Healthcare Connect Fund based on its experience with its RHC Pilot Program (established in 2006; closed to new applicants), where broadband health care provider networks were shown to reduce the cost and improve the quality of health care. The Pilot Program consists of 50 statewide or regional health care networks that provide broadband connectivity to roughly 3,800 HCP sites. With the necessary broadband connectivity, the Pilot Program participants were able to implement telemedicine and telehealth applications to help improve the quality of health care delivered to patients in rural areas, generate savings in the cost of providing health care, and reduce the time and expense associated with travel to distant locations to receive or provide care.

Pilot projects have already demonstrated how broadband health care networks can significantly improve the quality and reduce the cost of providing health care in rural areas. For example: the Palmetto State Providers Network, located in South Carolina, reports that it saved $18 million dollars in Medicaid costs over 18 months as a result of its telepsychiatryprogram. Psychiatric consults are now available 24/7. Previously, patients would wait for days to receive psychiatric consults.

Based on the success of the Pilot Program, the FCC established the Healthcare Connect Fund to further encourage access and use of broadband by networks and individual HCPs.

Skilled Nursing Facility Pilot Program

The FCC is also creating a Skilled Nursing Facility (SNF) Pilot Program to test how to support broadband connections to SNFs. SNFs are particularly well-suited to improve patient outcomes through greater use of broadband. By their nature, they are often remote from doctors and sophisticated laboratory and testing facilities, making the availability of EHRs and telehealth an especially valuable benefit to patients for whom traveling to see a doctor, diagnostician, or specialist would be especially difficult.

The SNF Pilot will focus on determining how to best utilize program support to assist SNFs that are using broadband connectivity to work with other health care providers (eligible for the FCC program) to optimize care for patients in SNFs through the use of EHRs, telemedicine, and other broadband-enabled health care applications. The pilot will provide up to $50 million in funding, over a three-year period, for discounted broadband connectivity. At the conclusion of the SNF Pilot, participants must demonstrate the health care cost savings and/or improved quality of patient care that they have realized through use of broadband, which should enable the Commission to gain experience and information that would allow it to determine whether such funding could be provided on a permanent basis.

The FCC is seeking input from government agencies and other stakeholders regarding the design of the pilot program, including the scoring criteria to be used to evaluate applications. The Commission expects to implement the program during Funding Year 2014.

C. Proposals to Extend the Interoperable Health IT Infrastructure and EHRs for Ineligible Providers

The following table identifies some proposals from some stakeholders regarding the need to extend the health IT infrastructure EHR certification to support interoperable exchange of health information on behalf of persons treated by ineligible provider types, such as LTPAC, and behavioral health providers. This summary is not intended to be a complete list of options that have been proposed. Rather the list serves to highlights some of the suggestions by some stakeholders regarding the need for infrastructure/EHR requirements for ineligible providers. Further, this list is not intended as endorsement of any one of these options. Instead, the summary serves only to list some of the proposals regarding the health IT/EHR infrastructure that could support the use of EHR technology by ineligible providers. The text in the table below quotes from the referenced documents.

Stakeholder Group Source and Statement of Proposed Action
  1. See http://www.ltpachealthit.org/system/files/MU%20Comments%20March%202010%20v4%205%20%284%29.pdf.
  2. See http://www.ltpachealthit.org/system/files/LTPAC%20HIT%20Collaborative%20Comments%20on%20ONC%20Federal% 20HIT%20Strategic%20Plan%205_9_11_FINALv2.pdf.
State Medicaid Directors Association (NASMD)

NASMD a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories).

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules, published in the January 13, 2010 Federal Register. "GUIDING PRINCIPLES"(p.3):
  1. The provider incentive program should ensure that we are not creating a two tiered system in which Medicaid is not fully integrated into the improved care delivery system enabled through this initiative….
  1. The provider incentive program should foster EHR adoption and meaningful use among eligible Medicaid providers pursuant to the NPRM, and strive towards including non-eligible providers that are critical to improve the quality and value of the Medicaid program, such as long-term care and behavioral health providers.
American Medical Directors Association (AMDA)

AMDA represents approximately 5,200 medical directors, attending physicians, and others who practice in the long-term care continuum.

AMDA-comments on the proposed rule Medicare and Medicaid Programs; Electronic Health Records Incentive Program--Stage 2.(p.1):
While the proposed rule does not preclude long term care physicians from adopting health information systems to achieve meaningful use, AMDA encourages the Centers for Medicare and Medicaid Services (CMS) to include language that supports and encourages adoption of electronic health records (EHR) in LTPAC. … To meet nationally stated goals of: (a) improving quality, safety, efficiency, and reduce health disparities; (b) improving care coordination; and (c) engaging patients and families, the health care team caring for a patient/resident must be able to electronically exchange meaningful clinical information throughout the entire spectrum of care, which includes LTPAC.
LeadingAge (formerly known as AAHSA (American Association for Homes and Services for the Aging))

LeadingAge 5,800 member organizations, many of which have served their communities for generations, offer the continuum of aging services: adult day services, home health, community services, senior housing, assisted living residences, continuing care retirement communities and nursing homes.

AAHSA Public Policy Priorities 2008 (pp.8-9):
One thing is clear: Technology will make a tremendous difference in quality and cost …

We therefore will advocate for:… Creating and standardizing private, and portable Personal and Electronic Health Records, which take into account the unique requirements of aging services, to be available to every senior (or citizen) in America to ensure continuity of information, continuity of care, reduced unnecessary interventions and errors, and increased ownership of one's medical history.

Statement for the Record. Investing in Health IT: A Stimulus for a Healthier America. January 15, 2009 (p.3):
We therefore urge you to include long-term care providers in any incentives you adopt, including direct bonuses, so as to enable long-term providers to prepare their information and communications infrastructure and deploy new technologies, including health IT and interoperable EHR systems, as well as other technologies enabling direct care workers to document their patients' care.

Secondly, we urge that any data collection by the Centers for Medicare and Medicaid Services be through interoperable systems. We will not be able to achieve the goal of interoperability by 2014 if data collection in long-term care is done through a proprietary format, as CMS plans to do with the new MDS 3.0. This will inevitably set back the efforts to integrate long-term care data collection with the rest of the health care system and ultimately increase cost of making all systems interoperable by 2014….

Such health IT infrastructure and EHR systems, that are interoperable across provider settings, ensure the continuity of information, and thus the continuity of care, and can lead to reducing medical errors, duplicative procedures and expenditures, while improving care quality, especially for the aging population.

AAHSA Public Policy Priorities 2010 (p.11):
AAHSA supports

  • Standards for electronic health records (EHR) that include long-term services and supports. Pilot projects for EHR technology should be on-going in aging services…

AAHSA Public Policy Priorities 2011 (p.4):
LeadingAge supports

  • Advancement of technology applications in long-term services and supports; and
  • Inclusion of this sector in federal programs to encourage broad use of health IT.

Financing (p.6):
Financing aging services also requires support for infrastructure, including access to capital for construction and improvements that add value and cost-saving efficiency, such as technology.

The Affordable Care Act provides for a number of exciting opportunities to better integrate acute and post-acute care services through collaboration among a variety of health care providers. This kind of collaboration will require extensive data sharing to ensure continuity and quality of services. Data collection and sharing, in turn, will absolutely depend on the use of health IT.

LeadingAge supports:
Standards for electronic health records (EHR) that include long-term services and supports. Pilot projects for EHR technology should be on-going in aging services…

Centers for Aging Services Technology, Homecare Technology Association of America (CAST)

CAST is leading the charge to expedite the development, evaluation and adoption of emerging technologies that can improve the aging experience. CAST has become an international coalition of more than 400 technology companies, aging services organizations, research universities, and government representatives.

"IMPEDIMENTS TO THE ROLL-OUT OF INFORMATION TECHNOLOGY HEALTH CARE STRATEGIES (pp.1-2):
Interoperable Electronic Health Records (EHR) & Personal Health Records (PHR) in Long-Term Care. The development of interoperable electronic health record and personal health records is critical to the success of technology implementation. We support the national initiatives to develop EHRs and encourage work on PHRs. These activities form the foundation for the future vision of how networked health care systems will operate between older adults, caregivers, family members and health care providers. … Key to maximizing the benefits of such networked health care system is the inclusion of long-term care settings, such as assisted living, skilled nursing, home health, home care and specialty services providers … [and] necessitates that the standards for such electronic record systems take into account the requirements of the long-term care providers, including functional assessment data and patient summaries, to allow the electronic exchange of critical health information among different care providers, including long-term care providers. Lack of interoperability is one of the important barriers to the adoption of these technologies…

More incentives, in the form of grants, tax-credits and low-interest loans, are needed to enable long-term providers to prepare their information and communications infrastructure and deploy new technologies, including health IT and interoperable EHR systems, and other technologies including technologies for care documentation by direct care workers that improve the quality of care. Such health IT infrastructure and EHR systems, that are interoperable across provider settings, ensure the continuity of information, and thus the continuity of care, and can lead to reducing medical errors, duplicative procedures and expenditures, while improving care quality, especially for the aging population.

National Association of Home Care (NAHC)

Home Care Technology Association of America (HCTAA)

HCTAA is a wholly-owned affiliate of the NAHC, and is organized to advance the accessibility and use of technology in home care and hospice settings. HCTAA was established to unite the home care technology industry into a stronger, more effective voice to Congress, the Administration, state legislatures, the home care industry, consumers, and the media. HCTAA believes that home care and hospice providers that are properly equipped with technological solutions will serve a central role in the delivery of health care by ensuring quality, efficiency, and patient care coordination.

NAHC and HCTAA: comments on the definition of "Meaningful Use" of Electronic Health Records (EHR), as required by the American Recovery and Reinvestment Act of 2009" (June 25, 2009):
We specifically would urge the ONCHIT to ensure that:
  • Grants and loans be made available to home health care providers to plan for and implement certified, interoperable HIT solutions; …
  • CMS adopts HITSP-accepted interoperability standards as it goes forward with new patient assessment requirements for home health agencies and other provider settings to accelerate the adoption and use of interoperable EHRs by these providers;…

…as we have stated, the goal of care coordination requires the exchange of timely health information among all care providers. This goal cannot be achieved unless it is inclusive of home health care and hospice providers. With appropriate resources for implementation and standardization of EHRs, further steps can be taken by the home care and hospice community to meet the objectives of the meaningful use of EHRs and care coordination.

NAHC and HCTAA comments on the proposed rule to define the "meaningful use" of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs (March 15, 2010) (pp.1-2):

  • Consider that the standards for Certified EHR technologies and the means by which EPs and eligible hospitals demonstrate meaningful use should work for all provider types; including home health care and hospice to ensure the maximization of the functionality of EHRs.
  • Recognize that standards for improved care coordination and the exchange of meaningful clinical information among the professional health care team should involve all health care provider types (including health care professionals who are defined within the scope of home health care service providers, such as: physician assistants, nurse practitioners, registered nurses, physical therapist, and clinicians).

NAHC/HCTAA comments on the 2011-2015 Federal Health Information Technology Strategic Plan (May 6, 2011) (pp.2-3):
The ONC needs to recognize that establishing a criteria and process to certify EHR technologies for hospitals and eligible providers has created a trajectory that must be adhered to by all providers, even those that are non-incentivized, if they want to be able to participate in the capture and exchange of health information. The ONC should link the goals … to provide support and build awareness of not only ONC-ATCB Certified EHRs but also other certified EHRs, such as the CCHIT Certified EHR home health add-on, that is interoperable with the federal standards. Currently, the vendor community is not developing the home health add-on because there is no federal government support or financial incentives attributed to the home care end user.

LTPAC Health IT Collaborative

Collaborative of associations representing HIT issues for LTPAC providers, professionals, and support services in skilled nursing facilities, nursing facilities, assisted living, home health agencies, etc.

Members include:
American Health Care Association, American Health Information Management Association, Home Care Technology Association of America, American Society of Consultant Pharmacists, Center for Aging Services Technology, Leading Age, National Association of Home Care and Hospice, National Association for the Support of Long-Term Care, National Center for Assisted Living, Program for All Inclusive Care for the Elderly

April 16, 2009. Inclusion of Long-Term Care Settings in ARRA Funded Projects Letter to the David Blumenthal (the National Health IT Coordinator):
We believe that implementing our ARRA recommendations would substantially help ensure that organizations likely to be primary drivers of adoption of standards-based EHRs and facilitators of health information exchange, such as Health Information Exchanges (HIEs), Regional Health Information Organizations (RHIOs) and Regional Health Information Technology Extensions Centers, are inclusive of all provider settings and serve broad and diverse populations, including persons requiring long-term care. Advancing policies that extend interoperable health information exchange and use to support the needs of persons requiring long-term care (including the use of standards for patient assessments) will be necessary to meet the ARRA goal that each person in the U.S. use an EHR by 2014.

June 11, 2009 Health IT Extension Program Comments. Letter to the David Blumenthal (the National Health IT Coordinator) (p.1):
Excluding long-term care will slow down the adoption of interoperable EHRs for each person in the U.S. and cause harm to our most vulnerable citizens as they migrate through the health care system with numerous providers during single episodes of care and overtime across multiple episodes of care.

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules.
This rule proposes to define the "meaningful use" of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs.a

LTPAC Recommendations on "Meaningful Use" (pp.1-2):

  • Consider that the Certified EHRs technologies approved for use by EPs and eligible hospitals must be measured by their ability to successfully send and receive standards-based patient summary records and clinical information and share them with all health care providers types (including skilled nursing facilities, nursing facilities, home health, etc.) as defined by the HITECH Act.
  • Recognize that the standards of meaningful use of Certified EHRs for 2013 must, at a minimum, include a defined standard for the transfer of care documentation between all providers as defined by Section 3000(3) of the HITECH Act. The recommendation of the LTPAC is for this to be addressed in 2011 rulemaking so that the industry has sufficient time to implement these standards and support meaningful use Stage 2.
  • Recognize that improved care coordination and the exchange of meaningful clinical information among the professional health care team should involve all health care provider types and that demonstration projects should be devised to demonstrate the exchange of meaningful clinical information between EPs, eligible hospitals and LTPAC providers.

January 18, 2011. President's Council of Advisors on Science and Technology "Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward" Letter to ONC.
(pp.1-2): The report urges the Centers for Medicare and Medicaid Services (CMS) to focus on increasing health information exchange and to exercise its' influence as a major payer to drive health information exchange. While currently long-term care providers are not eligible for Meaningful Use incentives for adoption of a certified electronic health record under ARRA-HITECH, CMS could leverage federally mandated LTPAC functional status assessments (such as MDS, OASIS and IRF-PAI) to accelerate the adoption of interoperable EHRs in this sector and increase the exchange of health information across health care provider settings. ONC should also support the creation of health data exchange programs that target and engage LTPAC providers.

(p.2): We strongly support the recommendation that CMS modernize their information systems and develop a strategy to use technology and standards that are consistent with the rest of the health care industry to leverage their influence and advance health information exchange activities for clinical, administrative, public health and research purposes and not deploy information technology requirements that only fit CMS business processes.

May 6, 2011. LTPAC Health IT Collaborative Public Comments on ONC Federal Health IT Strategic Plan 2011-2015.b (pp.2-5):
The following comments build on what is contained in the Strategic Plan and further extend it to better meet the needs of the large population that LTPAC serves….

OBJECTIVE I.A: Accelerate adoption of Electronic Health Records (EHR).
STRATEGY I.A.7: Align federal programs and services with the adoption and meaningful use of certified EHR
.
We applaud the ONC for planning to include methods to encourage providers that are not eligible for the incentive programs such as post acute and long term care to achieve meaningful use of IT as well.

OBJECTIVE I.B: Facilitate information exchange to support meaningful use of EHR.
Suggest including long-term and post-acute care settings" with any example of provider settings.

STRATEGY I.B.I: Foster Business models that create health information exchange.

  • Health Information Exchange strategies include the LTPAC community.
  • The ONC Direct engages a variety of providers in Health Information Exchange. Ensure that LTPAC providers are included in Direct Projects…
  • It is not readily apparent in the Strategic Plan that LTPAC is part of the Direct Project.

OBJECTIVE I.C: Support health IT adoption and information exchange for public health and populations with unique needs.
STRATEGY I.C.3: Support health IT adoption and information exchange in LTPAC, behavioral health, and emergency care settings
.
The Federal Health IT Strategic Plan notes ONC is working with SAMHSA and HRSA to address the policies and standards concerning the unique needs of behavioral health IT adoption and information exchange. The LTPAC Health IT Collaborative supports the inclusion of the unique needs of behavioral health identified in the strategic plan and offers these recommendations below supporting the unique needs of the LTPAC community:

  • Policies, standards, and incentives for vital links between health care providers to be encouraged to accelerate the care process outside current settings being incentivized [eligible hospitals, CAH, eligible professionals].
  • Policies, standards, and incentives to provide sustained effective care for the large numbers of vulnerable populations in settings outside acute systems.
  • Policies, standards, and incentives to develop communication between providers eligible for EHR incentive payments to establish and maintain connections supporting data exchange with those outside agencies who are NOT EHR incentive payment eligible to support consumer centric care across the continuum that includes the longitudinal care planning being discussed by Health IT Policy Committee for inclusion in the future stages of Meaningful Use.
  • Support for effective electronic health information exchange with ALL health professionals involved in delivering LTPAC needs of the consumer including Home Care services such as Care Management, Private Duty, and Skilled Nursing--and also the personal care needs, infusion, nutrition, rehabilitation, PT, OT, Speech therapy as well as durable medical equipment providers.
  • Support for Longitudinal assessments across the continuum which identify the patient's story. …
  • Health information exchange from LTPAC facilities to hospitals and vice versa to facilitate better transitions to meet unique needs.
  • Support for services or service delivery structure to the current EHR that provide a means to track unique needs of patients transitioning between settings. This includes patient care services--not just medical decision making.
  • Support for the concept of a problem that is not disease specific or a medical problem; examples of other issues that need to be addressed include transportation, personal care, activities of daily living (ADLs), financial issues which are barriers to sustained effective care beyond acute care and often result in hospitalizations, re-hospitalizations and greater medical costs.
  • Support for health care delivery for of ALL levels of care and prevention--not just support for traditional health care delivery episodes of care "check in to check out" or "admission to discharge".

OBJECTIVE II.A: Support more sophisticated uses of EHRs and other health IT to improve health system performance.
STRATEGY II.A.1: Identify and implement best practices that use EHRs and other health IT to improve care, efficiency, and population health
.
Usability is a critical issue that needs to be addressed in this GOAL so that systems providing clinical decision support provide consistent messaging and alerting across the continuum from acute care to LTPAC.

OBJECTIVE II.D: Support new approaches to the use of health IT in research, public and population health, and national health security.
STRATEGY II.D.1: Establish new approaches to and identify ways health IT can support national prevention, health promotion, public health, and national health security
.

  • Support for a link between quality and core processes important across the continuum which include medication reconciliation, care transitions, change of condition, and risk identification.
  • Support for health records associated with the longitudinal care plan and outcomes of care in various care settings that capture the essence of an individual's life in the community which are vital to the continuum of care. A more specific plan should be included for including these records in the near term meaningful use plans. This is particularly important for populations served by LTPAC.
  • Support for family histories which are a vital and rich part of the longitudinal care plan and unique assessment of the nursing home and LTPAC environment.

Notes

  1. See http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf.

  2. See http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf.

  3. S&I Framework. Data Segmentation for Privacy Use Cases. http://wiki.siframework.org/Data+Segmentation+for+Privacy+Use+Cases accessed June 2, 2012.

  4. See http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-12-150A1.pdf.

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APPENDIX O. ANTI-KICKBACK STATUTE EHR SAFE HARBOR REGULATION

This appendix provides a summary of the anti-kickback statute EHR safe harbor regulation, which is available to many providers, including certain ineligible providers. Below is an overview of the anti-kickback statute EHR safe harbor and its applicability to providers not eligible for the EHR Incentive Programs, followed by a table containing the safe harbor regulatory text. At the time this report was written, we were unable to identify any ineligible providers that received donations via arrangements protected by the EHR safe harbor. The last section of the appendix identifies a proposal advanced by two stakeholder groups to extend the anti-kickback statute EHR safe harbor.

Overview of Anti-Kickback Statute EHR Safe Harbor and Possible Donations to Providers Ineligible for the EHR Incentive Programs

HITECH and Health Care Reform create a key business imperative for EHs and EPs to partner with LTPAC providers to support HIE. Depending on the particular facts, certain arrangements between such parties may implicate the anti-kickback statute. In order to have assurances that their arrangements will not be subject to liability under this law, parties may seek to structure their arrangements to fit within a the safe harbor.1 To encourage the adoption of electronic health records technology consistent with the ultimate goal of achieving fully interoperable electronic health records for all patients, the Office of Inspector General (OIG) promulgated (August 2006) a safe harbor to the anti-kickback statute for certain arrangements involving the donation of interoperable EHR software or information technology and training services. See Table O1. Refer to: AKS: 42 CFR 1001.952(y).

The EHR safe harbor protects arrangements under which certain individuals and entities make donations (and cover up to 85 percent of cost) of EHR software or information technology and training services to health care providers (including those who are not eligible for the EHR Incentive Programs) if certain conditions are met (see Table O1). For example, a Medicare hospital could donate EHR software and training services to a nursing home, covering 85 percent of the cost, and receive safe harbor protection if all of the safe harbor conditions are met. Per regulation (see Table O1), the safe harbor requires that donated software be "interoperable" and provides that such software will be "deemed to be interoperable if a certifying body recognized by the Secretary has certified the software no more than 12 months prior to the date it is provided to the recipient."  The safe harbor is scheduled to sunset at the end of 2013.

NOTE: There are many important conditions in the EHR safe harbor, all of which MUST be met in order to receive protection. Those seeking to avail themselves of protection under this safe harbor should consult their legal counsel.

Proposals to Extend the Anti-Kickback Statute EHR Safe Harbor

The National Association for Home Care and Hospice (NAHC) asserts that the delivery of quality home health care and hospice services is very dependent upon the collaboration and exchange of health information across the continuum of care with physician and hospital systems. NAHC and its affiliated technology association, the Home Care Technology Association of America (HCTAA) have described their interest in strengthening the relationships of home health care agencies to both receive technologies from hospitals and other groups as well as to provide EHR technologies and services to physician partners under the EHR Safe Harbor provision. Towards that end, NAHC and HCTA have described:2

  • Described the need to extend the safe harbor provision that is scheduled to expire on December 31, 2013, and suggested aligning the EHR Safe Harbor provision with the EHR Incentive Programs to further encourage adoption of Certified Electronic Health Records by physicians.
  • Requested clarification regarding how the EHR Safe Harbor provision protects "other health care providers".
TABLE O1. Anti-Kickback Statute EHR Safe Harbor 42 CFR Sec. 1001.952(y)
Note to paragraph (y): For purposes of paragraph (y) of this section, health planshall have the meaning set forth at §1001.952(l)(2); interoperableshall mean able to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks, in various settings, and exchange data such that the clinical or operational purpose and meaning of the data are preserved and unaltered; and electronic health recordshall mean a repository of consumer health status information in computer processable form used for clinical diagnosis and treatment for a broad array of clinical conditions.
Electronic health records items and services.As used in section 1128B of the Act, "remuneration" does not include nonmonetary remuneration (consisting of items and services in the form of software or information technology and training services) necessary and used predominantly to create, maintain, transmit, or receive electronic health records, if all of the following conditions are met:
  1. The items and services are provided to an individual or entity engaged in the delivery of health care by-- (i)An individual or entity that provides services covered by a federal health care program and submits claims or requests for payment, either directly or through reassignment, to the federal health care program; or (ii)A health plan.
  1. The software is interoperable at the time it is provided to the recipient. For purposes of this subparagraph, software is deemed to be interoperable if a certifying body recognized by the Secretary has certified the software within no more than 12 months prior to the date it is provided to the recipient.
  1. The donor (or any person on the donor's behalf) does not take any action to limit or restrict the use, compatibility, or interoperability of the items or services with other electronic prescribing or electronic health records systems.
  1. Neither the recipient nor the recipient's practice (or any affiliated individual or entity) makes the receipt of items or services, or the amount or nature of the items or services, a condition of doing business with the donor.
  1. Neither the eligibility of a recipient for the items or services, nor the amount or nature of the items or services, is determined in a manner that directly takes into account the volume or value of referrals or other business generated between the parties. For the purposes of this paragraph (y)(5), the determination is deemed not to directly take into account the volume or value of referrals or other business generated between the parties if any one of the following conditions is met:
    1. The determination is based on the total number of prescriptions written by the recipient (but not the volume or value of prescriptions dispensed or paid by the donor or billed to a federal health care program);
    2. The determination is based on the size of the recipient's medical practice (for example, total patients, total patient encounters, or total relative value units);
    3. The determination is based on the total number of hours that the recipient practices medicine;
    4. The determination is based on the recipient's overall use of automated technology in his or her medical practice (without specific reference to the use of technology in connection with referrals made to the donor);
    5. The determination is based on whether the recipient is a member of the donor's medical staff, if the donor has a formal medical staff;
    6. The determination is based on the level of uncompensated care provided by the recipient; or
    7. The determination is made in any reasonable and verifiable manner that does not directly take into account the volume or value of referrals or other business generated between the parties.
  1. The arrangement is set forth in a written agreement that--
    1. Is signed by the parties;
    2. Specifies the items and services being provided, the donor's cost of those items and services, and the amount of the recipient's contribution; and
    3. Covers all of the electronic health records items and services to be provided by the donor (or any affiliate). This requirement will be met if all separate agreements between the donor (and affiliated parties) and the recipient incorporate each other by reference or if they cross-reference a master list of agreements that is maintained and updated centrally and is available for review by the Secretary upon request. The master list should be maintained in a manner that preserves the historical record of agreements.
  1. The donor does not have actual knowledge of, and does not act in reckless disregard or deliberate ignorance of, the fact that the recipient possesses or has obtained items or services equivalent to those provided by the donor.
  1. For items or services that are of the type that can be used for any patient without regard to payor status, the donor does not restrict, or take any action to limit, the recipient's right or ability to use the items or services for any patient.
  1. The items and services do not include staffing of the recipient's office and are not used primarily to conduct personal business or business unrelated to the recipient's clinical practice or clinical operations.
  1. The electronic health records software contains electronic prescribing capability, either through an electronic prescribing component or the ability to interface with the recipient's existing electronic prescribing system, that meets the applicable standards under Medicare Part D at the time the items and services are provided.
  1. Before receipt of the items and services, the recipient pays 15% of the donor's cost for the items and services. The donor (or any affiliated individual or entity) does not finance the recipient's payment or loan funds to be used by the recipient to pay for the items and services.
  1. The donor does not shift the costs of the items or services to any federal health care program.
  1. The transfer of the items and services occurs, and all conditions in this paragraph (y) have been satisfied, on or before December 31, 2013.

Notes

  1. 42 CFR Sec. 1001.952. http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol5/pdf/CFR-2010-title42-vol5-sec1001-952.pdf.

  2. HCTA Comment Letter EHR Safe Harbor: February 26, 2013. https://www.nahc.org/assets/1/7/4_HCTAA_SafeHarborProvisionsEHRs.docx.

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APPENDIX P. PRIVATE SECTOR PROGRAMS TO ADVANCE CERTIFIED EHR TECHNOLOGY

This appendix provides a summary of the private sector programs that were identified to advance the use of health IT/EHRs. Program highlights are presented in table format followed by a narrative description. During the environmental scan of federal and state initiatives to advance certified EHR technology, a number of private sector programs were identified. This table captures the programs that we identified, but should not be considered exhaustive since we did not conduct a targeted review of private sector initiatives.

A. Program Highlights

Authority and Funder Description Recipient: State Provider Used and Geographic Location Provider Type Impacted Amount
(if known)
  1. See http://www.itriagehealth.com/.
  2. See http://www.chadis.com/ accessed May 16, 2012.
  3. See http://innovation.cms.gov/initiatives/Strong-Start/index.html.
  4. See http://innovation.cms.gov/initiatives/strong-start/what-you-can-do-to-help.html.
Private Sector:
HealthBridge
HealthBridge, an HIE organization, is working to address transitions in care (hospital to home or another facility, etc.) and continuity of care initiatives including EHR to EHR, EHR to HIE, and EHR to registry. A participant in the ONC Connect Project, they are also connecting care providers from hospitals to some of the nursing home health agencies. Provider KY, OH and IN HIE, Hospitals, Nursing Homes  
Private Payor:
Aetna and UnitedHealth Group
Aetna's iTriagea helps users figure out what condition they might have and, using their device's GPS capabilities, points them in the direction of appropriate medical care.

United Healthcare members carry advanced magnetic Providers stripe and bar code ID Cards which can greatly reduce transaction errors by minimizing the hand-keying of member information on most "enrollee number" searches.

All Nationwide All Providers  
Private Sector:
Multiple sources including a Small Business Initiated Research (SBIR) award from NICHD: resources.b
Child Health and Development Interactive System (CHADIS) which is a web-based screening, diagnostic and management system that provides physicians with instant access to clinical data. It incorporates all American Academy of Pediatrics (AAP), "Bright Futures" and Medicaid guidelines for preventive education and screening for child well care visits. Physicians can select from over 100 screening questionnaires in CHADIS and they automatically see a screen that reflects the child's age and the appropriate routine child health information for each visit Provider Pediatric practices in 37 states Clinical Practices In MD, a state pilot project for autism that was credited with savings MD approximately $880,000 compared with MD's standard screening process.
Private Sector:
March of Dimes, American College of OB/GYNs, Association of Women's Health, Obstetric and Neonatal Nurses, Text4Baby, and other advocacy and professional organizations with CMS
Strong Startc: A "toolkit"d that allows health care providers to access patient safety checklists, participate in quality improvement initiatives and share information with expectant mothers and families. Patient and community-based organizations can also share the online resources with patients and provider. Provider Nationwide Health care providers and community-based organizations Nationwide

B. Program Summary

HealthBridge1

HealthBridge is working in Kentucky, Ohio and Indiana2 to address transitions in care (hospital to home or another facility, etc.) and continuity of care initiatives including EHR to EHR, EHR to HIE, and EHR to registry. A participant in the ONC Connect Project, they are also connecting care providers from hospitals to some of the nursing home health agencies.

CONNECT is a free, open source software solution that supports health information exchange, locally and at the national level. CONNECT uses Nationwide Health Information Network standards, services, and policies to make sure health information exchange organizations are compatible with other exchanges being set up throughout the country. CONNECT, available free to all organizations, can be used to help set up health information exchange and share data using nationally recognized interoperability standards. This software solution was initially developed by federal agencies to support their health-related missions.3

Aetna and UnitedHealth Group

Health insurance company Aetna, which owns two large health IT vendors addressing Meaningful Use requirements, ActiveHealth (CDSS) and Medicity (HIE data aggregation), has expanded its technology offering with the launch of iTriage, an enhanced version of the widely used mobile application. iTriage helps users figure out what condition they might have and, using their device's GPS capabilities, points them in the direction of appropriate medical care.4 This program may be applicable to ineligible providers such as FQHCs, RHCs, and Emergency Medical Service Providers.

UnitedHealth Group's subsidiaries include ATCB-ONC certified CareTracker EHR. "United Healthcare members carry advanced magnetic stripe and bar code ID Cards which can greatly reduce transaction errors by minimizing the hand-keying of member information on most "enrollee number" searches."5 This program may be applicable to ineligible providers such as FQHCs, RHCs and behavioral health providers.

Strong Start Toolkit

CMS, working in partnership with the March of Dimes, American College of OB/GYNs, Association of Women's Health, Obstetric and Neonatal Nurses, Text4Baby, and other advocacy and professional organizations, has released a "toolkit" in connection with CMS's Strong Start for Mothers and Newborns Initiative6 that allows health care providers to access patient safety checklists, participate in quality improvement initiatives and share information with expectant mothers and families. Patient and community-based organizations can also share the online resources with patients and provider.7 This program may be applicable to ineligible providers such as FQHCs and RHCs.

Child Health and Development Interactive System (CHADIS)

Child Health and Development Interactive System (CHADIS) is a web-based screening, diagnostic and management system that provides physicians with instant access to clinical data. It incorporates all American Academy of Pediatrics (AAP), "Bright Futures" and Medicaid guidelines for preventive education and screening for child well care visits. Funded through multiple sources including a Small Business Initiated Research (SBIR) award from NICHD,8 physicians can select from over 100 screening questionnaires in CHADIS and automatically see a screen that reflects the child's age and the appropriate routine child health information for each visit. This program may be applicable to ineligible providers such as FQHCs and RHCs.

Notes

  1. U.S. Department of Health and Human Services. States Leading the Way on Implementation: HHS Awards "Early Innovator" Grants to Seven States (news release, February 16, 2011) http://www.hhs.gov/news/press/2011pres/02/20110216a.html accessed May 16, 2011.

  2. Information Exchange: You're you Use Cases. CMIO (April 25, 2011). http://www.cmio.net/index.php?option=com_articles&view=article&id=27439:information-exchange-know-your-use-casesvv, accessed May 16, 2011.

  3. The CONNECT Open Source Solution: a Gateway to the Nationwide Health Information Network. http://healthit.hhs.gov/portal/server.pt/document/953718/connect_data_sheet_pdf, accessed June 2, 2012.

  4. Matthew Holt and Laura Montini. "Aetna Launches the New iTriage," Health 2.0 News (March 5, 2012) http://www.health2news.com/2012/03/05/aetna-launches-the-new-itriage/, accessed June 2, 2012.

  5. United Healthcare Online. Health Care ID Card Technology. https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=74559b24553c2110VgnVCM100000c520720a, accessed June 1, 2012.

  6. Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. "Strong Start for Mothers and Newborns. http://innovation.cms.gov/initiatives/Strong-Start/index.html, accessed June 1, 2012.

  7. Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. "Strong Start for Mothers and Newborns: what you can do to help" http://innovations.cms.gov/initiatives/strong-start/what-you-can-do-to-help.html, accessed June 1, 2012.

  8. Child Health & Development Interactive System (CHADIS) http://www.chadis.com/, accessed May 16, 2012.

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APPENDIX Q. REGULATIONS FOR MEDICAL RECORDS

This appendix provides excerpts from the Medicare Conditions of Participation (CoP) concerning medical records and plans of care for health care providers. Existing CoPlanguage could be updated to reflect contemporary use of EHR technology and aligned with Meaningful Use criteria. The following sections highlight regulatory requirements and interpretive guidelines surrounding patient medical records to demonstrate where they might align with the EHR Incentive Program and where the language could be updated to reflect current use of EHR technology and aligned with meaningful use criteria.

Regulatory language is provided for: (1) Hospitals, (2) Long-Term Care Facilities, (3)Home Health Agencies, (4) Hospice, (5) Outpatient Rehabilitation, (6) Outpatient Physical Therapy and Speech-Language Pathology, (7) Ambulatory Surgical Centers, (8) End Stage Renal Disease, (9) Psychiatric Hospitals, (10) Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), and (11) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID).

A. Federal Regulations -- Hospital Conditions of Participation [Excepts Pertaining to Medical Records]1

§482.13 Condition of Participation: Patient's Rights

(d) Standard: Confidentiality of patient records.

  1. The patient has the right to the confidentiality of his or her clinical records.

  2. The patient has the right to access information contained in his or her clinical records within a reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits.

Interpretive Guidelines §482.13(d)(2)

The patient has the right to easily access his/her medical records. Reasonable cost-based fees may be imposed only to cover the cost of copying, postage, and/or preparing an explanation or summary of patient health information, as outlined in 42 CFR §164.524(c). The cost of duplicating a patient's record must not create a barrier to the individual's receiving his or her medical record.

Survey Procedures §482.13(d)(2)

  • Does the hospital promote and protect the patient's right to access information contained in his/her clinical record?
  • Does the hospital have a procedure for providing records to patients within a reasonable time frame?
  • Does the hospital's system frustrate the legitimate efforts of individuals to gain access to their own medical record?
  • Does the procedure include the method to identify what documents were not provided and the reason?

§482.23(c)(2)

  1. If verbal orders are used, they are to be used infrequently.
  2. When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent with federal and state law.

Interpretive Guidelines §482.23(c)(2)(i)

Verbal orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into a computer (in the case of a hospital with an electronic prescribing system) without delaying treatment.

§482.24 Condition of Participation: Medical Record Services
[51 FR 22042, June 17, 1986, as amended at 71 FR 68694, November 27, 2006; 72 FR 66933, November 27, 2007; 77 FR 29074, May 16, 2012]

The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital.

Interpretive Guidelines §482.24

The term "medical records" includes at least written documents, computerized electronic information, radiology film and scans, laboratory reports and pathology slides, videos, audio recordings, and other forms of information regarding the condition of a patient.

  1. Standard: Organization and staffing. The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records.

§482.24(b) Standard: Form and Retention of Record

The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

Interpretive Guidelines §482.24(b)

These requirements apply to both manual and electronic medical record systems.

§482.24(b)(1) -- Medical records must be retained in their original or legally reproduced form for a period of at least 5 years.

Interpretive Guidelines §482.24(b)(1)

Medical records are retained in their original or legally reproduced form in hard copy, microfilm, computer memory, or other electronic storage media. The hospital must be able to promptly retrieve the complete medical record of every individual evaluated or treated in any part or location of the hospital within the last 5 years.

Survey Procedures §482.24(b)(1)

  • Determine that records are retained for at least 5 years, or more if required by state or local laws.
  • Select a sample of patients, both inpatient and outpatient who were patients of the hospital between the previous 48-60 months. Request their medical record. Is it promptly retrieved? Is it complete? Is it in original or in a legally reproduced form?

§482.24(b)(2) -- The hospital must have a system of coding and indexing medical records. The system must allow for timely retrieval by diagnosis and procedure, in order to support medical care evaluation studies.

§482.24(b)(3) -- The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with federal or state laws, court orders, or subpoenas.

Interpretive Guidelines §482.24(b)(3)

The hospital has sufficient safeguards to ensure that access to all information regarding patients is limited to those individuals designated by law, regulation, and policy; or duly authorized as having a need to know. No unauthorized access or dissemination of clinical records is permitted. Clinical records are kept secure and are only viewed when necessary by those persons having a part in the patient's care.

The right to confidentiality means safeguarding the content of information, including patient paper records, video, audio, and/or computer stored information from unauthorized disclosure without the specific informed consent of the individual, parent of a minor child, or legal guardian. Hospital staff and consultants, hired to provide services to the individual, should have access to only that portion of information that is necessary to provide effective responsive services to that individual.

Confidentiality applies to both central records and clinical record information that may be kept at dispersed locations.

The hospital's patient record system must ensure the security of patient records. The hospital must ensure that unauthorized individuals cannot gain access to patient records and that individuals cannot alter patient records. Patient records must be secure at all times and in all locations. This includes open patient records for patients who are currently inpatients in the hospital and outpatients in outpatient clinics.

Survey Procedures §482.24(b)(3)

  • Verify that only authorized persons are permitted access to records maintained by the medical records department.
  • Verify that the hospital has a policy to grant patients direct access to his/her medical record if the responsible official (e.g., MD/DO responsible for patient's care) determines that direct access is not likely to have an adverse effect on the patient.
  • Verify that medical records and other confidential patient information are released only for patient care evaluation, utilization review, treatment, quality assurance programs, in-house educational purposes, or in accordance with federal or state law, court orders, or subpoenas.
  • Verify that copies of medical records and other confidential patient information are released outside the hospital only upon written authorization of the patient, legal guardian, or person with an appropriate -- power of attorney to act on the patient's behalf, or only if there is a properly executed subpoena or court order, or as mandated by federal and state law.
  • Verify that precautions are taken to prevent unauthorized persons from gaining physical access or electronic access to information in patient records.
  • Observe the hospital's security practices for patient records. Are patient records left unsecured or unattended? Are patient records unsecured or unattended in hallways, patient rooms, nurse's stations, or on counters where an unauthorized person could gain access to patient records?
  • Verify that there is an established system in place that addresses protecting the confidentiality of medical information.
  • If the hospital uses electronic patient records, are appropriate security safeguards in place? Is access to patient records controlled?
  • Verify that adequate precautions are taken to prevent physical or electronic altering, damaging or deletion/destruction of patient records or information in patient records.
  1. Standard: Content of record. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.

Interpretive Guidelines §482.24(c)

The medical record must contain information such as notes, documentation, records, reports, recordings, test results, assessments etc. to:

  • Justify admission;
  • Justify continued hospitalization;
  • Support the diagnosis;
  • Describe the patient's progress;
  • Describe the patient's response to medications; and
  • Describe the patient's response to services such as interventions, care, treatments, etc.

The medical record must contain complete information/documentation regarding evaluations, interventions, care provided, services, care plans, discharge plans, and the patient's response to those activities.

Patient medical record information, such as, laboratory reports, test results, consults, assessments, radiology reports, dictated notes, etc. must be promptly filed in the patient's medical record in order to be available to the physician and other care providers to use in making assessments of the patient's condition, to justify continued hospitalization, to support the diagnosis, to describe the patient's progress, and to describe the patient's response to medications, interventions, and services, in planning the patient's care, and in making decisions on the provision of care to the patient.

§482.24(c)(1) -- All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Interpretive Guidelines §482.24(c)(1)

All entries in the medical record must be legible. Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.

All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. With these criteria in mind, an individual entry into the medical record must contain sufficient information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard.

All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.

  • The time and date of each entry (orders, reports, notes, etc.) must be accurately documented. Timing establishes when an order was given, when an activity happened or when an activity is to take place. Timing and dating entries is necessary for patient safety and quality of care. Timing and dating of entries establishes a baseline for future actions or assessments and establishes a timeline of events. Many patient interventions or assessments are based on time intervals or timelines of various signs, symptoms, or events. (71 FR 68687)
  • The hospital must have a method to establish the identity of the author of each entry. This would include verification of the author of faxed orders/entries or computer entries.
  • The hospital must have a method to require that each author takes a specific action to verify that the entry being authenticated is his/her entry or that he/she is responsible for the entry, and that the entry is accurate.

The requirements for dating and timing do not apply to orders or prescriptions that are generated outside of the hospital until they are presented to the hospital at the time of service. Once the hospital begins processing such an order or prescription, it is responsible for ensuring that the implementation of the order or prescription by the hospital is promptly dated, and timed in the patient's medical record.

In the case of a pre-established electronic order set, the same principles would apply, so that the practitioner would date, time and authenticate the final order that resulted from the electronic selection/annotation process, with the exception that pages with internal changes would not need to be initialed or signed if they are part of an integrated single electronic document.

Authentication of medical record entries may include written signatures, initials, computer key, or other code. For authentication, in written or electronic form, a method must be established to identify the author. When rubber stamps or electronic authorizations are used for authentication, the hospital must have policies and procedures to ensure that such stamps or authorizations are used only by the individuals whose signature they represent. There shall be no delegation of stamps or authentication codes to another individual. It should be noted that some insurers and other payers may have a policy prohibiting the use of rubber stamps as a means of authenticating the medical records that support a claim for payment. Medicare payment policy, for example, no longer permits such use of rubber stamps. Thus, while the use of a rubber stamp for signature authentication is not prohibited under the CoPs and analysis of the rubber stamp method per se is not an element of the survey process,hospitals may wish to eliminate their usage in order to avoid denial of claims for payment.

Where an electronic medical record is in use, the hospital must demonstrate how it prevents alterations of record entries after they have been authenticated. Information needed to review an electronic medical record, including pertinent codes and security features, must be readily available to surveyors to permit their review of sampled medical records while on-site in the hospital.

When state law and/or hospital policy requires that entries in the medical record made by residents or non-physicians be countersigned by supervisory or attending medical staff members, then the medical staff rules and regulations must address counter-signature requirements and processes.

A system of auto-authentication in which a physician or other practitioner authenticates an entry that he or she cannot review (e.g., because it has not yet been transcribed, or the electronic entry cannot be displayed) is not consistent with these requirements. There must be a method of determining that the practitioner did, in fact, authenticate the entry after it was created. In addition, failure to disapprove an entry within a specific time period is not acceptable as authentication.

The practitioner must separately date and time his/her signature authenticating an entry, even though there may already be a date and time on the document, since the latter may not reflect when the entry was authenticated. For certain electronically-generated documents, where the date and time that the physician reviewed the electronic transcription is automatically printed on the document, the requirements of this section would be satisfied. However, if the electronically-generated document only prints the date and time that an event occurred (e.g., EKG printouts, lab results, etc.) and does not print the date and time that the practitioner actually reviewed the document, then the practitioner must either authenticate, date, and time this document itself or incorporate an acknowledgment that the document was reviewed into another document (such as the H&P, a progress note, etc.), which would then be authenticated, dated, and timed by the practitioner.

Survey Procedures §482.24(c)(1)

Review a sample of open and closed medical records.

  • Determine whether all medical record entries are legible. Are they clearly written in such a way that they are not likely to be misread or misinterpreted?
  • Determine whether orders, progress notes, nursing notes, or other entries in the medical record are complete. Does the medical record contain sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers?
  • Determine whether medical record entries are dated, timed, and appropriately authenticated by the person who is responsible for ordering, providing, or evaluating the service provided.
  • Determine whether all orders, including verbal orders, are written in the medical record and signed by the practitioner who is caring for the patient and who is authorized by hospital policy and in accordance with state law to write orders.
  • Determine whether the hospital has a means for verifying signatures, both written and electronic, written initials, codes, and stamps when such are used for authorship identification. For electronic medical records, ask the hospital to demonstrate the security features that maintain the integrity of entries and verification of electronic signatures and authorizations. Examine the hospital's policies and procedures for using the system, and determine if documents are being authenticated after they are created.

§482.24(c)(2) -- All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

§482.24(c)(3) -- Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital:

  1. Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership;
  2. Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines;
  3. Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols; and
  4. Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or by another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

§482.24(c)(4) -- All records must document the following, as appropriate:

  1. Evidence of --

    1. A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be placed in the patient's medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Interpretive Guidelines §482.24(c)(4)(i)(A)

The medical record must include documentation that a medical history and physical examination (H&P) was completed and documented for each patient no more than 30 days prior to hospital admission or registration, or 24 hours after hospital admission or registration, but in all cases prior to surgery or a procedure requiring anesthesia services.

The purpose of an H&P is to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as an allergy to a medication that must be avoided, or a co-morbidity that requires certain additional interventions to reduce risk to the patient.

The H&P documentation must be placed in the medical record within 24 hours of admission or registration, but in all cases prior to surgery or a procedure requiring anesthesia services, including all inpatient, outpatient, or same-day surgeries or procedures. (71 FR 68676) The H&P may be handwritten or transcribed. An H&P that is completed within 24 hours of the patient's admission or registration, but after surgery or a procedure requiring anesthesia would not be in compliance.

§482.24(c)(4) -- [All records must document the following, as appropriate:

  1. Evidence of --]

    (B) An updated examination of the patient, including any changes in the patient's condition, when the medical history and physical examination are completed within 30 days before admission or registration. Documentation of the updated examination must be placed in the patient's medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Interpretive Guidelines §482.24(c)(4)(i)(B)

When an H&P is completed within the 30 days before admission or registration, the hospital must ensure that an updated medical record entry documenting an examination for any changes in the patient's condition is placed in the patient's medical record within 24 hours after admission or registration, but, in all cases involving surgery or a procedure requiring anesthesia services, prior to the surgery or procedure. The examination must be conducted by a practitioner who is credentialed and privileged by the hospital's medical staff to perform an H&P. The update note must document an examination for any changes in the patient's condition since the time that the patient's H&P was performed that might be significant for the planned course of treatment. The physician, oromaxillofacial surgeon, or qualified licensed individual uses his/her clinical judgment, based upon his/her assessment of the patient's condition and co-morbidities, if any, in relation to the patient's planned course of treatment to decide the extent of the update assessment needed as well as the information to be included in the update note in the patient's medical record. If, upon examination, the licensed practitioner finds no change in the patient's condition since the H&P was completed, he/she may indicate in the patient's medical record that the H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed. (71 FR 68676) Any changes in the patient's condition must be documented by the practitioner in the update note and placed in the patient's medical record within 24 hours of admission or registration, but prior to surgery or a procedure requirement anesthesia services. Additionally, if the practitioner finds that the H&P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the patient, and completing the update may disregard the existing H&P, and conduct and document in the medical record a new H&P within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia.

§482.24(c)(4)(ii) -- Admitting diagnosis.

Interpretive Guidelines §482.24(c)(4)(ii)

All inpatient medical records must contain the admitting diagnosis.

§482.24(c)(4)(iii) -- Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.

Interpretive Guidelines §482.24(c)(4)(iii)

All patient records, both inpatient and outpatient, must contain the results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This information must be promptly filed in the patient's medical record in order to be available to the physician or other care providers to use in making assessments of the patient's condition, to justify treatment or continued hospitalization, to support or revise the patient's diagnosis, to support or revise the plan of care, to describe the patient's progress and to describe the patient's response to medications, treatments, and services.

[All records must document the following, as appropriate:]
§482.24(c)(4)(iv) -- Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia.

Interpretive Guidelines §482.24(c)(2)(iv)

All patient medical records, both inpatient and outpatient, must document: Complication; Hospital-acquired infections; Unfavorable reactions to drugs; and Unfavorable reactions to anesthesia.

[All records must document the following, as appropriate:]
§482.24(c)(4)(v) -- Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state law if applicable, to require written patient consent.

Interpretive Guidelines §482.24(c)(4)(v)

Informed consent is discussed in three locations in the CMS Hospital CoPs. See also the guidelines for 42 CFR 482.13(b)(2) pertaining to patients' rights, and the guidelines for 42 CFR 482.51(b)(2), pertaining to surgical services. The medical record must contain a document recording the patient's informed consent for those procedures and treatments that have been specified as requiring informed consent. Medical staff policies should address which procedures and treatments require written informed consent. There may also be applicable federal or state law requiring informed consent. The informed consent form contained in the medical record should provide evidence that it was properly executed. Signature of the patient or the patient's legal representative; and date and time the informed consent form is signed by the patient or the patient's legal representative.

§482.24(c)(4)(vi) -- All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition.

Interpretive Guidelines §482.24(c)(4)(vi)

The requirement means that the stated information is necessary to monitor the patient's condition and that this and other necessary information must be in the patient's medical record. In order for necessary information to be used it must be promptly filed in the medical record so that health care staff involved in the patient's care can access/retrieve this information in order to monitor the patient's condition and provide appropriate care.

The medical record must contain: All practitioner's orders (properly authenticated); All nursing notes (including nursing care plans); All reports of treatment (including complications and hospital-acquired infections); All medication records (including unfavorable reactions to drugs); All radiology reports; All laboratory reports; All vital signs; and All other information necessary to monitor the patient's condition.

[All records must document the following, as appropriate:]
§482.24(c)(4)(vii) -- Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care.

Interpretive Guidelines §482.24(c)(4)(vii)

All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living.

[All records must document the following, as appropriate:]
§482.24(c)(4)(viii) -- Final diagnosis with completion of medical records within 30 days following discharge.

Interpretive Guidelines §482.24(c)(4)(viii)

All medical records must contain a final diagnosis. All medical records must be complete within 30 days of discharge or outpatient care.

Survey Procedures §482.24(c)(4)(viii)

Select a sample of patients who have been discharged for more than 30 days. Request their medical records. Are those records complete? Does each record have the patient's final diagnosis?

B. Federal Regulations -- Long-Term Care Facility Conditions of Participation [Excepts Pertaining to Medical Records]2

§483.20 Resident Assessment

The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.

Intent §483.20

To provide the facility with ongoing assessment information necessary to develop a care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The facility is expected to use resident observation and communication as the primary source of information when completing the RAI. In addition to direct observation and communication with the resident, the facility should use a variety of other sources, including communication with licensed and non-licensed staff members on all shifts and may include discussions with the resident's physician, family members, or outside consultants and review of the resident's record.

  1. Admission orders. At the time each resident is admitted, the facility must have physician orders for the resident's immediate care.

  2. Comprehensive assessments --

    1. Resident assessment instrument. A facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the state. The assessment must include at least the following:

      1. Identification and demographic information.
      2. Customary routine.
      3. Cognitive patterns.
      4. Communication.
      5. Vision.
      6. Mood and behavior patterns.
      7. Psychosocial well-being.
      8. Physical functioning and structural problems.
      9. Continence.
      10. Disease diagnoses and health conditions.
      11. Dental and nutritional status.
      12. Skin condition.
      13. Activity pursuit.
      14. Medications.
      15. Special treatments and procedures.
      16. Discharge potential.
      17. Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
      18. Documentation of participation in assessment.

      The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicenseddirect care staff members on all shifts.

      Intent §483.20(b)

      To ensure that the RAI is used in conducting comprehensive assessments as part of an ongoing process through which the facility identifies the resident's functional capacity and health status.

      §483.20(b) Guidelines

      The information required in §483.20(b)(i-xvi) is incorporated into the MDS, which forms the core of each state's approved RAI. Additional assessment information is also gathered using triggered CAAs[care area assessments].

      Each facility must use its state-specified RAI (which includes the MDS, utilization guidelines and the CAAs) to assess newly admitted residents, conduct an annual reassessment and assess those residents who experience a significant change in status. The facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or CAAs. The scope of the RAI does not limit the facility's responsibility to assess and address all care needed by the resident.

      Furthermore: ....

      (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS.

      "Documentation of summary information (xvii) regarding the additional assessment performed through the CAAs refers to documentation concerning which CAAs have been triggered, documentation of assessment information in support of clinical decision making relevant to the CAAs, documentation regarding where, in the clinical record, information related to the CAAs can be found, and for each triggered CAA, whether the identified problem was included in the care plan.

    2. When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.

      1. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.)
      2. Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purposes of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident'shealth status, and requires interdisciplinary review or revision of the care plan, or both.)
      3. Not less often than once every 12 months.

      Interpretive Guidelines §483.20(b)(2)(iii)

      The annual resident assessment must be completed within 366 days after the ARD of the most recent comprehensive resident assessment. (NOTE: For information on assessment scheduling for the MDS, see Chapter 2 of the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, effective 10/1/2010, which is located on the CMS MDS 3.0 website (http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage).

      Probes §483.20(b)(2)

      • Has each resident in the sample been comprehensively assessed using the state-specified RAI within the regulatory timeframes (i.e., within 14 days after admission, on significant change in status, and at least annually)?
      • Has the facility identified, in a timely manner, those residents who have experienced a change?
      • Has the facility reassessed residents using the state-specific RAI who had a significant change in status within 14 days after determining the change was significant?
      • Has the facility gathered supplemental assessment information based on triggered CAAs prior to establishing the care plan?
      • Does information in the RAI correspond with information obtained during observations of and interviews with the resident, facility staff and resident's family?
  3. Quarterly review assessment. A facility must assess a resident using the quarterly review instrument specified by the state and approved by CMS not less frequently than once every 3 months.

    Interpretive Guidelines §483.20(c)

    At least each quarter, the facility shall review each resident with respect to those MDS items specified under the state's quarterly review requirement. At a minimum, this would include all items contained in CMS' standard quarterly review form. A Quarterly review assessment must be completed within 92 days of the ARD of the most recent, clinical assessment. If the resident has experienced a significant change in status, the next quarterly review is due no later than 3 months after the ARD of the significant change reassessment.

    Probes §483.20(c)

    • Is the facility assessing and acting, no less than once every 3 months, on the results of resident's functional and cognitive status examinations?
    • Is the quarterly review of the resident's condition consistent with information in the progress notes, the plan of care and your resident observations and interviews?
  4. Use.A facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care.

    Interpretive Guidelines §483.20(d)

    The requirement to maintain 15 months of data in the resident's active clinical record applies regardless of form of storage to all MDS records, including the CAA Summary, Quarterly Assessment records, Identification Information and Entry, Discharge and Reentry Tracking Records and MDS Correction Requests (including signed attestation). MDS assessments must be kept in the resident's active clinical record for 15 months following the final completion date for all assessments and correction requests. Other assessment types require maintaining them in the resident's active clinical record for 15 months following:

    • The entry date for tracking records including re-entry; and
    • The date of discharge or death for discharge and death in facility records.

    Facilities may maintain MDS data electronically regardless of whether the entire clinical record is maintained electronically and regardless of whether the facility has an electronic signature process in place.

    Facilities that maintain their MDS data electronically and do not utilize an electronic signature process must ensure that hard copies of the MDS assessment signature pages are maintained for every MDS assessment conducted in the resident's active clinical record for 15 months. (This includes enough information to identify the resident and type and date of assessment linked with the particular assessment's signature pages),

    The information, regardless of form of storage (i.e., hard copy or electronic), must be kept in a centralized location and must be readily and easily accessible. This information must be available to all professional staff members (including consultants) who need to review the information in order to provide care to the resident. (This information must also be made readily and easily accessible for review by the State Survey agency and CMS.)

    After the 15-month period, RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested by clinical staff, the state agency, or CMS.

  5. Coordination.A facility must coordinate assessments with the preadmission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and effort.

  6. Automated data processing requirement --

    1. Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:

      1. Admission assessment.
      2. Annual assessment updates.
      3. Significant change in status assessments.
      4. Quarterly review assessments.
      5. A subset of items upon a resident's transfer, reentry, discharge, and death.
      6. Background (face-sheet) information, if there is no admission assessment.

      Intent §483.20(f)(1)

      Facilities are required to encode MDS data for each resident in the facility.

      Interpretive Guidelines §483.20(f)(1)

      Background (face-sheet) information refers to the MDS Entry tracking record, while the discharge subset of items refers to the MDS Discharge assessment.

    2. Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the state.

    3. Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:

      1. Admission assessment.
      2. Annual assessment.
      3. Significant change in status assessment.
      4. Significant correction of prior full assessment.
      5. Significant correction of prior quarterly assessment.
      6. Quarterly review.
      7. A subset of items upon a resident's transfer, reentry, discharge, and death.
      8. Background (face-sheet) information, for an initial transmission of MDS data on a resident that does not have an admission assessment.

      Intent §483.20(f)(3)

      Facilities are required to electronically transmit MDS data to the CMS System for each resident in the facility. The CMS System for MDS data is named the QIES ASAP System.

      Interpretive Guidelines §483.20(f)(3)

      Background (face-sheet) information refers to the MDS Entry tracking record, while the discharge subset of items refers to the MDS Discharge assessment.

    4. Data format. The facility must transmit data in the format specified by CMS or, for a state which has an alternate RAI approved by CMS, in the format specified by the state and approved by CMS.

      Intent §483.20(f)(1-4)

      The intent is to enable a facility to better monitor a resident's decline and progress over time. Computer-aided data analysis facilitates a more efficient, comprehensive and sophisticated review of health data. The primary purpose of maintaining the assessment data is so a facility can monitor resident progress over time. The information should be readily available at all times.

      Interpretive Guidelines §483.20(f)(1-4)

      "Encoding" means entering MDS information into a computer.

      "Transmitting data" refers to electronically sending encoded MDS information, from the facility to the QIES ASAP System, using a modemand communications software.

      "Capable of transmitting" means that the facility has encoded and edited according to CMS specifications, the record accurately reflects the resident's overall clinical status as of the assessment reference date, and the record is ready for transmission.

      "Passing standard edits" means that the encoded responses to MDS items are consistent and within range, in accordance with CMS specified standards. In general, inconsistent responses are either not plausible or ignore a skip pattern on the MDS. An example of inconsistency would be if one or more MDS items on a list were checked as present, and the "None of the Above" response was also checked for the same list. Out of range responses are invalid responses, such as using a response code of 2 for an MDS item for which the valid responses are zero or 1.

      "Transmitted" means electronically transmitting to the QIES ASAP System, an MDS record that passes CMS' standard edits and is accepted into the system, within 14days of the final completion date, or event date in the case of Entry, Discharge and Death in Facility situations, of the record.

      "Accurate" means that the encoded MDS data matches the MDS form in the clinical record. Also refer to guidance regarding accuracy at §483.20(g),and the information accurately reflects the resident's status as of the Assessment Reference Date (ARD).

      "Complete" means that all items required according to the record type,and in accordance with CMS' record specifications and state required edits are in effect at the time the record is completed.

      In accordance with the final rule, facilities will be responsible to edit the encoded MDS data to ensure that it meets the standard edit specifications.

      We encourage facilities to use software that has a programmed capability to automatically edit MDS records according to CMS' edit specifications.

      For §483.20(f)(1)(v), the subset of items required upon a resident's entry, transfer, discharge and death are contained in the Entry and Death in Facility Tracking records and Discharge assessments. Refer to Chapter 2 of Appendix R (the MDS manual) for further information about these records.

      All nursing homes must computerize MDS information. The facility must edit MDS information using standard CMS-specified edits, revise the information to conform to the edits and to be accurate, and be capable of transmitting that data to the QIES ASAP system within 7 days of:

      • Completing a comprehensive assessment (the care plan completion date);
      • Completing an assessment that is not comprehensive (the MDS completion date);
      • A discharge event (the date of death or discharge);
      • An entry event (the date of entry (admission or reentry)); or
      • Completing a correction request.

      Submission must be according to state and federal time frames. Therefore the facility must:

      • Encode the MDS and CAAs Summary (where applicable) in machine readable format; and
      • Edit the MDS and CAA Summary (where applicable) according to edits specified by CMS. Within the 7 day time period specified above for editing, the facility must revise any information on the encoded MDS and CAA Summary (if applicable) that does not pass CMS-specified edits, revise any otherwise inaccurate information, and make the information ready for submission. The MDS Vendor software used at the facility should have an automated editing process that alerts the user to entries in an MDS record that do not conform with the CMS-specified edits and that prompts the facility to complete revisions within the 7-day editing and revision period. After editing and revision, MDS information and CAA summary information (if applicable) must always accurately reflect the resident's overall clinical status as of the original ARD for an assessment or the original event date for a discharge or entry.

      Electronically submit MDS information to the QIES ASAP system within 14 days of:

      • Completing a comprehensive assessment (the care plan completion date);
      • Completing an assessment that is not comprehensive (the MDS completion date);
      • A discharge event (the date of death or discharge);
      • An entry event (the date of entry (admission or reentry)); or
      • Completing a correction request.

      For a discussion of the process that a facility should follow in the event an error is discovered in an MDS record after editing and revision but before it is transmitted to the QIES ASAP system, refer to Appendix R of the State Operations Manual, Chapter 5.

      Facilities are required to maintain 15 months of assessment data in the resident's active clinical record. Refer to the interpretive guidelines at §483.20(d) for information regarding this requirement.

      A facility must complete and submit to the QIES ASAP system a subset of items when a resident enters the facility (entry tracking record -- admission or reentry), is discharged from the facility (discharge assessment -- return anticipated or return not anticipated) or dies in the facility (death in facility tracking record).

    5. Resident-identifiable information.

      1. A facility may not release information that is resident-identifiable to the public.
      2. The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
  7. Accuracy of assessments. The assessment must accurately reflect the resident's status.

    Interpretive Guidelines §483.20(g)

    "The accuracy of the assessment" means that the appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. The initial comprehensive assessment provides baseline data for ongoing assessment of resident progress.

  8. Coordination.A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

    Interpretive Guidelines §483.20(h)

    According to the Utilization Guidelines for each state's RAI, the physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs.

    Probes §483.20(g)(h)

    • Have appropriate health professionals assessed the resident? For example, has the resident's nutritional status been assessed by someone who is knowledgeable in nutrition and capable of correctly assessing a resident?
    • If the resident's medical status, functional abilities, or psychosocial status declined and the decline wasnot clinically unavoidable, were the appropriate health professionals involved in assessing the resident?
    • Based on your total review of the resident, is each portion of the assessment accurate?
    • Are the appropriate certifications in place, including the RN Coordinator's certification of completion of an assessment or Correction Request, and the certification of individual assessors of the accuracy and completion of the portion(s) of the assessment or tracking recordcompleted or corrected. On an assessment or correction request, the RN Assessment Coordinator is responsible for certifying overall completion once all individual assessors have completed and signed their portion(s) of the MDS. When MDS records are completed directly on the facility's computer, (e.g., no paper form has been manually completed), the RN Coordinator signs and dates the computer generated hard copy, or provides an electronic signature,after reviewing it for completeness, including the signatures of all individual assessors. Backdating a completion date is not acceptable -- note that recording the actual date of completion is not considered backdating. For example, if an MDS was completed electronically and a hard copy was printed two days later, writing the date the MDS was completed on the hard copy is not considered backdating.
  9. Certification.

    1. A registered nurse must sign and certify that the assessment is completed.

    2. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

    Interpretive Guidelines §483.20(i)

    Whether the MDS assessments are manually completed, or computer generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. Manually completed forms are signed and dated by each individual assessor the day they complete their portion(s) of the MDS record. When MDS forms are completed directly on the facility's computer (e.g., no paper form has been manually completed), then each individual assessor signs and dates a computer generated hard copy, or provides an electronic signature, after they review it for accuracy of the portion(s) they completed. Backdating completion dates is not acceptable -- note that recording the actual date of completion is not considered backdating. For example, if an MDS was completed electronically and a hard copy was printed two days later, writing the date the MDS was completed on the hard copy is not considered backdating.

  10. Penalty for falsification.

    1. Under Medicare and Medicaid, an individual who willfully and knowingly --

      1. Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
      2. Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment.
    2. Clinical disagreement does not constitute a material and false statement.

      Interpretive Guidelines §483.20(j)

      MDS information serves as the clinical basis for care planning and delivery. With the introduction of additional uses of MDS information such as for payment rate setting and quality monitoring, MDS information as it is reported impacts a nursing home's payment rate and standing in terms of the quality monitoring process. A pattern within a nursing home of clinical documentation or of MDS assessment or reporting practices that result in higher RUG scores, untriggering CAA(s), or unflagging QI(s), where the information does not accurately reflect the resident's status, may be indicative of payment fraud or avoidance of the quality monitoring process. Such practices may include but are not limited to a pattern or high prevalence of the following:

      • Submitting MDS Assessments (including any reason(s) for assessment, routine or non-routine) or tracking records, where the information does not accurately reflect the resident's status as of the ARD, or the Discharge or Entry date, as applicable;
      • Submitting correction(s) to information in the QIES ASAP system where the corrected information does not accurately reflect the resident's status as of the original ARD, or the original Discharge or Entry date, as applicable, or where the record it claims to correct does not appear to have been in error;
      • Submitting Significant Correction Assessments where the assessment it claims to correct does not appear to have been in error;
      • Submitting Significant Change in Status Assessments where the criteria for significant change in the resident's status do not appear to be met;
      • Delaying or withholding MDS Assessments (including any reason(s) for assessment, routine or non-routine), Discharge or Entry Tracking information, or correction(s) to information in the QIES ASAP system.

      When such patterns or practices are noticed, they should be reported by the State Agency to the proper authority.

  11. Comprehensive care plans.

    1. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following --

      1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and
      2. Any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

      Interpretive Guidelines §483.20(k)

      An interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The interdisciplinary team should show evidence in the CAA summary or clinical record of the following:

      • The resident's status in triggered CAA areas;
      • The facility's rationale for deciding whether to proceed with care planning; and
      • Evidence that the facility considered the development of care planning interventions for all CAAs triggered by the MDS.

      The care plan must reflect intermediate steps for each outcome objective if identification of those steps will enhance the resident's ability to meet his/her objectives. Facility staff will use these objectives to monitor resident progress. Facilities may, for some residents, need to prioritize their care plan interventions. This should be noted in the clinical record or on the plan or care.

      The requirements reflect the facility's responsibilities to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. However, in some cases, a resident may wish to refuse certain services or treatments that professional staff believe may be indicated to assist the resident in reaching his or her highest practicable level of well-being. Desires of the resident should be documented in the clinical record (see guidelines at §483.10(b)(4) for additional guidance concerning refusal of treatment).

    2. A comprehensive care plan must be --

      1. Developed within 7 days after completion of the comprehensive assessment;
      2. Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and
      3. Periodically reviewed and revised by a team of qualified persons after each assessment.
    3. The services provided or arranged by the facility must --

      1. Meet professional standards of quality; and
      2. Be provided by qualified persons in accordance with each resident's written plan of care.
  12. Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes --

    1. A recapitulation of the resident's stay;

    2. A final summary of the resident's status to include items in paragraph (b)(2) of this section, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative; and

    3. A post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment.

      Interpretive Guidelines §483.20(l)(3)

      A post-discharge plan of care for an anticipated discharge applies to a resident whom the facility discharges to a private residence, to another NF or SNF, or to another type of residential facility such as a board and care home or an intermediate care facility for individuals with mental retardation. Resident protection concerning transfer and discharge are found at §483.12. A "post-discharge plan of care" means the discharge planning process which includes: assessing continuing care needs and developing a plan designed to ensure the individual's needs will be met after discharge from the facility into the community.

  13. Preadmission screening for mentally ill individuals and individuals with intellectual disability.

    1. A nursing facility must not admit, on or after January 1, 1989, any new resident with --

      1. Mental illness as defined in paragraph (f)(2)(i) of this section, unless the state mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the state mental health authority, prior to admission,
        1. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
        2. If the individual requires such level of services, whether the individual requires specialized services; or
      2. Mental retardation, as defined in paragraph (f)(2)(ii) of this section, unless the state intellectual disability or developmental disability authority has determined prior to admission --
        1. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
        2. If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.75(l) Clinical Records

  1. The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are--

    1. Complete;
    2. Accurately documented;
    3. Readily accessible; and
    4. Systematically organized.

Intent §483.75(l)(1)

To assure that the facility maintains accurate, complete and organized clinical information about each resident that is readily accessible for resident care.

Interpretive Guidelines §483.75(l)(1)

A complete clinical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. Documentation should provide a picture of the resident's progress, including response to treatment, change in condition, and changes in treatment.

The facility determines how frequently documentation of an individual's progress takes place apart from the annual comprehensive assessment, periodic reassessments when a significant change in status occurs, and quarterly monitoring assessments. Good practice indicates that for functional and behavioral objectives, the clinical record should document change toward achieving care plan goals. Thus, while there is no "right" frequency or format for "reporting" progress, there is a unique reporting schedule to chart each resident's progress in maintaining or improving functional abilities and mental and psychosocial status. Be more concerned with whether the staff has sufficient progress information to work with the resident and less with how often that information is gathered.

In cases in which facilities have created the option for an individual's record to be maintained by computer, rather than hard copy, electronic signatures are acceptable. In cases when such attestation is done on computer records, safeguards to prevent unauthorized access, and reconstruction of information must be in place. The following guideline is an example of how such a system may be set up:

  • There is a written policy, at the health care facility, describing the attestation policy(ies) in force at the facility.
  • The computer has built-in safeguards to minimize the possibility of fraud.
  • Each person responsible for an attestation has an individualized identifier.
  • The date and time is recorded from the computer's internal clock at the time of entry
  • An entry is not to be changed after it has been recorded.
  • The computer program controls what sections/areas any individual can access or enter data, based on the individual's personal identifier (and, therefore his/her level of professional qualifications).

§483.75(l)(5) the clinical record must contain --

  1. Sufficient information to identify the resident;
  2. A record of the resident's assessments;
  3. the plan of care and services provided;
  4. The results of any preadmission screening conducted by the state; and
  5. progress notes.

§483.75(l)(2) Clinical records must be retained for --

  1. The period of time required by state law; or
  2. Five years from the date of discharge when there is no requirement in state law; or,
  3. For a minor, 3 years after a resident reaches legal age under state law.

§483.20(f)(5) Resident-identifiable information.

  1. A facility may not release information that is resident-identifiable to the public.
  2. The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

Interpretive Guidelines §483.20(f)(5)

Automated RAI data are part of a resident's clinical record and as such are protected from improper disclosure by facilities under current law. Facilities are required by §§1819(c)(1)(A)(iv) and 1919(c)(1)(A)(iv) of the Act and 42 CFR Part 483.75(l)(3) and (l)(4), to keep confidential all information contained in the resident's record and to maintain safeguards against the unauthorized use of a resident's clinical record information, regardless of the storage method of the records.

§483.75(l)(3) The facility must safeguard clinical record information against loss, destruction, or unauthorized use;

Intent §483.75(l)(3)

To maintain the safety and confidentiality of the resident's record.

Procedures §483.75(l)(3)

Determine through observations and interviews with staff, the policy and implementation of that policy, for maintaining confidentiality of residents' records.

Probes §483.75(1)(3)

  • How does the facility ensure confidentiality of resident records
  • If there is a problem with confidentiality, is it systematic, that is, does the problem lie in the recordkeeping system, or with a staff person's use of records (e.g., leaving records in a place easily accessible to residents, visitors, or other unauthorized persons)?

C. Federal Regulations -- Home Health Conditions of Participation [Excepts Pertaining to Medical Records (including plans of care)]3

§484.10 Condition of Participation: Patient Rights.

  1. Standard: Notice of rights.

    1. The HHA must provide the patient with a written notice of the patient's rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment.

    2. The HHA must maintain documentation showing that it has complied with the requirements of this section.

Interpretive Guidelines §484.10(a)(1)

In the stratified sample of clinical records selected for review, look for notations that a statement of the patient's rights, including the statement concerning the collection and reporting of OASIS information, has been given to the patient by the HHA staff prior to care being initiated. This written statement must have been provided during admission, the patient's initial evaluation visit, or the patient's first professional visit.

The OASIS database is subject to the requirements of the Federal Privacy Act of 1974. The Privacy Act allows the disclosure of information from a system of records without an individual's consent if the information is to be used for a purpose that is compatible with the purposes for which the information was collected. However, under existing patient's rights regulations, the HHA must provide the patient with a written notice of this collection of information (i.e., OASIS in advance of furnishing care to the patient).

Before comprehensive assessments (that include collection of OASIS data items) are conducted, the HHA must tell patients about OASIS and explain their rights with respect to the collection and reporting of OASIS information. These rights include:

  • The right to be informed that OASIS information will be collected and for what purpose;
  • The right to have the information kept confidential and secure;
  • The right to be informed that OASIS information will not be disclosed except for legitimate purposes allowed by the Privacy Act;
  • The right to refuse to answer a specific question; and
  • The right to see, review, and request changes on their assessment.

If the HHA chooses to continue to collect OASIS information from non-Medicare/non-Medicaid patients the patient should be provided with the Notice about Privacy (for non-Medicare/non-Medicaid patients). If a home visit is made, the verification could also include a conversation with the patient and any material on patient rights that the patient has received from the HHA. A notation in the clinical record might also include a statement regarding any limitations the patient had in being able to understand the information.

Probes §484.10(a)(1)

  • How do HHA employees, and staff used by the HHA under an arrangement or contract, implement HHA procedures for informing patients of their rights?
  • What are the HHA's admission policies concerning the OASIS Privacy Act Statement?
  • How does the HHA assure that the patient understands the OASIS Privacy Act Statement? Is the patient given a copy of the OASIS Privacy Act Statement?
  • What is the HHA's policy and procedure for requests to see, copy, review, or change assessment information?
  • Does the patient receive a written copy of the HHA's response when a change request is not granted?

(d) Standard: Confidentiality of medical records. The patient has the right to confidentiality of the clinical records maintained by the HHA. The HHA must advise the patient of the agency's policies and procedures regarding disclosure of clinical records.

Probes §484.10(d)

  • How does the HHA ensure the confidentiality of the patient's clinical record?
  • If the HHA leaves a portion of the clinical record in the home (such as in some high technology situations when frequent clinical entries are important), how does the HHA instruct the patient or caretaker about protecting the confidentiality of the record?
  • What documentation in the clinical record indicates that the HHA informed the patient of the HHA's policies and procedures concerning clinical record disclosure?

§484.11 Condition of Participation: Release of Patient Identifiable OASIS Information.

The HHA and agent acting on behalf of the HHA in accordance with a written contract must ensure the confidentiality of all patient identifiable information contained in the clinical record, including OASIS data, and may not release patient identifiable OASIS information to the public.

Interpretive Guidelines §484.11

Protection of confidentiality of OASIS information is two-fold; the HHA has a responsibility to keep OASIS information confidential and CMS has a responsibility to keep it confidential, once it has been transmitted to the OASIS state system.

Under this condition of participation, the HHA is required to maintain the confidentiality of OASIS data while it is being used for patient care and may not release it without the consent of the patient for any reason other than for what it is intended, which is to appropriately deliver patient care. HHAs must have policies and procedures for limiting access to OASIS information to only those persons the HHA designates.

If the HHA contracts with a vendor for transmission of its OASIS data, a written agreement that addresses the confidentiality of that data must be in place. Violations of data confidentiality by an entity contracted by the HHA are still the responsibility of the HHA and would constitute condition-level non-compliance; therefore the HHA is ultimately responsible for compliance with the confidentiality requirements and is the responsible party if the contractor does not meet the requirements.

For privacy and security reasons, communication of OASIS information (from branch to branch, branch to parent, parent to vendor, etc.) must be done in accordance with CMS policies on the communication of patient-identifiable information. HHAs must have processes in place to assure that access to and transfer and delivery of OASIS information is limited to only authorized personnel.

HHAs that contract with accrediting organizations (AO), such as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the Community Health Accreditation Program (CHAP), for determining compliance with the Medicare Conditions of Participation may share Outcome-based Quality Improvement /Monitoring (OBQI/M) reports with representatives of the appropriate AO on survey. The AO has a responsibility to review the OBQI/M reports and the HHA must provide the reports in the course of normal HHA business. State Agencies and Regional Offices may not share OBQI/M reports with the AO because no data use agreement exists with the SA/RO and the AO.

The other step in assuring confidentiality of the OASIS data is at the federal level and involves the Federal Privacy Act of 1974. Coverage under the Federal Privacy Act begins when the data reaches the state agency. The Privacy Act requires that policies and procedures related to the collection of information be made available to the public describing the reasons for collecting OASIS data, what will be done with it, and who will have access to it in an identifiable format. The Privacy Act puts into place certain processes that protect patient identifiable data from unauthorized use and disclosure. Provisions of the Privacy Act as they relate to the collection of OASIS data are described in detail on the OASIS Statement of Patient Privacy Rights (See §484.10(a)).

Onsite Activity -- Verify that the HHA has established a mechanism to ensure confidentiality of OASIS data. Interview the administrator and staff regarding:

  • Protecting confidentiality of OASIS data (written and/or electronic).
  • Assignment and maintenance of secure passwords for data encoding and transmission.
  • Determine how OASIS data, whether in hard copy or electronic format is kept confidential before and after transmission to the state agency.

Interview the HHA administrator or system administrator for:

  • Knowledge and application of rights to add, edit, or otherwise modify encoded OASIS data;
  • Assignment of passwords;
  • Assurance that only specified staff have contact with assessment information; and
  • Actions taken when an employee with access to the system leaves the HHA's employment.

If possible, observe security of the OASIS data-entry location. Observe if the computer screen is logged off or password protected when not attended.

If applicable, review vendor contracts for provisions protecting confidentiality of OASIS data and determine what systems are in place to assure confidentiality throughout the transmission process. Vendors must be aware of the requirements and security policies of the HHA.

If questions are raised through interview or record review, review HHA's policies regarding confidentiality of patient information.

§484.14 Condition of Participation: Organization, Services, and Administration.

(g) Standard: Coordination of patient services. All personnel furnishing services maintain liaison to ensure that their efforts are coordinated effectively and support the objectives outlined in the plan of care. The clinical record or minutes of case conferences establish that effective interchange, reporting, and coordination of patient care does occur. A written summary report for each patient is sent to the attending physician at least every 60 days.

§484.18 Condition of Participation: Acceptance of Patients, Plan of Care, and Medical Supervision.

Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.

Interpretive Guidelines §484.18

It is CMS' policy to require that the HHA must have a plan of care for each patient, regardless of the patient's Medicare status or that nurse practice acts do not specifically require a physician's order. The CoPs do not require a physician's order for services furnished by the HHA that are not related to the patient's illness, injury, or treatment of the patient's medical, nursing, or social needs.

Medical orders may authorize a specific range in the frequency of visits for each service (i.e., 2-4 visits per week) to ensure that the most appropriate level of service is provided to the patient. However, ranges include "0" as a frequency are not allowed, because "0" is not a frequency. The regulation requires the HHA to alert the physician to any changes that suggest a need to alter the plan of care. If the HHA provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified The HHA must maintain documentation in the clinical record indicating that the physician was notified and is aware of the missed visit.

  1. Standard: Plan of care. The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration. The therapist and other agency personnel participate in developing the plan of care.

    Interpretive Guidelines §484.18(a)

    A statutory change renamed the "plan of treatment" to "the plan of care." These terms are synonymous. Neither is to be confused with a nursing care plan.

    The conditions do not require an HHA to either develop or maintain a nursing care plan as opposed to a medical plan of care. This does not preclude an HHA from using nursing care plans if it believes that such plans strengthen patient care management, the organization and delivery of services, and the ability to evaluate patient outcomes.

    Review a case-mix, stratified sample of clinical records (see §2200B) to determine if the requirements of this standard are met.

    Written HHA policies and procedures should specify that all clinical services are implemented only in accordance with a plan of care established by a physician's written orders. Policies should also specify if the HHA:

    • Accepts physician's orders on referral communicated verbally by an institution's discharge planner, nurse practitioner, physician's assistant, or other authorized staff member followed by written, signed and dated physician's orders, in order to begin HHA services as soon as possible.
    • Accepts signed physician certification and recertification of plans of care, as well as signed orders changing the plan of care, by telecommunication systems ("fax"), which are filed in the clinical record.

    The plan of care must be established and authorized in writing by the physician based on an evaluation of the patient's immediate and long-term needs. The HHA staff, and if appropriate, other professional personnel, shall have a substantial role in assessing patient needs, consulting with the physician, and helping to develop the overall plan of care.

    The patient has the right, and should be encouraged, to participate in the development of the plan of care before care is started and when changes in the established plan of care are implemented. (See §484.10(c)(2).)

  2. Standard: Periodic review of plan of care. The total plan of care is reviewed by the attending physician and HHA personnel as often as the severity of the patient's condition requires, but at least once every 60 days or more frequently when there is a beneficiary elected transfer; a significant change in condition resulting in a change in the case-mix assignment; or a discharge and return to the same HHA during the 60-day episode. Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care.

    Interpretive Guidelines §484.18(b)

    Changes in the patient's condition that require a change in the plan of care should be documented in the patient's clinical record.

  3. Standard: Conformance with physician orders. Drugs and treatments are administered by agency staff only as ordered by the physician with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per agency policy developed in consultation with a physician, and after an assessment for contraindications. Verbal orders are put in writing and signed and dated with the date of receipt by the registered nurse or qualified therapist (as defined in §484.4 of this chapter) responsible for furnishing or supervising the ordered services. Verbal orders are only accepted by personnel authorized to do so by applicable state and federal laws and regulations as well as by the HHA's internal policies.

    Interpretive Guidelines §484.18(c)

    Review HHA policies and procedures in regard to obtaining physician orders, changes in orders, and verbal orders. All physician orders must be included in the patient's clinical record. Plans of care must be signed and dated by the physician.

    Verbal orders must be countersigned by the physician as soon as possible. Ask HHA's, whose pattern of obtaining signed physicians' orders exceeds the HHA's policy or state law, to clarify or explain what circumstances created the time lapse, and how they are approaching a resolution to the problem.

    Other designated HHA personnel who accept verbal orders must do so in accordance with state and federal law and regulations and HHA policy. Verbal orders must be signed and dated by the registered nurse or qualified therapist who is furnishing or supervising the ordered service. It is the RN's or therapist's responsibility to make any necessary revisions to the plan of care based on that order.

§484.20 Condition of Participation: Reporting OASIS Information.

HHAs must electronically report all OASIS data collected in accordance with §484.55.

Interpretive Guidelines §484.20

HHA's must, at least monthly, electronically report OASIS data on all applicable patients in a format that meets CMS electronic data and edit specifications. For purposes of this requirement, the term "reporting" means electronic reporting.

Effective December 8, 2003, the collection of OASIS data on the non-Medicare/non-Medicaid patients of an HHA was temporarily suspended. HHAs must continue to comply with the aspects of the regulation at 42 CFR 484.55 regarding the comprehensive assessment of patients.

HHAs may continue to collect OASIS data on their non-Medicare/non-Medicaid patients for their own use. HHAs must continue to collect, encode, and transmit OASIS data for their non-maternity Medicare and Medicaid patients that are age 18 and over and receiving skilled services.

Private pay patients are defined to include any patient for whom (M0150 ) the Current Payment Source for Home Care does not include any of the following responses:

1- Medicare (Traditional fee-for-service)
2- Medicare (HMO/ managed care)
3- Medicaid (Traditional fee-for-service)
4- Medicaid(HMO/managed care).

If a patient has a private pay insurance andM0150 response 1, 2, 3, or 4 as an insurance to which the agency is billing the services, the comprehensive assessment including OASIS must be collected and transmitted. Medicare (HMO/managed care) does include Medicare Advantage (MA), formerly known as Medicare+Choice(M+C) plans and Medicare PPO plans.

HHAs or contracted entities acting on behalf of the HHA can report OASIS data to the state agency using the HAVEN software CMS provides free of charge or by using HAVEN-like software that conforms to the same specifications used to develop HAVEN.

Reported OASIS data will be analyzed and findings made available to HHA's by way of reports that will help HHA's identify their performance level in the provision of care to the patient population they serve as compared with other HHA's on either a national, state or local level.

As part of the ongoing survey process, state agencies may establish policies in keeping with unannounced surveys that include the ongoing request, at specified intervals, for the submission of a current census (number) of patients being serviced by the HHA. Census information should include only a count of non-Medicare/non-Medicaid patients. Since OASIS data on non-Medicare/non-Medicaid patients will be received by the OASIS state system in an unidentifiable format, names of non-Medicare/non-Medicaid patients on the census are not appropriate.

With this information, surveyors can conduct a gross comparison of patient counts to data from the OASIS state system and monitor, offsite, if required OASIS data are being transmitted to the state.

  1. Standard: Encoding and transmitting OASIS data. An HHA must encode and electronically transmit each completed OASIS assessment to the state agency or the CMS OASIS contractor, regarding each beneficiary with respect to which such information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary.

    Interpretive Guidelines §484.20(a)

    After OASIS data are collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points (i.e., start of care, resumption of care, follow-up, transfer to inpatient facility with or without discharge, discharge to community, and death at home), HHAs may take up to seven calendar days after the date of completion of the comprehensive assessment to enter (encode) the OASIS data into their computers using HAVEN or HAVEN-like software. The day the clinician completes the assessment is day zero for purposes of calculating the 7-day window. Encoding of all OASIS data items must be complete (i.e., locked) in order to accurately compute the information (health insurance prospective payment system or HIPPS code) necessary for billing Medicare patients under the prospective payment system.

    Pre-Survey Activity -- Check with the state OASIS Education or Automation Coordinator and/or review OASIS data management reports to determine if OASIS items are encoded, checked for errors and locked within 7 days of collection using Haven or Haven-like software (i.e., made transmission ready).

    Onsite Activity -- Check to see if the HHA is transmitting its own data or has an arrangement with an outside entity acting on behalf of the HHA to electronically submit OASIS data to the state agency. If so, make sure a written contract exists that describes the arrangement the HHA has with the outside entity to enter and transmit OASIS data on behalf of the HHA.

    Determine the process for encoding and locking OASIS data being readied for transmission to the state.

    If questions are raised through interview or record review, review the HHA's policies regarding encoding time frames.

    Initial Survey -- New HHA's seeking initial certification must apply for appropriate state and federal HHA identification and passwords and be able to demonstrate compliance with collecting, completing, encoding and reporting OASIS data for all applicable patients in an electronic format that meets CMS specifications prior to the initial survey.

  2. Standard: Accuracy of encoded OASIS data. The encoded OASIS data must accurately reflect the patient's status at the time of assessment.

    Interpretive Guidelines §484.20(b)

    Check to see how the HHA monitors the accuracy of their data to ensure the data collected, encoded, and reported accurately reflects the patient's status at the time of the assessment. Some tips for establishing a program to monitor the quality and accuracy of OASIS data are found in Chapter 12 of the OASIS Implementation Manual -- Data Quality Audits.

    Onsite Activity -- When reviewing the clinical records, determine that a visit was made to conduct the assessment, as applicable. Also, determine that other clinical information in the patient record does not contradict OASIS data collected during the assessment, encoded or reported.

    New patient admission -- If possible, include a home visit for a newly admitted patient who is scheduled to have a comprehensive assessment done. Determine that the OASIS data collected accurately reflects the patient's status at the time of the assessment.

    Patient currently on service -- If a home visit is made on a patient for whom an assessment has already been conducted and is not now scheduled to have one conducted, review the most current assessment and compare it with your observation of patient status, keeping in mind the patient's progress/decline and the normal progression of the clinical condition.

    Determine that other clinical information in the patient record does not contradict OASIS data.

  3. Standard: Transmittal of OASIS data. An HHA must --

    1. For all completed assessments, transmit OASIS data in a format that meets the requirements of paragraph (d) of this section.

      Interpretive Guidelines §484.20(c)(1)

      By the last day of the current month, HHA's must electronically transmit all OASIS data collected, encoded, and locked in the previous month for each patient (as applicable), to the state agency or CMS OASIS contractor. At a minimum, HHA's must transmit OASIS data at least monthly; HHA's may transmit OASIS data more frequently, if desired, and are free to develop schedules for transmitting data to best suit their needs.

      Rejected data that requires correcting and re-transmitting must be received by the OASIS state system within the same required time frame. Submission of data with identified fatal errors does not justify extending the required time frame. While overdue assessments will be accepted, HHA's (or their contracted vendors) may not wait until the end of the month to transmit their OASIS data in case errors are identified that require retransmittal or system problems develop that prevent transmission.

      Entities submitting OASIS data to the state agency or CMS OASIS contractor on behalf of the HHA (i.e., corporate offices or vendors under contract) must share the feedback reports with the HHA in order for them to monitor their encoding and transmission process.

      Pre-Survey Activity -- Check with the state OASIS Education or Automation Coordinator and/or review OASIS data management reports to determine if OASIS data are being transmitted as required. Determine whether the HHA is: (1) submitting data less often than monthly; and/or (2) has greater than 20 percent of records rejected in accordance with pre-survey preparation guidelines (SOM Section 2200).

      Onsite Activity -- If either probe noted above is triggered, investigate compliance with OASIS transmission requirements of this section, during the survey through the partial extended survey process. Ask the HHA to demonstrate how it creates, saves and transmits OASIS data to the state agency. Randomly select patient assessments and ask the HHA for the final validation report to demonstrate that they were received by the state.

    2. Successfully transmit test data to the state agency or CMS OASIS contractor.

      Interpretive Guidelines §484.20(c)(2)

      Determine that all required OASIS assessments are being transmitted.

      Certain missing information or inconsistencies will cause a record to be completely rejected requiring correction by the HHA and retransmission. These are called fatal errors. For example, a fatal error will occur when a record is submitted without the HHA's state-assigned identification number, without the patient's last name, when the record is a duplicate of one previously received or the record is missing or has an incorrect branch identification number in M0016. A complete listing of current record rejection criteria is available in the HHA Error Message Guide on the OASIS website (http://www.cms.hhs.gov/oasis/usermanu.asp).

      HHA's have the ability to electronically correct nearly all errors found in their production OASIS submissions that have been transmitted to the SA or CMS OASIS contractor. There is no current time limit to correcting errors in previously submitted records. SA should not be accepting requests for manual key field changes. Instead, HHA's should use the inactivation procedures to correct assessments containing key field errors. HAVEN 5.0 or above will give HHA's the ability to electronically correct nearly any kind of assessment errors.

    3. Transmit data using electronics communications software that provides a direct telephone connection from the HHA to the state agency or CMS OASIS contractor.

      Interpretive Guidelines §484.20(c)(3)

      The purpose of making a test transmission to the state agency or CMS OASIS contractor is to establish connectivity. Once the test has been successfully completed, HHA's must not routinely use the test function to prepare their submission of production (required) OASIS data.

      Initial Survey -- New HHA's seeking initial certification must apply for state and federal HHA identification numbers and passwords in order to demonstrate compliance with the OASIS submission requirements prior to Medicare approval.

      Prior to the initial survey, HHA's must demonstrate connectivity to the OASIS state system by --

      • Making a test transmission of any start of care or resumption of care OASIS data that passes CMS edit checks; and
      • Receiving validation reports back from the state confirming transmission of data.
    4. Transmit data that includes the CMS-assigned branch identification number, as applicable.

      Interpretive Guidelines §484.20(c)(4)

      HHA's must have a computer system that supports dial-up communications for the transmission of OASIS data to the state agency or CMS OASIS contractor, transmits the export files, and receives validation information. Corporate offices or contracted vendors submitting OASIS data on behalf of the HHA must provide the HHA with either an electronic copy of the validation information received from the state agency or CMS OASIS contractor, or a summary of that information.

      All HHA's must use of the Medicare Data Communication Network (MDCN) to connect to the state agency for submission of OASIS data. When incorporation is complete, OASIS data from branch locations may be submitted directly by the branch as long as the appropriate user identification and passwords have been obtained.

  4. Standard: Data Format. The HHA must encode and transmit data using the software available from CMS or software that conforms to CMS standard electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set.

    Interpretive Guidelines §484.20(d)

    Reasons for non-submission include lack of compliance with the requirement to electronically transmit OASIS data by the HHA, or transmission using an improper format. HHA's must encode and transmit data using the HAVEN software available from CMS or HAVEN-like software that conforms to all CMS data transmission specifications available on the OASIS website. The software must also include the most current version of the OASIS data items which are available on the OASIS website at all times.

    Pre-Survey Activity -- Review any OASIS state system data management reports to determine if there are indications of problems with OASIS data transmission. Check with the State OASIS Education or Automation coordinator to see if he/she has identified a problem with OASIS data transmission.

    Onsite Activity -- If problems with OASIS data transmission were determined during presurvey activity, on survey, interview the appropriate staff to assess the extent of the problem, and to identify steps the HHA is taking to correct any transmission problems.

§484.30 Condition of Participation: Skilled Nursing Services.

The HHA furnishes skilled nursing services by or under the supervision of a registered nurse and in accordance with the plan of care.

  1. Standard: Duties of the registered nurse. The registered nurse makes the initial evaluation visit, regularly reevaluates the patient's nursing needs, initiates the plan of care and necessary revisions, furnishes those services requiring substantial and specialized nursing skill, initiates appropriate preventive and rehabilitative nursing procedures, prepares clinical and progress notes, coordinates services, informs the physician and other personnel of changes in the patient's condition and needs, counsels the patient and family in meeting nursing and related needs, participates in in-service programs, and supervises and teaches other nursing personnel.

    Interpretive Guidelines 484.30(a)

    An RN is required to make the initial evaluation visit except in those circumstances where the physician has ordered only therapy services. If the physician orders only therapy services, it would be acceptable for the appropriate therapist (physical therapist or speech-language pathologist) to perform the initial evaluation visit. This does not mean that an HHA is precluded from having the RN perform all initial evaluation visits if the HHA believes that this promotes coordinated patient care, and/or if this is part of the HHA's own policies, procedures, and particular approach to patient care services.

    Review a case-mix, stratified sample of clinical records according to the HHA survey and certification process, and make home visits to determine if RNs perform their responsibilities within the state's nurse practice act and in compliance with the plan of care.

  2. Standard: Duties of the licensed practical nurse. The licensed practical nurse furnishes services in accordance with agency policies, prepares clinical and progress notes, assists the physician and registered nurse in performing specialized procedures, prepares equipment and materials for treatments observing aseptic technique as required, and assists the patient in learning appropriate self-care techniques.

    Interpretive Guidelines §484.30(b)

    Determine if services are provided in accordance with the HHA's professional practice standards and with guidance and supervision from RNs. Make the same comparisons set forth in the §484.30(a) probe when reviewing duties of the LPN.

§484.32 Condition of Participation: Therapy Services.

Any therapy services offered by the HHA directly or under arrangement are given by a qualified therapist or by a qualified therapy assistant under the supervision of a qualified therapist and in accordance with the plan of care. The qualified therapist assists the physician in evaluating level of function, helps develop the plan of care (revising it as necessary), prepares clinical and progress notes, advises and consults with the family and other agency personnel, and participates in in-service programs.

Probes §484.32

  • How does the HHA ensure that therapy services furnished by staff under arrangement or contract meet the requirements of this condition?
  • Does the clinical record documentation describe the patient responses to therapy?
  • How does the HHA coordinate therapy services with other skilled services to complete the plan of care and promote positive therapeutic outcomes?
  1. Standard: Supervision of physical therapy assistant and occupational therapy assistant. Services furnished by a qualified physical therapy assistant or qualified occupational therapy assistant may be furnished under the supervision of a qualified physical or occupational therapist. A physical therapy assistant or occupational therapy assistant performs services planned, delegated, and supervised by the therapist, assists in preparing clinical notes and progress reports, and participates in educating the patient and family, and in in-service programs.

    Interpretive Guidelines §484.32(a)

    Specific instructions for assistants must be based on treatments prescribed in the plan of care, patient evaluations by the therapist, and accepted standards of professional practice. The therapist evaluates the effectiveness of the services furnished by the assistant.

    Documentation in the clinical record should show that communication and supervision exist between the assistant and therapist about the patient's condition, the patient's response to services furnished by the assistant, and the need to change the plan of care.

§484.34 Condition of Participation: Medical Social Services.

If the agency furnishes medical social services, those services are given by a qualified social worker or by a qualified social work assistant under the supervision of a qualified social worker, and in accordance with the plan of care. The social worker assists the physician and other team members in understanding the significant social and emotional factors related to the health problems, participates in the development of the plan of care, prepares clinical and progress notes, works with the family, uses appropriate community resources, participates in discharge planning and in-service programs, and acts as a consultant to other agency personnel.

§484.48 Condition of Participation: Clinical Records.

A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary. The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient's medical and health status at discharge.

Interpretive Guidelines §484.48

The clinical record must provide a current, organized, and clearly written synopsis of the patient's course of treatment, including services provided for the HHA by arrangement or contract. The clinical record should facilitate effective, efficient, and coordinated care.

Questionable patterns, rather than isolated instances, in clinical records are an indicator that the quality of care provided by the HHA needs to be carefully assessed for compliance with the plan of care, coordination of service, concurrence with the HHA's stated policies and procedures, and evaluations of patient outcomes. However, isolated instances, depending on their nature and severity, can serve as the basis of a deficiency and enforcement action (e.g., immediate and serious threat as outlined in Appendix Q).

Electronic Signatures
While the regulations specify that documents must be signed, they do not prohibit the use of electronic signatures. HHA's that have created the option for an individual's record to be maintained by computer, rather than hard copy, may use electronic signatures as long as there is a process for reconstruction of the information, and there are safeguards to prevent unauthorized access to the records. If necessary, review written policies maintained by the HHA describing the clinical record and authentication policy(ies) in force. Clinical, progress notes, and summary reports as defined at §484.2 must be maintained on all patients.

Physician's Rubber Stamp Signatures
Home health agencies may accept a physician's rubber stamp signature for their clinical record documentation if this is permitted by federal, state and local law and authorized by the HHA's policy. The individual whose signature the stamp represents must place in the Administrative office of the agency a signed statement attesting that he/she is the only one who has the stamp and uses it. All state licensure and state practice regulations continue to apply to Medicare approved HHA's. Where state law is more restrictive than Medicare, the provider needs to apply the state law standard. Note that this does not supersede any current policy related to Medicare coverage and eligibility rules or instructions from the Regional Home Health Intermediaries.

Correction of Clinical Records
The HHA is encouraged to create policies and procedures that govern correction of clinical records. It is prudent for the HHA to include latitude for correction of records in the event of staff turnover or staff schedules. For example, a clinical supervisor may be permitted by agency policy to make corrections when the original clinician is no longer available due to staff turnover.

When a comprehensive assessment is corrected, the HHA must maintain the original assessment record as well as all subsequent corrected assessments in the patient's clinical record for 5 years, or longer, in accordance with the clinical record requirements at 42 CFR 484.48. If maintained electronically, the HHA must be capable of retrieving and reproducing a hard copy of these assessments upon request. It is acceptable to have multiple corrected assessments for an OASIS assessment, as long as the OASIS and the clinical record are documented in accordance with the requirements at 42 CFR 484.48, Clinical records.

Clinical Implications of Corrected Assessment Records
When corrections are made to an assessment already submitted to the state system, the HHA must determine if there is an impact on the patient's current care plan. If there is an impact, in addition to the correction made to the assessment, the HHA must make corresponding changes to the current plan of care. If there are any other records where the correction has an impact, for example, the Home Health Resource Group, the Plan of Treatment, or the Request for Anticipated Payment, the agency should make corresponding changes to that record, as applicable. The agency should establish a procedure to review the impact of any corrections made to assessment records and make corresponding changes to other records that are affected."

Some agencies use a manual corrections form for one or more OASIS items that can be acceptable after confirming the correction with the original clinician or as described in the agency's policies and procedures. As long as the correction form clearly identifies the item or items of the specific assessment and remain with the original assessment as part of the permanent record in order to have a complete picture of the entire assessment; these suggestions are consistent with CMS's overall guidelines for maintaining clinical records in accordance with accepted professional standards.

The regulations do not dictate the form to be used as a progress note and/or a summary report. Notations should be appropriately labeled and should provide an overall, comprehensive view of the patient's total progress and/or current summary report including social, emotional, or behavioral adjustments relative to the diagnosis, treatment, rehabilitation potential, and anticipated outcomes toward recovery or further debilitation.

The regulation does not dictate the frequency with which progress notes must be written. If necessary, review the HHA's policies and procedures concerning the frequency of preparing progress notes.

The discharge summary need not be a separate piece of paper and may be incorporated into the routine summary reports already furnished to the physician.

Probes §484.48

  • Are there patterns in the clinical records that are of concern?
  • Do clinical records document patient progress and outcomes of care based on changes in the patient's condition?
  • How does the HHA inform the attending physician of the availability of a discharge summary?
  • How does the HHA ensure that the discharge summary is sent to the attending physician upon his/her request?
  • If you have concerns about any part of the clinical record or correction policy ask the HHA to explain its process.
  1. Standards: Retention of records. Clinical records are retained for 5 years after the month the cost report to which the records apply is filed with the intermediary, unless state law stipulates a longer period of time. Policies provide for retention even if the HHA discontinues operations. If a patient is transferred to another health facility, a copy of the record or abstract is sent with the patient.

    Interpretive Guidelines §484.48(a)

    An HHA may store clinical and health insurance records electronically (i.e., on disk, on microfilm, or on optical disk imaging systems). This includes the storage of OASIS information. All material must be available for review by CMS, the intermediary, Department of Health and Human Services, or other specially designated components for bill review, audit, or other examination during the retention period.

    With respect to a state agency or federal survey to ensure compliance with the Conditions of Participation, clinical records requested by the surveyor, along with the equipment necessary to read them, must be made available during the course of the unannounced survey.

    The final validation reports from submission of OASIS records and OBQI/M reports are not part of the clinical record and as such need not be retained for 5 years. It is recommended that final validation reports be retained for a period of 12 months until the new expected annual OBQI/M reports are received.

  2. Standards: Protection of records. Clinical record information is safe-guarded against loss or unauthorized use. Written procedures govern use and removal of records and the conditions for release of information. Patient's written consent is required for release of information not authorized by law.

    Probes §484.48(b)

    • How are clinical records stored to protect them from physical destruction and unauthorized use?
    • What written policies and procedures govern the use, removal, and release of clinical records?
    • How does the HHA make the records available for all personnel furnishing services on behalf of the HHA?

§484.52 Condition of Participation: Evaluation of the Agency's Program.

The HHA has written policies requiring an overall evaluation of the agency's total program at least once a year by the group of professional personnel (or a committee of this group), HHA staff, and consumers, or by professional people outside the agency working in conjunction with consumers. The evaluation consists of an overall policy and administrative review and a clinical record review. The evaluation assesses the extent to which the agency's program is appropriate, adequate, effective, and efficient. Results of the evaluation are reported to and acted upon by those responsible for the operation of the agency and are maintained separately as administrative records.

(b) Standard: Clinical record review. At least quarterly, appropriate health professionals, representing at least the scope of the program, review a sample of both active and closed clinical records to determine whether established policies are followed in furnishing services directly or under arrangement. There is a continuing review of clinical records for each 60-day period that a patient receives home health services to determine adequacy of the plan of care and appropriateness of continuation of care.

Interpretive Guidelines §484.52(b)

Quarterly reviews need not be performed at a joint, sit-down meeting of the professionals performing the review. Each professional may review the records separately, at different times.

The HHA should evaluate all services provided for consistency with professional practice standards for HHA's and the HHA's policies and procedures, compliance with the plan of care, the appropriateness, adequacy, and effectiveness of the services offered, and evaluations of anticipated patient outcomes. Evaluations should be based on specific record review criteria that are consistent with the HHAs admission policies and other

HHA specific patient care policies and procedures. The review by appropriate health professionals should include those professionals representing the scope of services provided in that quarter. Therefore, for example, if no speech therapy services were performed, the speech therapist need not be a part of that quarterly review.

If the survey reveals that one (or more) approved services are never, or rarely, provided either for Medicare/Medicaid patients or non-Medicare/Medicaid patients, undertake the following actions to determine whether the HHA is complying with the patients' plans of care (§484.18):

  • Review the HHA's policies relevant to the evaluation of patient care needs.
  • Review HHA contracts for unservedor underserved services, if they are provided under contract or arrangement.
  • Review plans of care to determine if the services were ordered by a physician but not delivered.
  • Ask the HHA under what circumstances it would contact the patient's physician to request modification of a patient's plan of care.

Probes §484.52(b)

  1. What patterns or problems does the summary report of the clinical record reviews identify?
  2. What is the HHA's plan of correction? Are time frames for implementation and another evaluation review planned?
  3. How does the HHA select the clinical records to be reviewed?
  4. How do the procedures for review ensure that the review will ascertain whether:
  5. HHA policies and procedures are followed?
    • Patients are being helped to attain and maintain their highest practicable functional capacity?
    • Goals or anticipated patient outcomes are appropriate to the diagnosis(es), plan of care, services provided, and patient potential?

§484.55 Condition of Participation: Comprehensive Assessment of Patients.

Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. The comprehensive assessment must identify the patient's continuing need for home care and meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. The comprehensive assessment must also incorporate the use of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary.

Interpretive Guidelines §484.55

The comprehensive assessment includes the collection of OASIS data items for most patients, as described below, by a qualified clinician (i.e., an RN, physical therapist, occupational therapist, or speech language pathologist). For Medicare patients, there are some additional requirements. HHAs are expected to conduct a comprehensive assessment of each patient that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires, per the requirements at 42 CFR 484.18 (a) and (b).

The requirement to conduct a drug regimen review at §484.55(c) as part of the comprehensive assessment applies to all patients serviced by the HHA.

...in addition to an initial assessment visit, the HHA must also conduct a start of care comprehensive assessment with OASIS data items integrated on patients to whom the requirements are applicable. Subsequent comprehensive assessments (updates and recertification) must be conducted at certain time points during the admission. These updates must include certain data items (i.e., those in the current OASIS data set). The recertification, transfer to an inpatient facility, resumption of care, significant change in condition (SCIC), and discharge comprehensive assessment apply to all patients, but it does not have to include OASIS for private pay patients. The recertification comprehensive assessment can be completed before the 5 day window as long as it continues to be done "not less frequently than the last five days of every 60 day episode beginning with the start-of-care date."

OASIS data items are not meant to be the only items included in an HHA's assessment process. They are standardized health assessment items that must be incorporated into an HHA's own existing assessment policies and process. An example of a comprehensive assessment showing an integration of the OASIS data items with other agency assessment items can be found in "Appendix C: Sample Clinical Records Incorporating OASIS B-1 Data Set," in the OASIS User's Manual. For therapy-only cases, the comprehensive assessment should incorporate OASIS data items as well as other assessment data items the HHA currently collects for therapy patients, as opposed to simply adding them at the beginning or end.

Medicare patients: For Medicare patients, the HHA must include a determination of the patient's eligibility for the home health benefit, including homebound status.

Incorporating OASIS items: HHA's must incorporate the OASIS data items into their own assessment instrument using the exact language of the items, replacing similar items/questions on their current assessment tool as opposed to simply adding the OASIS items at the beginning or end of the existing assessment tool.

  1. Standard: Initial assessment visit.

    1. A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician-ordered start of care date.

      Interpretive Guidelines §484.55(a)(1)

      The initial assessment visit is conducted to determine the immediate care and support needs of the patient.

      For Medicare patients, the initial assessment visit must include a determination of the patient's eligibility for the home health benefit, including homebound status. Verification of a patient's eligibility for the Medicare home health benefit including homebound status does not apply to Medicaid patients, beneficiaries receiving Medicare outpatient services, or private pay patients.

      Review a case-mix, stratified sample of clinical records and make home visits according to the survey process (see §§2200 and 2202) to determine compliance with this requirement.

      For Medicare patients, if the initial assessment indicates that the patient is not eligible for the Medicare home health care benefit (i.e., the patient is not homebound, has no skilled need, etc.), and the HHA does not admit the patient, then there is no indication for the HHA to conduct a comprehensive assessment or to collect, encode, or transmit OASIS data to the state.

    2. When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional.

      Interpretive Guidelines §484.55(a)(2)

      For non-Medicare patients, if the need for a single therapy service establishes initial home health eligibility, the corresponding practitioner, (including a physical therapist, speech-language pathologist, or occupational therapist) can conduct the initial assessment visit.

      For the Medicare home health benefit, occupational therapy services provided at the start of care alone do not establish eligibility; therefore, occupational therapists may not conduct the initial assessment visit under Medicare. Patients needing only occupational therapy services on admission to the agency may qualify for eligibility under programs other than Medicare.

      When physical therapy (PT), speech language pathology (SLP), or occupational therapy (OT) is the only service ordered by the physician, a PT, SLP, or OT may complete the initial assessment visit if the need for that service establishes program eligibility.

      Review a case-mix, stratified sample of clinical records and make home visits according to the survey process (see §§2200 and 2202) to determine compliance with this requirement. For a sample of patients, determine who conducted the initial assessments, if the homebound status for Medicare was identified, and the dates of the referral and initial assessments.

      Probes §484.55(a)(2)

      Review patient records in which therapy (occupational therapy, physical therapy, or speech language pathology) was the only skilled service provided. Determine if the appropriate discipline completed the initial assessment. According to state law, some HHA's may use RNs for initial assessments in therapy-only cases.

  2. Standard: Completion of the comprehensive assessment.

    1. The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care.

    2. Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status.

    3. When physical therapy, speech-language pathology, or occupational therapy is the only service ordered by the physician, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility.

  3. Standard: Drug regimen review. The comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

  4. Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than --

    1. The last 5 days of every 60 days beginning with the start-of-care date, unless there is a --

      1. Beneficiary elected transfer;
      2. Significant change in condition; or
      3. Discharge and return to the same HHA during the 60-day episode.
    2. Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests;

    3. At discharge.

  5. Standard: Incorporation of OASIS data items. The OASIS data items determined by the Secretary must be incorporated into the HHA's own assessment and must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentarystatus, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only.

D. Federal Regulations -- Conditions for Participation, Hospice [Excepts Pertaining to Medical Records]4

§418.22 Certification of Terminal Illness.

(b) Content of certification. Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements:

  1. The certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.

  2. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment.

  3. The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

    1. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature.
    2. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.
    3. The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his/her examination of the patient.
    4. The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients.
    5. The narrative associated with the third benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less.
  4. The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.

  5. All certifications and recertifications must be signed and dated by the physician(s), and must include the benefit period dates to which the certification or recertification applies.

(c) Sources of certification.

  1. For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from --

    1. The medical director of the hospice or the physician member of the hospice interdisciplinary group; and
    2. The individual's attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in §410.20 of this subchapter.
  2. For subsequent periods, the only requirement is certification by one of the physicians listed in paragraph (c)(1)(i) of this section.

(d) Maintenance of records. Hospice staff must --

  1. Make an appropriate entry in the patient's medical record as soon as they receive an oral certification; and

  2. File written certifications in the medical record.

§418.26 Dischargefrom Hospice Care.

  1. Reasons for discharge. A hospice may discharge a patient if --

    1. The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause that meets the requirements of paragraphs (a)(3)(i) through (a)(3)(iv) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. The hospice must do the following before it seeks to discharge a patient for cause:

      (iv) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its medical records.

  2. Discharge order. Prior to discharging a patient for any reason listed in paragraph (a) of this section, the hospice must obtain a written physician's discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.

§418.52 Condition of Participation: Patient's Rights.

(c) Standard: Rights of the patient. The patient has a right to the following:

  1. Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164.

(e) Standard: Patient outcome measures.

  1. The comprehensive assessment must include data elements that allow for measurement of outcomes. The hospice must measure and document data in the same way for all patients. The data elements must take into consideration aspects of care related to hospice and palliation.

  2. The data elements must be an integral part of the comprehensive assessment and must be documented in a systematic and retrievable way for each patient. The data elements for each patient must be used in individual patient care planning and in the coordination of services, and must be used in the aggregate for the hospice's quality assessment and performance improvement program.

§418.56 Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services.

The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

(d) Standard: Content of the plan of care. The hospice must develop an individualized written plan of care for each patient.

(e) Standard: Coordination of services. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to --

  1. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.

  2. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.

§418.58 Condition of Participation: Quality Assessment and Performance Improvement.

The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS.

§418.104 Condition of Participation: Clinical Records.

A clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient's attending physician and hospice staff. The clinical record may be maintained electronically.

  1. Standard: Content. Each patient's record must include the following:

    1. The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes.

    2. Signed copies of the notice of patient rights in accordance with §418.52 and election statement in accordance with §418.24.

    3. Responses to medications, symptom management, treatments, and services.

    4. Outcome measure data elements, as described in §418.54(e) of this subpart.

    5. Physician certification and recertification of terminal illness as required in §§418.22 and 418.25 and described in §§418.102(b) and 418.102(c) respectively, if appropriate.

    6. Any advance directives as described in §418.52(a)(2).

    7. Physician orders.

  2. Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice.

  3. Standard: Protection of information. The clinical record, its contents and the information contained therein must be safeguarded against loss or unauthorized use. The hospice must be in compliance with the Department's rules regarding personal health information as set out at 45 CFR parts 160 and 164.

  4. Standard: Retention of records. Patient clinical records must be retained for 6 years after the death or discharge of the patient, unless state law stipulates a longer period of time. If the hospice discontinues operation, hospice policies must provide for retention and storage of clinical records. The hospice must inform its state agency and its CMS Regional office where such clinical records will be stored and how they may be accessed.

  5. Standard: Discharge or transfer of care.

    1. If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward to the receiving facility, a copy of --

      1. The hospice discharge summary; and
      2. The patient's clinical record, if requested.
    2. If a patient revokes the election of hospice care, or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician, a copy of --

      1. The hospice discharge summary; and
      2. The patient's clinical record, if requested.
    3. The hospice discharge summary as required in paragraph (e)(1) and (e)(2) of this section must include --

      1. A summary of the patient's stay including treatments, symptoms and pain management.
      2. The patient's current plan of care.
      3. The patient's latest physician orders. and
      4. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.
  6. Standard: Retrieval of clinical records. The clinical record, whether hard copy or in electronic form, must be made readily available on request by an appropriate authority.

§418.106 Condition of Participation: Drugs and Biologicals, Medical Supplies, and Durable Medical Equipment.

(b) Standard: Ordering of drugs.

  1. Only a physician as defined by section 1861(r)(1) of the Act, or a nurse practitioner in accordance with the plan of care and state law, may order drugs for the patient.

  2. If the drug order is verbal or given by or through electronic transmission --

    1. It must be given only to a licensed nurse, nurse practitioner (where appropriate), pharmacist, or physician; and
    2. The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with state and federal regulations.

(e) Standard: Labeling, disposing, and storing of drugs and biologicals

  1. Disposing.

    (C) Document in the patient's clinical record that the written policies and procedures for managing controlled drugs was provided and discussed.

§418.108 Condition of Participation: Short-Term Inpatient Care.

(c) Standard: Inpatient care provided under arrangements. If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice, and at a minimum specifies --

  1. That the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge;

§418.112 Condition of Participation: Hospices that Provide Hospice Care to Residents of a SNF/NF or ICF/IID.

(d) Standard: Hospice plan of care. In accordance with §418.56, a written hospice plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided must be in accordance with this hospice plan of care.

  1. The hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care.

  2. The hospice plan of care reflects the participation of the hospice, the SNF/NF or ICF/IID, and the patient and family to the extent possible.

  3. Any changes in the hospice plan of care must be discussed with the patient or representative, and SNF/NF or ICF/IID representatives, and must be approved by the hospice before implementation.

(e) Standard: Coordination of services. The hospice must:

  1. Designate a member of each interdisciplinary group that is responsible for a patient who is a resident of a SNF/NF or ICF/IID. The designated interdisciplinary group member is responsible for:

    1. Providing overall coordination of the hospice care of the SNF/NF or ICF/IID resident with SNF/NF or ICF/IID representatives; and
    2. Communicating with SNF/NF or ICF/IID representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family.
  2. Ensure that the hospice IDG communicates with the SNF/NF or ICF/IID medical director, the patient's attending physician, and other physicians participating in the provision of care to the patient as needed to coordinate the hospice care of the hospice patient with the medical care provided by other physicians.

  3. Provide the SNF/NF or ICF/IID with the following information:

    1. The most recent hospice plan of care specific to each patient;
    2. Hospice election form and any advance directives specific to each patient;
    3. Physician certification and recertification of the terminal illness specific to each patient;
    4. Names and contact information for hospice personnel involved in hospice care of each patient;
    5. Instructions on how to access the hospice's 24-hour on-call system;
    6. Hospice medication information specific to each patient; and
    7. Hospice physician and attending physician (if any) orders specific to each patient.

§418.205 Special Requirements for Hospice Pre-Election Evaluation and Counseling Services.

(b) General.

  1. Documentation.

    1. If the individual's physician initiates the request for services of the hospice medical director or physician, appropriate documentation is required.
    2. The request or referral must be in writing, and the hospice medical director or physician employee is expected to provide a written note on the patient's medical record.
    3. The hospice agency employing the physician providing these services is required to maintain a written record of the services furnished.
    4. If the services are initiated by the beneficiary, the hospice agency is required to maintain a record of the services and documentation that communication between the hospice medical director or physician and the beneficiary's physician occurs, with the beneficiary's permission, to the extent necessary to ensure continuity of care.

E. Federal Regulations -- Comprehensive Outpatient Rehabilitation Facilities Conditions of Participation [Excepts Pertaining to Medical Records]

§485.56 Condition of Participation: Governing Body and Administration.

  1. Criteria for patient admission, continuing care, and discharge.

  2. Procedures for preparing and maintaining clinical records on all patients.

  3. A procedure for explaining to the patient and the patient's family the extent and purpose of the services to be provided.

  4. A procedure to assist the referring physician in locating another level of care for -- patients whose treatment has terminated and who are discharged.

  5. A requirement that patients accepted by the facility must be under the care of a physician.

  6. A requirement that there be a plan of treatment established by a physician for each patient.

  7. A procedure to ensure that the group of professional personnel reviews and takes appropriate action on recommendations from the utilization review committee regarding patient care policies.

F. Federal Regulations -- Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services [Excepts Pertaining to Medical Records]5

§485.711 Condition of Participation: Plan of Care and Physician Involvement.

For each patient in need of outpatient physical therapy or speech pathology services, there is a written plan of care established and periodically reviewed by a physician, or by a physical therapist or speech pathologist respectively.

  1. Standard: Medical history and prior treatment. The following are obtained by the organization before or at the time of initiation of treatment:

    1. The patient's significant past history.

    2. Current medical findings, if any.

    3. Diagnosis(es), if established.

    4. Physician's orders, if any.

    5. Rehabilitation goals, if determined.

    6. Contraindications, if any.

    7. The extent to which the patient is aware of the diagnosis(es) and prognosis.

    8. If appropriate, the summary of treatment furnished and results achieved during previous periods of rehabilitation services or institutionalization.

  2. Standard: Plan of care.

    1. For each patient there is a written plan of care established by the physician or by the physical therapist or speech-language pathologist who furnishes the services.

    2. The plan of care for physical therapy or speech pathology services indicates anticipated goals and specifies for those services the --

      1. Type;
      2. Amount;
      3. Frequency; and
      4. Duration.
    3. The plan of care and results of treatment are reviewed by the physician or by the individual who established the plan at least as often as the patient's condition requires, and the indicated action is taken.

    4. Changes in the plan of care are noted in the clinical record. If the patient has an attending physician, the therapist or speech-language pathologist who furnishes the services promptly notifies him or her of any change in the patient's condition or in the plan of care.

§485.721 Condition of Participation: Clinical Records.

The organization maintains clinical records on all patients in accordance with accepted professional standards, and practices. The clinical records are completely and accurately documented, readily accessible, and systematically organized to facilitate retrieving and compiling information.

  1. Standard: Protection of clinical record information. The organization recognizes the confidentiality of clinical record information and provides safeguards against loss, destruction, or unauthorized use. Written procedures govern the use and removal of records and the conditions for release of information. The patient's written consent is required for release of information not authorized by law.

  2. Standard: Content. The clinical record contains sufficient information to identify the patient clearly, to justify the diagnosis(es) and treatment, and to document the results accurately. All clinical records contain the following general categories of data:

    1. Documented evidence of the assessment of the needs of the patient, of an appropriate plan of care, and of the care and services furnished.

    2. Identification data and consent forms.

    3. Medical history.

    4. Report of physical examinations, if any.

    5. Observations and progress notes.

    6. Reports of treatments and clinical findings.

    7. Discharge summary including final diagnosis(es) and prognosis.

  3. Standard: Completion of records and centralization of reports. Current clinical records and those of discharged patients are completed promptly. All clinical information pertaining to a patient is centralized in the patient's clinical record. Each physician signs the entries that he or she makes in the clinical record.

  4. Standard: Retention and preservation. Clinical records are retained for at least:

    1. The period determined by the respective state statute, or the statute of limitations in the state; or

    2. In the absence of a state statute --

      1. Five years after the date of discharge; or
      2. In the case of a minor, 3 years after the patient becomes of age under state law or 5 years after the date of discharge, whichever is longer.
  5. Standard: Indexes. Clinical records are indexed at least according to name of patient to facilitate acquisition of statistical medical information and retrieval of records for research or administrative action.

  6. Standard: Location and facilities. The organization maintains adequate facilities and equipment, conveniently located, to provide efficient processing of clinical records (reviewing, indexing, filing, and prompt retrieval).

G. Federal Regulations -- Conditions for Coverage, Ambulatory Surgical Center [Excepts Pertaining to Medical Records]6

§416.47 Condition for Coverage -- Medical Records.

The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care.

  1. Standard: Organization. The ASC must develop and maintain a system for the proper collection, storage, and use of patient records.

  2. Standard: Form and content of record. The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed. Medical records must include at least the following:

    1. Patient identification.

    2. Significant medical history and results of physical examination.

    3. Pre-operative diagnostic studies (entered before surgery), if performed.

    4. Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body.

    5. Any allergies and abnormal drug reactions.

    6. Entries related to anesthesia administration.

    7. Documentation of properly executed informed patient consent.

    8. Discharge diagnosis.

H. Federal Regulations -- Conditions for Coverage, End Stage Renal Disease Facility [Excepts Pertaining to Medical Records]7

§494.170 Condition: Medical Records.

The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.

  1. Standard: Protection of the patient's record. The dialysis facility must --

    1. Safeguard patient records against loss, destruction, or unauthorized use; and

    2. Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following:

      1. The transfer of the patient to another facility.
      2. Certain exceptions provided for in the law.
      3. Provisions allowed under third party payment contracts.
      4. Approval by the patient.
      5. Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.
    3. Obtaining written authorization from the patient or legal representative before releasing information that is not authorized by law.

  2. Standard: Completion of patient records and centralization of clinical information.

    1. Current medical records and those of discharged patients must be completed promptly.

    2. All clinical information pertaining to a patient must be centralized in the patient's record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient's condition and prescribed treatment.

    3. The dialysis facility must complete, maintain, and monitor home care patients' records, including the records of patients who receive supplies and equipment from a durable medical equipment supplier.

  3. Standard: Record retention and preservation. In accordance with 45 CFR §164.530(j)(2), all patient records must be retained for 6 years from the date of the patient's discharge, transfer, or death.

  4. Standard: Transfer of patient record information. When a dialysis patient is transferred, the dialysis facility releasing the patient must send all requested medical record information to the receiving facility within 1 working day of the transfer.

I. Federal Regulations -- Facility Conditions of Participation, Psychiatric Hospitals [Excepts Pertaining to Medical Records]8

§482.1 Basis and Scope (Conditions of Participation for Hospitals; Subpart A, General Provisions)

  1. Statutory basis.

    1. Section 1861(f) of the Act provides that an institution participating in Medicare as a psychiatric hospital must meet certain specified requirements imposed on hospitals under section 1861(e), must be primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons, must maintain clinical records and other records that the Secretary finds necessary, and must meet staffing requirements that the Secretary finds necessary to carry out an active program of treatment for individuals who are furnished services in the hospital. A distinct part of an institution can participate as a psychiatric hospital if the institution meets the specified 1861(e) requirements and is primarily engaged in providing psychiatric services, and if the distinct part meets the records and staffing requirements that the Secretary finds necessary.

§482.60 Special Provisions Applying to Psychiatric Hospitals.

Psychiatric hospital must --

(c) Maintain clinical records on all patients, including records sufficient to permit CMS to determine the degree and intensity of treatment furnished to Medicare beneficiaries, as specified in §482.61.

§482.61 Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals.

The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution.

  1. Standard: Development of assessment/diagnostic data. Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized.

    1. The identification data must include the patient's legal status.

    2. A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnoses of intercurrentdiseases as well as the psychiatric diagnoses.

    3. The reasons for admission must be clearly documented as stated by the patient and/or others significantly involved.

    4. The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.

    5. When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.

  2. Standard: Psychiatric evaluation. Each patient must receive a psychiatric evaluation that must --

    1. Be completed within 60 hours of admission;

    2. Include a medical history;

    3. Contain a record of mental status;

    4. Note the onset of illness and the circumstances leading to admission;

    5. Describe attitudes and behavior;

    6. Estimate intellectual functioning, memory functioning, and orientation; and

    7. Include an inventory of the patient's assets in descriptive, not interpretative, fashion.

  3. Standard: Treatment plan.

    1. Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the patient's strengths and disabilities. The written plan must include --

      1. A substantiated diagnosis;
      2. Short-term and long-range goals;
      3. The specific treatment modalities utilized;
      4. The responsibilities of each member of the treatment team; and
      5. Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.
    2. The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included.

  4. Standard: Recording progress. Progress notes must be recorded by the doctor of medicine or osteopathy responsible for the care of the patient as specified in §482.12(c), nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but must be recorded at least weekly for the first 2 months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the patient's progress in accordance with the original or revised treatment plan.

  5. Standard: Discharge planning and discharge summary. The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient's condition on discharge.

§412.27 Excluded Psychiatric Units: Additional Requirements.

In order to be excluded from the prospective payment system..., a psychiatric unit must meet the following requirements:

(c) Maintain medical records that permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the unit, and that meet the following requirements:

  1. Development of assessment/diagnostic data. Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the inpatient is treated in the unit.

    1. The identification data must include the inpatient's legal status.
    2. A provisional or admitting diagnosis must be made on every inpatient at the time of admission, and must include the diagnoses of intercurrentdiseases as well as the psychiatric diagnoses.
    3. The reasons for admission must be clearly documented as stated by the inpatient or others significantly involved, or both.
    4. The social service records, including reports of interviews with inpatients, family members, and others must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.
    5. When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.
  2. Psychiatric evaluation. Each inpatient must receive a psychiatric evaluation that must --

    1. Be completed within 60 hours of admission;
    2. Include a medical history;
    3. Contain a record of mental status;
    4. Note the onset of illness and the circumstances leading to admission;
    5. Describe attitudes and behavior;
    6. Estimate intellectual functioning, memory functioning, and orientation; and
    7. Include an inventory of the inpatient's assets in descriptive, not interpretative fashion.
  3. Treatment plan.

    1. Each inpatient must have an individual comprehensive treatment plan that must be based on an inventory of the inpatient's strengths and disabilities. The written plan must include a substantiated diagnosis; short-term and long-term goals; the specific treatment modalities utilized; the responsibilities of each member of the treatment team; and adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out; and
    2. The treatment received by the inpatient must be documented in such a way as to assure that all active therapeutic efforts are included.
  4. Recording progress. Progress notes must be recorded by the doctor of medicine or osteopathy responsible for the care of the inpatient, a nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the inpatient but must be recorded at least weekly for the first 2 months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the inpatient's progress in accordance with the original or revised treatment plan.

  5. Discharge planning and discharge summary. The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the inpatient's hospitalization in the unit and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient's condition on discharge.

J. Federal Regulations -- Conditions for Certification, Rural Health Clinics, and Conditions for Coverage, FQHCs [Excepts Pertaining to Medical Records]

§491 Certification of Certain Health Facilities

Subpart A -- Rural Health Clinics: Conditions for Certification; and FQHCs Conditions for Coverage

§491.10 Patient Health Records.

  1. Records system.

    1. The clinic or center maintains a clinical record system in accordance with written policies and procedures.

    2. A designated member of the professional staff is responsible for maintaining the records and for insuring that they are completely and accurately documented, readily accessible, and systematically organized.

    3. For each patient receiving health care services, the clinic or center maintains a record that includes, as applicable:

      1. Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;
      2. Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;
      3. All physician's orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress;
      4. Signatures of the physician or other health care professional.
  2. Protection of record information.

    1. The clinic or center maintains the confidentiality of record information and provides safeguards against loss, destruction or unauthorized use.

    2. Written policies and procedures govern the use and removal of records from the clinic or center and the conditions for release of information.

    3. The patient's written consent is required for release of information not authorized to be released without such consent.

  3. Retention of records. The records are retained for at least 6 years from date of last entry, and longer if required by state statute.

K. Federal Regulations -- Conditions of Participation, Intermediate Care Facilities for the Mentally Retarded [Developmentally Disabled] [Excepts Pertaining to Medical Records]9

Subpart I -- Conditions of Participation for Intermediate Care Facilities for Individuals with Intellectual Disabilities

§483.410 Condition of Participation: Governing Body and Management.

(c) Standard: Client records.

  1. The facility must develop and maintain a recordkeeping system that includes a separate record for each client and that documents the client's health care, active treatment, social information, and protection of the client's rights.

  2. The facility must keep confidential all information contained in the clients' records, regardless of the form or storage method of the records.

  3. The facility must develop and implement policies and procedures governing the release of any client information, including consents necessary from the client, or parents (if the client is a minor) or legal guardian.

  4. Any individual who makes an entry in a client's record must make it legibly, date it, and sign it.

  5. The facility must provide a legend to explain any symbol or abbreviation used in a client's record.

  6. The facility must provide each identified residential living unit with appropriate aspects of each client's record.

§483.440 Condition of Participation: Active Treatment Services.

(b) Standard: Admissions, transfers, and discharge.

  1. If a client is to be either transferred or discharged, the facility must --

    1. Have documentation in the client's record that the client was transferred or discharged for good cause
  2. At the time of the discharge, the facility must --

    1. Develop a final summary of the client's developmental, behavioral, social, health and nutritional status and, with the consent of the client, parents (if the client is a minor) or legal guardian, provide a copy to authorized persons and agencies; and
    2. Provide a post-discharge plan of care that will assist the client to adjust to the new living environment.

§483.460 Condition of Participation: Health Care Services.

(h) Standard: Documentation of dental services.

  1. If the facility maintains an in-house dental service, the facility must keep a permanent dental record for each client, with a dental summary maintained in the client's living unit.

  2. If the facility does not maintain an in-house dental service, the facility must obtain a dental summary of the results of dental visits and maintain the summary in the client's living unit.

(j) Standard: Drug regimen review.

  1. The pharmacist must prepare a record of each client's drug regimen reviews and the facility must maintain that record.

  2. An individual medication administration record must be maintained for each client.

Notes

  1. Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

  2. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

  3. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=2c0d6cefce8daa249571bfb22e865528&rgn=div5&view=text&node=42:5.0.1.1.3&idno=42#42:5.0.1.1.3.2.7.6.

  4. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=aec381340057f7b4eb73bab508d2a3e8&tpl=/ecfrbrowse/Title42/42cfr418_main_02.tpl.

  5. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=41203e44b7b2b8457802dc82530232af;rgn=div5;view=text;node=42%3A5.0.1.1.4;idno=42;cc=ecfr#42:5.0.1.1.4.6.7.1.

  6. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=aec381340057f7b4eb73bab508d2a3e8&rgn=div8&view=text&node=42:3.0.1.1.3.3.1.8&idno=42.

  7. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=aec381340057f7b4eb73bab508d2a3e8&tpl=/ecfrbrowse/Title42/42cfr494_main_02.tpl.

  8. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=41203e44b7b2b8457802dc82530232af;rgn=div5;view=text;node=42%3A5.0.1.1.1;idno=42;cc=ecfr#42:5.0.1.1.1.5.4.1.

  9. See http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=82d96ee680e3f752e0d847653203c6df;rgn=div5;view=text;node=42%3A5.0.1.1.2;idno=42;cc=ecfr#42:5.0.1.1.2.9.

[Return to the Table of Contents]

 

APPENDIX R. TECHNICAL ADVISORY GROUP SUMMARY

This appendix provides a summary of the Technical Advisory Group (TAG) meeting held at HHS on June 13, 2012. The TAG meeting brought together experts to provide feedback and input to advise the contractor (the AHIMA Foundation) on ineligible providers and incentive/funding considerations. The information from the TAG was used in the development of a final report to ASPE to support preparation of the report required by the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5). The TAG's specific role was to perform the following:

  • Provide feedback on the:

    • identification and categorization of providers ineligible for incentives/other funding of use of EHRs; and
    • completeness/accuracyof identified EHR incentives/funding options.
  • Consider whether current incentives/other funding to support the use of certified EHRs will be sufficient to:

    • achieve the goals of the EHR Incentive Programs for Eligible Professionals/Eligible Hospitals;
    • support the use of certified EHRs/health IT by all/some of the ineligible providers; and
    • if the current support is sufficient, why and how; and if not, why not.
  • Identify factors that should be considered when examining the costs of making available at least some incentives/ funding options for certain ineligible providers.

  • Identify barriers to implementing incentives/other options and methods to address identified barriers.

Summary: The TAG focused on the following key themes throughout the meeting:

  • Establish goals for what is to be achieved with the availability of additional incentives and/or other funding for ineligible providers. These goals should be:

    • Focused on the patient and support the Center for Medicare and Medicaid Innovation (CMMI) Triple Aim.
    • Future-looking to support new healthcare delivery and payment models.
    • Supportive of meaningful use by eligible hospitals and eligible professionals.
  • Do not apply a one-size-fits-all approach to incentive and/or other funding programs targeted at ineligible providers. Programs should be prioritized for targeted providers and custom fit to help the providers overcome barriers in achieving the desired goal.

  • Prioritize the LTPAC and Behavioral Health ineligible providers for incentives and/or other funding.

  • Do not limit programs to just EHR technology. Application and modules may be appropriate to facilitate interoperable health information exchange.

TAG Feedback on Ineligible Providers

The TAG reviewed the methodology for selecting the ineligible providers to be the focus of the study and final report (Figure R1 outlines the methodology used). The TAG agreed with the methodology used to identify and select the ineligible providers focusing on providers who are identified in HITECH §3000(3), grouping the providers into two categories -- those eligible for payment incentives under HITECH and those who are ineligible, and selecting the ineligible providers who participate in the Medicare and Medicaid programs.

The TAG reviewed and provided feedback on the providers who were identified as ineligible for payment incentives under HITECH. Based on the methodology used to identify the ineligible providers, not all providers in the United States health care system will be the focus of this study. The TAG noted that there are health care provider organizations (facility/place), professionals/ practitioners (people), and health care service programs. To remain consistent with the HITECH, healthcare services (such as home and community-based services) are not included in this study.

Other TAG recommendations:

  • Correctional Facilities, Jails, and Prisons are not identified as providers in HITECH or eligible for Medicare and/or Medicaid, however, the TAG discussed the importance of having health information available and exchanged particularly when inmates leave the prison system and require continued treatment and services for medical and/or behavioral health conditions.

  • Some of the ineligible providers may have access to certified EHR technology through their affiliation with an eligible hospital or eligible professional.

    • Reevaluate Ambulatory Surgery Centers on the ineligible provider list. Their eligibility may be an issue of affiliation or ownership (i.e., hospital-based).
  • Recognize that the ancillary providers identified in the Other Healthcare Provider section may not use EHR, but may merely require an interface (as discussed above for labs, pharmacies, blood banks, and ambulance services). Reconsider these providers on the ineligible provider list because they are a service organization and do not maintain an EHR. They provide valuable information and must have the capability to exchange information with an EHR. The TAG suggested a footnote in the main report that expresses the importance of these providers to interoperability exchange of health information.

Current Environment and Drivers for EHR Technology Adoption

The TAG discussed the current environment and drivers for adoption. As part of that discussion, they reviewed and commented on the proposed evaluation criteria definitions below and identified additional evaluation criteria.

The TAG recommended that the final report define a goal to be met with incentives or other funding that supports a provider's interoperability to benefit the patient and CMMI Triple Aim: better health in the overall population, better health care delivery, and reduction in per capita cost of care. The goal would serve as a point of focus for evaluation criteria on how the technology supports the interoperability and the CMMI Triple Aim.

The TAG identified three important factors in evaluating the use of EHRs/health IT by ineligible providers. The major difference from the proposed criteria is to differentiate between use and utility on how it benefits the provider and how it benefits the patient/society to improve care.

FIGURE R1. TAG Priorities for Evaluation Criteria
Level of Technology Adoption Benefit of Technology to the Provider Benefit of Technology to the Patient and to Improve Patient Care
  • Denominator for each sector is crucial to understand adoption rates when being used for incentives
  • Determine adoption rates for the subset of providers that receive Medicare and Medicaid
  • How provides use technology to benefit their business
  • Agreed with prioritizing meaningful use criteria but recognized that it may not apply to all ineligible providers
  • Prioritize technology and functionality that will benefit the patient
  • Improves care for the patient
  • Improves the value of care (cost & efficiency)
  • Addresses re-hospitalizations
  • Addresses societal needs

TAG Discussion on Adoption Rates of EHR Technology by Ineligible Providers

The TAG did not support limiting the measurement of EHR adoption rates to certified EHR technology (CEHRT) because the definitions do not apply to the ineligible providers. They recognized that adoption statistics for EHR technology are an important factor when determining incentive or funding options, however, concerns were raised about the ability to measure adoption in a consistent manner against national averages.1 While ONC reports EHR adoption statistics for eligible hospitals and professionals on their dashboard,2 standardized definitions and surveys are not in place for ineligible providers except Federally Qualified Health Centers. HRSA collects EHR data from Centers from the Uniform Data Systems administrative dataset.

TAG Discussion on Clinical Utility of EHR Technology by Ineligible Providers

The TAG viewed clinical utility differently than the proposed definition which focused on how the technology supported the provider's clinical and business operations. They recommend that clinical utility be framed from the patient's perspective -- how technology supports patient care, coordination, and transitions. The TAG recommended that clinical utility be defined as how the EHR technology directly enables the provider's ability to deliver efficient and effective patient care. Considerations include:

  • How is patient care affected by technology?

  • Will having this technology improve care?

  • Will some providers have a greater need for technology to share information than others? For example, some consideration highlighted by the TAG include:

    • Patients who have high re-admission rates;
    • Providers who serve patients with multiple, chronic conditions and require multiple care givers to share and coordinate care; and/or
    • Providers who support patients who are a lifetime residents and require frequent interaction with the continuum of care (such as providers serving the developmentally disabled).

The TAG noted that the clinical utility of an EHR may be greater for providers who serve patients with numerous transitions and/or re-hospitalizations. There is a similar direct relationship between clinical utility and providers serving lifetime patients where there are frequent care coordination needs with multiple specialists.

TAG Discussion on Use of Technology by ineligible Providers

The TAG supported the use of a technology definition focused on meaningful use stage criteria. They agreed that some providers had a greater need to use technology. The TAG also noted that not all ineligible providers would benefit from EHRs or incentives for EHRs, specifically:

  • Ancillary service providers (such as labs or pharmacies) need technology that facilitates interoperability and communication with providers' EHR system. These ancillary providers may need a module or application to exchange interoperable health information rather than adopt a complete EHR.

  • Emergency Service/Ambulance Providers could benefit from interoperable systems, particularly viewing information on a patient and transmitting data to a provider's EHR. A module or application that allows viewing and sharing common information would be beneficial.

Other Evaluation Criteria Identified by the TAG

The TAG discussed other criteria that could be useful to evaluate the need for EHR incentives and/or other funding. The following summarizes the criteria and points of consideration.

Ability to Survive Market Forces

Incentive and/or other funding should only be available to providers who will survive market changes. Questions to consider include: Which providers will still be delivering services in 2014 and beyond? Where will there be consolidation? Will the provider be able to survive without incentives? Will they meet the changing demands of the healthcare delivery and payment system on their own? Some providers will not need incentives or other funding to adopt interoperable technology because business forces will push adoption. For example, a pharmacy serving large providers in urban areas may invest in health IT for business reasons to facilitate interoperable communication but a small pharmacy or lab in rural areas may need support to implement interoperable technology.

Benefit to Medicare and Medicaid (Expenditures/Costs)

Incentives and/or other funding should benefit Medicare and Medicaid. Who bears the cost and who gets the benefit from EHR technology (EHRT)? Where is there cost savings? What are the Medicare and Medicaid expenditures by the provider? Are there opportunities to reduce costs and improve quality through the use of CEHRT? Would the technology allow Medicare and Medicaid move toward risk adjusted and pay for performance models? The costs per treating a patient (per year/per episode) may also be a relevant factor in prioritizing providers for incentives.

Capacity to Invest (Margins)

The extent to which provider payments exceed costs (i.e., margins) should be taken into account in determining a provider's ability to invest in technology on their own without incentives and/or other funding. What are the margins for the ineligible providers? For some provider types Medicare margins may be high (e.g., home health) and in some instances margins may vary for subcategories of particular provider types (e.g., rural vs. urban). In contrast, Medicaid margins are believed to be lower. Providers (e.g., Medicaid-reliant providers) with lower margins may need to rely on grants for funding and other means to support the costs of acquisition and/or use of technology. Margin data can be found in Medicare Payment Advisory Commission reports and Medicare and Medicaid cost summary reports. Some ancillary providers have margins that far exceed standard health care providers (e.g., CVS pharmacies) and should not be the target for incentives and/or funding.

Market Size/Capacity

Information on the number of the providers or professionals in the market and number of patients treated could be important in prioritizing the providers and the impact incentives and/or other funding may have on the largest number of patients.

Need for Exchange Now and with Future Business Models

In order for exchange to be meaningful, some providers may be more involved in transitions on care in current and future service delivery models. To what extent is exchange necessary between health providers to improve transitions now? Which providers are important to new delivery models such as ACOs to improve care? Which providers are important to a state to monitor public health?

Support for Current EHR Incentive Programs

Providers could be prioritized for incentives and/or other funding based on their importance to eligible hospitals and professionals to meet their meaningful use criteria. Do the ineligible providers assist eligible providers in meeting meaningful use requirements? Will incentivizing CEHRT for the ineligible provider improve care across the continuum?

Relationship to Eligible Organization

Some providers and professionals may be ineligible, but work for or are part of an eligible hospital or professional organization with access to CEHRT. Is there a way to determine how many are free-standing or not-associated with an eligible hospital/professional? If there are minimal free-standing providers, there may not be a reason to prioritize them for possible incentive or other funding.

Geography

The location of an ineligible provider may be an important factor in determining whether to extend incentives and/or other funding particularly if they are a safety net provider or in rural or underserved areas. Margins are also impacted by geography.

Availability of Other Funding to Adopt & Use EHRs

Some ineligible providers have access to other funding sources and grants to support adoption and use of technology minimizing the need to extend other programs or incentives. Are there other funding sources beside EHR Incentive Program incentives to assist in the adoption and use of CEHRT? For example, Safety Net providers have grantfunding available to adopt technology and other funding has been directed to these providers to support their use of this technology. The availability of funds to support the acquisition and use of EHRT may not make these providers a priority to receive additional incentives.

Provider Track Record

Incentive and/or other funding programs should not be offered to providers where there are serious fraud concerns. Do the providers have a good record as a Medicare provider? Is there any litigation against them? The TAG members expressed concerns about some providers such as home care where there are fraud rings in Florida. Programs should be designed to ensure only legitimate providers are assisted.

Summary of Evaluation Criteria/Principles

  • The need for technology that supports future care delivery, business models, and providers.

  • The need for technology to support care coordination and management, and health information exchange.

  • Information known about adoption costs to acquire and maintain the technology.

  • Cost of the incentive.

  • The benefit of technology to improve care delivery and outcomes for the patient.

  • The provider's benefit and their need for EHRs that supports best practices and outcomes for their patient.

  • The ineligible provider's ability to access capital and/or cover the cost of technology based on their profit margin.

  • The benefit to Medicare and Medicaid of incenting technology that supports:

    • Quality and financial oversight.
    • Data for risk adjustments and pay for performance.
  • The benefit to society (public health/population health).

General TAG Recommendations on the Need for Incentives

Interventions Should Have the Future in Mind

The TAG recommended that the final report look at the future (2014 and later) and emerging business models. Health care is moving towards new delivery and payment models with health care reform. The report should look at the future and identify the ineligible providers who will survive the transition or be priority providers that need interoperable technologies.

Interventions Need to Be Patient Centered

If actions are undertaken, they must support a patient-centered approach to care delivery.

Interventions Should Support Meaningful Use

Any actions/interventions for ineligible providers should focus on meaningful use and help eligible hospitals and professionals meet the program priorities.

There Should Not Be a "One-Size-Fits-All" Approach to Incentives and Other Funding for Ineligible Providers

The TAG agreed that broadly applying the EHR Incentive Programs to all of the ineligible providers is not necessary. They recognized that the ineligible providers would have different needs or barriers to overcome and some are adopting the technology more successfully than others and would not require the same level of support. The TAG recommended an approach that identified specific goals and used different interventions to meet the goals. They outlined general categories.

Overview of Levels of Support

The TAG discussed the concept of levels of support to tailor interventions to the needs of the ineligible provider in meeting goals.

  • Level 1 -- No Assistance: The market will naturally evolve and do it anyway

  • Level 2 -- Mandate the implementation of technology using federal and state authority (e.g., through regulatory requirements)

  • Level 3 -- Provide direct support (e.g., grants, loan programs)

  • Level 4 -- Provide indirect support (e.g., technical assistance/consulting services)

  • Level 5 -- Provide financial incentives (e.g., extend EHR incentive programs)

Barriers to Ineligible Provider EHR Technology Adoption

To determine what interventions (incentives/other funding) or level of support may be necessary, the TAG summarized their perception of the current barriers to adoption by ineligible providers. The following is a general list of barriers. To tailor interventions, the goals and barriers would need to be identified for each ineligible provider type.

  1. Lack of standards across continuum of care.

  2. Lag time in vendor's adoption of standards.

  3. Lack of clear clinical/economic reason for stand-alone facilities to adopt CEHRT (No business case).

  4. Workforce issues -- not trained on health IT/EHR technology and/or small in size particularly in health IT to operate EHR systems and infrastructure.

  5. Confusion over what technology to adopt.

  6. Current workflow set; do not want to adopt technology.

  7. Lack of access to capital markets.

  8. Lack of free capital (thin margins, as in the case of many Medicaid providers).

  9. Perceived privacy concerns and the technological barrier 42 CFR presents particularly with behavioral health settings providing substance abuse services.

  10. Individual provider lacks infrastructure/knowledge to win grants and other funding.

Program that Could Apply to All/Almost All Ineligible Providers

The TAG identified the following set of funding or other programs that could be applied to all/almost all ineligible providers at a relatively low cost:

  • Anti-Kickback Statute EHR Safe Harbor Regulation

  • Deployment of broadband internet everywhere

  • ONC Direct Project

  • Leverage federal Conditions of Participation to require certain EHR/health IT capabilities

  • Grant requirements that include conditions on key EHR/health IT capabilities

  • Current infrastructure opportunities in programs such as Medicaid grant opportunities, technical assistance to states on health IT, etc.

Framework for Evaluating Actions per Ineligible Provider

After considerable discussion, the TAG recommended that each ineligible provider type be evaluated for a course of action. They identified evaluation questions and three general actions as outlined below.

  • Why is the EHR/health IT important to support national goals? Why is it important to patients, providers, emerging business models, and current meaningful use provider?

  • What is known about the provider, their use of EHRs, the availability of interoperable health IT, their barriers and the desired outcomes?

  • How will the use of technology support the desired outcome?

  • What program action should be considered?

    1. Ignore: Due to the current financial status and prevalence of grants or other funding, no further incentive/funding action should be directed to the provider.
    2. Encourage: Use carrots and sticks to encourage desired action. Carrots could include the EHR Incentive Program, pay for performance programs, positive payment rate adjustments, low interest loan, grants, and other interventions. Sticks include implementing negative payment rate adjustment or other penalties for not adopting/using interoperable EHR technology.
    3. Mandate: Drive the desired action by creating an administrative requirement (e.g., Condition of Participation) to earn Medicare/Medicaid funding or fees, or program participation.

Sample Application of the Framework

The TAG applied the framework to three provider settings: Home Health Agencies; Community Mental Health Clinic; and Federally Qualified Health Clinic. The framework was an exercise to demonstrate a process and not to be considered a formal recommendation by the TAG. The information used in the exercise may or may not be accurate and was based on TAG member knowledge or perceptions rather than researched facts.

Home Health Agency

Why is EHR technology important?

The population served by home health agencies experiences multiple transitions and has complex clinical needs. As a result, home health is a prime candidate for health IT support. Areas of potential support include remote monitoring and support to achieve an interoperable technology infrastructure needed for health delivery reform such as new ACO delivery and payment models. Improving communication and information sharing is critical with transitions of care and re-hospitalization issues. For the home care provider EHRs support improved patient management and communication. Clinical decision support and other technology supports would be beneficial for skilled nursing/therapy services such as wound care. Technology also improves internal communications between care givers and nurses/therapists.

What do we know about the provider and their use of technology?

There are EHR vendors for home health agencies, but they have not yet deployed interoperability standards that allow exchange with eligible hospitals and professionals to support the EHR Incentive Programs.

Adoption Status: Adoption of EHRs is at 39 percent. The sector is starting to adopt EHR technology on their own, although a business case to invest in interoperable technologies has not emerged. Over time the economic/clinical reasons for the agency to adopt technology may change with healthcare reform to ensure referral sources from eligible hospitals and professionals.

Home health vendors may be challenged to keep up with the demand for multiple interfaces as every HIE organization requires a custom interface which is expensive custom programming. The sector lacks interoperable standards and technology to exchange basic information such as summary records. It is not clear which interoperability standards apply to home health agencies.

Barriers: Connectivity in the home is still an issue in some regions due to limited broadband availability, however connectivity is becoming increasingly available.

Other general barriers apply to home health, particularly related to workforce as many organizations don't employ staff with expertise in EHR technology.

Program Actions: Encourage plus mandate

  1. Combine a mandate with a carrot: Require the use of interoperable technologies through the Home Health Care federal Conditions of Participation (stick) in combination with a carrot. MedPACdiscussed having standards for the home health benefit. Until standards and formats are available, it is difficult to move forward.
  2. Encourage (Carrots/Sticks): Could make available various approaches based on size and sophistication:

    1. Adjust Payment -- "rate minus" if an agency does not implement technology or "rate plus" if they do. Require certain capabilities.
    2. Low interest loans for agencies with lower capital or less access to capital markets.
    3. Grants to acquire technology targeted to Medicaid providers.
  3. Disseminate information on the applicability of the Anti-kickback Safe Harbor Statute to home health care providers.

  4. Extend technical assistance (TA) and workforce training programs to certain types of home health agencies (such as TA through Regional Extension Center services).

The TAG indicated the home health analysis could also be applied to long-term care facilities (SNF/NF) because there are similar characteristics.

Community Mental Health Clinic (CMHC)

Why is EHR technology important?

The National Council for Behavioral Health just released a survey on health IT use which showed that the severely mentally ill have numerous health conditions and problems not limited to behavioral health. They are complex patients, frequently have housing issues, and often have substance abuse issues. These patients are expensive and are often described as accessing health care services through a "revolving door".

The Community Mental Health Center is frequently the patient's primary contact with the health system, but often has poor connections with the primary medical care system. They could be considered the safety net provider for many Medicaid behavioral health patients. Case management/care coordination is very important to improving quality of care, care delivery, and efficiency.

The lack of interoperable technology by community mental health clinics solidifies the silos between behavioral health care and primary care for medical conditions. Coordination and communication between primary care and CMHC is critical particularly with medication coordination and reconciliation.

Health care reform brings new models including health homes which will provide the case management/care coordination needed, however, CMHCs will need the technical infrastructure to actively participate in the emerging health home models.

What do we know about the provider and their use of technology?

The adoption of EHRs by CMHC is low. Psychiatrists are eligible for EHR incentive payments, but many have their own practice and will use EHR Incentive Program payments for their own EHR acquisition rather than reassigning the payment to the CMHC.

The primary payer for CMHCs is Medicaid with some funding through Medicare and private grants. The typical patient with schizophrenia costs Medicaid approximately $18K per year. Generally CMHCs have very limited resources to invest in technology and no profit margins. The TAG recognized that they needed more information on the market size and costs of the population.

Barriers include a lack of resources (including workforce) to invest in both EHR and interoperable technology. There are privacy and consent concerns with interoperability that are yet to be addressed with a standards-based technical infrastructure. Many state HIE organizations are not investing in exchange use cases to support behavioral health providers due to the lack of standards to address the complex privacy and consent issues.

Program Actions: Encourage

  • Extend a modified EHR Incentive Programs (potentially through grants with similar features to meaningful use) to CMHCs which would include:

    • Funding to support the acquisition and use of CEHRT.
    • Development of national standards to address privacy and consent issues (which would benefit all of health care).
    • Technical assistance to implement CEHRT (e.g., RECs).
  • Grant programs/funding options with Health Homes:

    • Grants to support infrastructure development and standards.
    • The TAG recognized that additional analysis was needed evaluate opportunities with the health home Medicaid state plan amendment and whether there was funding available that could be used as an incentive or grant for CMHCs.

Federally Qualified Health Center (FQHC)

The TAG began to analyze FQHCs and noted the following facts:

  • FQHCs have received a fair amount of HIT grant funding from HRSA. Some eligible professionals may assign their benefits to the health center (although the data on how many do so is limited).

  • EHR Adoption rate is higher than other ineligible providers.

  • FQHCs have a Medicaid cost based system that is more generous than other providers.

  • Medicare has a higher reimbursement for FQHCs than other providers.

For these reasons, the TAG recommended no additional incentive action for FQHCs is needed.

TAG Members

The TAG was comprised of individuals from both the private sector and Federal Government. Individuals were invited and selected who had expertise on health care policy and payment methodologies, specific ineligible provider types, health care economics, and health IT/EHR use, incentives and funding programs. The following individuals comprised the Technical Advisory Group for the "Study and Report on Application of EHRs and Payment Incentives for Providers Not Receiving Other Incentive Payments:"

John Allison, Acting Technical Director, CMS in the Center for Medicaid and CHIP Services

Maureen Boyle, Ph.D., Lead Public Health Advisor and the Team Lead for Health Information Technology at the Substance Abuse and Mental Health Services Administration (SAMHSA)

Richard G. Frank, Ph.D., Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy at Harvard Medical School.

Marsha Gold, Ph.D., Senior Fellow, Mathematicain Washington, DC.

Jennie Harvell, Project Officer; Senior Policy Analyst, HHS in the Office of the Assistant Secretary for Planning and Evaluation

Lorin Hitt, Ph.D., Professor of Operations and Information Management at the University of Pennsylvania, Wharton School

Warren Jones, M.D., FAAFP, Executive Director of the Mississippi Institute for Improvement of Geographic and Minority Health Disparities

Ruth E. Katz, Associate Deputy Assistant Secretary for the Office of Disability, Aging and Long-Term Care Policy, HHS in the Office of the Assistant Secretary for Planning and Evaluation

Peter Kemper, Deputy Assistant Secretary for Disability, Aging, and Long-Term Care Policy, HHS in the Office of the Assistant Secretary for Planning and Evaluation

Patricia MacTaggart, MBA, MMA, LeadResearch Scientist and Lecturer, George Washington University, Adjunct Associate Professor

Rachel Maisler, Health Insurance Specialist, Centers for Medicare and Medicaid Services in the Office of e-Health Standards and Services

Michael Millenson, President, Health Quality Advisors, LLC

Judy Murphy, RN, FACMI, FHIMSS, FAAN, Deputy National Coordinator for Programs and Policy Office of the National Coordinator for Health IT, HHS

Michael Pepper, Analyst, HHS in the Office of the Assistant Secretary for Planning and Evaluation

William Rudman, PhD, RHIA, Executive Director, AHIMA Foundation

Michelle Dougherty, MA, RHIA, CHP, Director of Research, AHIMA Foundation

Notes

  1. Adoption estimates should be interpreted with caution due to "significant variability in breadth and depth of survey content, data item construction, terminology, and definitions (when definitions are provided at all), as well as issues of sample size and representativeness." http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm#assess.

  2. See http://dashboard.healthit.gov/HITAdoption/.

[Return to the Table of Contents]

 

APPENDIX S. EVALUATING BENEFITS AND COSTS OF NEW INCENTIVES FOR EHR ADOPTION BY INELIGIBLE PROVIDERS

The material below was prepared for this study by David Dranove, PhD, an economist and the Walter McNerney Professor at Northwestern University's Kellogg School of Management.

In this section presents results of original research on the effect of the HITECH Act on adoption of EHR by hospitals. The research highlights the potential for incentives to promote EHR adoption and discusses factors for evaluating the cost and benefits.

I. Overview

This section of the report presents a framework for estimating the benefits and costs of programs to accelerate adoption of EHR by ineligible providers. First a number of key theoretical issues in cost-benefit analysis are examined, followed by a review of the research evidence on the effectiveness of the EHR and a presentation of criteria for evaluating the costs and benefits of incentive programs. These criteria to assess several specific programs, and finally issues associated with promoting interoperability are considered.

A. The Importance of Looking at Incremental Effects

Cost-benefit analysis (CBA) compares the incremental benefits accruing from a policy program against the incrementalcosts. A program creates incremental benefits or costs if it causes changes in behaviors. This is important to bear in mind because the adoption of EHR by ineligible providers is expected to continue to grow with or without government intervention. (See Table S1 for estimates of adoption by various categories of ineligible providers.1) Any program designed to increase adoption will engender benefits only if it accelerates adoption above and beyond the projected growth path. For example, suppose that 60 percent of providers currently adopt EHR and that figure is expected to increase to 80 percent in the absence of any policy intervention. If a policy intervention increases adoption by to 90 percent, then the incremental benefits of the policy accrue from the 10 percentage point increment in adoption above the forecasted level.

While the benefits of a program accrue from incremental adoption above the forecast trend, the cost of the program may accrue from all future adopters. Continuing our example, suppose that the intervention involves a subsidy to all future adopters, whether or not they planned to adopt without the subsidy. This subsidy would be paid out to the 30 percent that adopt EHR -- this includes the 10 percent that respond to the subsidy and the 20 percent that would have adopted EHR regardless. Because it may be difficult to target a subsidy towards incremental adopters, the cost of such programs can be very high relative to the benefits.

B. The Importance of Perspective

The calculation of benefits and costs of any intervention depends on one's perspective. Suppose that it costs a medical provider $40,000 to adopt EHR. A new government policy will subsidize 75 percent of the cost of adoption. What cost should be used in a CBA framework? If one takes the perspective of the provider, the cost of adoption is $10,000. From the government's perspective, the cost is $30,000. From the perspective of the EHR vendor, adoption is a benefit. Similar concerns arise for the calculation of benefits.

It is common when assessing government interventions to view the costs as those accruing to the government. In the previous example, this would include $30,000 in subsidy payments plus any costs associated with administering the incentive program. It is also common to view the benefits as accruing to the ultimate beneficiaries of the intervention. In the case of EHR, those benefits would include reductions in medical spending (some of which may ultimately be recouped by the government through lower medical fees) and improvements in the quality of care. This is the manner in which costs and benefits in this analysis.

C. Evidence on Benefits and Costs

There have been numerous studies of the benefits and costs of EHR adoption. Every EHR study begins from the same place: EHR is expensive. One prominent estimate, from the Congressional Budget Office (CBO 2008), estimates that the cost of adopting EHR for office-based physicians is between $25,000 and $45,000 per physician, with annual maintenance costs of $3000-$9000. For a typical urban hospital, these figures range from $3-$9 million for adoption and $700,000-$1.35 million for maintenance. In context these costs are quite significant: If the adoption costs are amortized over 10 years, EHR can account for about 1 percent of total provider costs. It would be no surprise, therefore, if research suggested that EHR may not pay for itself, let alone generate hundreds of millions of dollars in savings.

In their review of 257 studies of EHR effectiveness, Chaudry et al. (2006) note that few studies focus on cost savings, providing, at best, indirect evidence of productivity gains.2 Most of the studies they review focus on quality of care, with mixed results.3 Ten studies examine the effects of EHR on utilization of various services. Eight studies show significant reductions of 8.5-24 percent, mainly in laboratory and radiology testing. While 15 studies contained some data on costs, none offered reliable estimates of cost savings. Indeed, only three reported the costs of implementing EHR and two of these studies were more than 10 years old.

One of the most widely cited cost studies, Hillestad et al. (2005) uses results from prior studies of EHR and medical utilization and extrapolates the potential cost savings net of adoption costs. They identify several dozen potential areas of cost savings, including reduced drug, radiology, and laboratory usage, reduced nursing time, reductions in clerical staff, fewer medical errors, and shorter inpatient lengths of stay. They estimate that if 90 percent of United States hospitals were to adopt EHR, total savings in the first year would equal $41.8 billion, rising to $77.4 billion after 15 years. They also predict that EHR adoption could eliminate several million adverse drug events annually, and save tens of thousands of lives through improved chronic disease management. Sidorov (2006) challenges these findings, arguing that the projected savings are based on unrealistic assumptions. Sidorovalso questions whether EHR will generate forecasted reductions in medical errors.

Buntin et al. (2011) reviewed 73 studies of the impact of EHR on medical utilization. EHR is associated with a significant reduction in utilization in 51 (70 percent) of these studies. They do not break these down into specific areas of savings, however. Buntin et al. do not identify any studies of EHR and costs. To our knowledge, such studies remain few and far between.

Indeed, only three focused cost studies have been identified.4 Borzokowski(2009) examines whether early versions of financial and clinical information technology systems generated significant savings between 1987 and 1994. He finds that hospitals adopting the most thoroughly automated versions of EHR realize up to 5 percent savings within 5 years of adoption. He also finds that hospitals that adopt less automated versions of EHR experience an increase in costs. His conclusions mirror the popular discussion: there appears to be the potential for savings but there is little understanding of the drivers of the heterogeneity across hospitals. Furukawa, Raghu, and Shao (2010) study the effect of EHR adoption on overall costs among hospitals in California for the period 1998-2007. They find that EHR adoption is associated with 6-10 percent higher costs per discharge in medical-surgical acute units, in large part because nursing hours per patient day increased by 15-26 percent. This is plausible because nurse use of EHR can be very time consuming. Finally, Agha(2012) analyzes 2.5 million inpatient admissions across 3,900 hospitals between the years 1998-2005. She finds no evidence of cost savings, even 5 years after adoption. Additionally, adoption appears to have little impact on the quality of care, measured by patient mortality, medical complication rates, adverse drug events, and readmission rates.

Overall, these studies present an ambiguous picture of EHR effectiveness. Two recent studies take more nuanced views of EHR and help to explain the seemingly inconsistent findings. Dranoveet al. (2012) view EHR as a business process innovation whose success requires human capital that is skilled at working with information technology. They present evidence that hospitals that are located in more information technology-intensive communities enjoy larger cost savings after adoption of EHR. In addition, hospitals that have more experience with early (from the 1990s), primitive forms of EHR enjoy large cost savings after adoption of advanced EHR. Finally, McCullough et al. (2012) find that EHR adoption reduces mortality for patients with complex diagnoses but has no effect on mortality of patients with average severity.

In its 2008 study, the CBO anticipates a cost reduction of 0.36 percent as a result of implementation of the HITECH ACT, although it is difficult to find supporting empirical evidence.5 Despite the ambiguous and noisy evidence at hand, it is still worth exploring the potential savings from EHR adoption. In doing so, savings rates ranging from 0.25 percent to 1.5 percent are assumed, not because any particular figure is likely to be valid, but rather to illustrate how one might perform these calculations were we to have more precise information about EHR effects.

D. Interoperability

The full potential of EHR may not be unleashed until providers use the technology to share clinical information. Thus far, however, the EHR market is fragmented and exchanging information across different vendor platforms can be difficult. Even providers adopting the same vendor platform may find it difficult to exchange data with other providers. One exception is the EPIC platform, which was developed and marketed to facilitate information exchange among other providers that use the Epic system.

In principle, any estimate of the benefits of EHR adoption should be sensitive to the extent of information exchange. While the HITECH Act encourages information exchange, this does not appear to be a requirement for the incentives for Stage 1 of the Medicare and Medicaid EHR Incentive Programs. Moreover, it is difficult to predict the magnitude of the benefits of information exchange and these benefits may vary substantially across provider types. Thus, this analysis does not attempt to model or quantify any benefits from information exchange.

II. Preliminary Evidence on Effects of Incentives on Adoption

In this section we present results of original research on the effect of the HITECH Act on adoption of EHR by hospitals. The research highlights the powerful potential for incentives to promote EHR adoption.

A. HIMSS Data

Evidence on the effectiveness of adoption incentives can be obtained by examining how eligible providers have responded to the incentives in the HITECH Act. To perform this analysis we rely on data provided by the Healthcare Information and Management Systems Society (HIMSS) Analytics database. The HIMSS Annual Study collects information systems data related to software and hardware inventory and reports the current status of EHR implementation in more than 5,300 health care providers nationwide. Organizations that seek access to HIMSS Analytics data must provide their information on software and hardware use. Because most organizations tend to participate for a long period of time, the HIMSS Analytics data closely approximates panel data and can be used for fixed effects regression.

Most of the surveyed respondents are eligible for incentives under the HITECH Act (mainly hospitals). However, HIMSS also surveys many ineligible providers, nearly all of which are affiliated with hospital systems. These can be categorized into three groups of providers: Subacute, Ambulatory Care, and Home Health.

HIMSS reports adoption of 99 different technologies in 18 categories. Examples include Emergency Department Information Systems, Financial Modeling for Financial Decision Support, and a Laboratory Information System. For hospital and subacute providers, we restrict attention to five applications in the category Electronic Medical Records that are commonly used in other studies of EHR adoption:

  • A Clinical Data Repository (CDR) is a real time database that combines disparate information about patients into a single file. This information may include test results, drug utilization, pathology reports, patient demographics, and discharge summaries.

  • Clinical Decision Support Systems (CDSS) use clinical information to help providers diagnose patients and develop treatment plans.

  • Order Entry provides electronic forms to streamline hospital operations (replacing faxes and paper forms).

  • Computerized Provider Order Entry (CPOE) is a more sophisticated type of electronic order entry and involves physician entry of orders into the computer network to medical staff and to departments such as pharmacy or radiology. CPOE systems typically include patient information and clinical guidelines, and can flag potential adverse drug reactions.

  • Physician Documentation (PD) helps physicians use clinical information to generate diagnostic codes that are meaningful for other practitioners and valid for reimbursement.

These closely represent the kind of EHR applications that many proponents believe will lead to dramatic cost savings and quality enhancements.

For hospitals and subacute care providers, the five EHR applications are aggregated into two broad categories labeled the "basic" and "advanced" EHR. Applications within each of these categories involve similar costs of adoption and require similar types of co-invention to be used successfully. It is determined that a provider has basic EHR if it has adopted a clinical data repository (CDR), clinical decision support systems (CDSS), or order entry/communication. A provider has advanced EHR if it has adopted either computerized practitioner order entry (CPOE) or physician documentation, applications that are more difficult to implement and more difficult to operate successfully due to the need for physician training and involvement. Analyses of health IT adoption, such as the HIMSS Forecasting Model, consider advanced EHR applications to represent the final stage of EHR adoption (HIMSS Analytics 2011).

Tables S2-S7 show adoption rates for each category of provider for every year that data is available for that category, through 2011. The tables also report adoption trends for the Epic EHR platform. Adoption by all provider types has been trending steadily upward since 2001. It seems that the pace of adoption quickens around 2008 and 2009, around the time of passage of the HITECH Act. This is especially noteworthy because with each passing year there are fewer holdouts; it appears that a greater percentage of holdouts chose to adopt EHR after HITECH. In addition, there is a strong increase in adoption of Epic EHR following HITECH.

B. Statistical Analysis of Adoption Trends

In this section the results of a statistical analysis of the effects of the HITECH Act on EHR adoption by hospitals is reported and "Hazard Regression" models are estimated. Hazard regressions study the rate at which some event occurs over time. In this case the "event" is the adoption of EHR. The key variable under study is the adoption "rate;" which can be thought of as the fraction of hospitals in a given year that (a) had not yet adopted EHR and (b) adopt EHR in that year. For example, if there are 1,000 total hospitals and as of 2005, 600 have adopted EHR, it stands to reason that 400 hospitals have not adopted EHR. If the hazard rate is 10 percent, then we would expect 40 of the 400 hospitals to adopt EHR in 2005, leaving 360 without EHR at the start of 2006. If the hazard rate remains 10 percent, an additional 36 hospitals can be expected to adopt EHR in 2006. Hazard regression can be used to determine whether the HITECH Act increased the hazard rate.

Table S8 presents results of a hazard regression for hospital adoption of both elements (CPOE and PD) of advanced EHR. These elements are important for hospitals to satisfy the meaningful use criteria in HITECH, but hospitals with advanced EHR do not necessarily exchange information with other providers, a requirement for meaningful use. Thus, results are suggestive of the impact of HITECH on the fulfillment of the meaningful use requirement, but not definitive. The key predictors in the model include an indicator for the passage of HITECH and interactions between the passage of HITECH and various hospital characteristics.

The regression results imply that for the average hospital, the adoption rate increased after the passage of the HITECH Act by a considerable amount. Prior to the Act, only 29.8 percent of hospitals had adopted both elements of advanced EHR and the new adoption rate by these hospitals was approximately 6 percent. After the Act, the new adoption rate increased to approximately 20 percent. Thanks to this increase, 54.8 percent of hospitals used both advanced EHR applications by 2011. If this adoption rate continues, then 84.3 percent of hospitals will adopt both applications by 2016. Had the adoption rate remained at 6 percent, then only 70.9 percent will have adopted EHR by 2016. In other words, the increase in the adoption rate that occurs at the time that HITECH is enacted is predicted to lead to a 13.4 percentage point increase in the number of hospitals that adopt both elements of advanced EHR by 2016.6

The coefficients on hospital characteristics indicate that smaller and for-profit hospitals were less likely to adopt advanced EHR prior to the Act but saw a larger increase in their adoption rate after the Act. Smaller hospitals may view the costs of adoption as excessive relative to the benefits, and therefore would be more responsive to subsidies. Likewise, for-profits may have been reluctant to invest in EHR without subsidies. Academic hospitals were more likely to invest prior to the Act and also saw a larger than average increase in adoption after the Act. Finally, hospitals that were part of larger systems were more likely to adopt advanced EHR prior to the Act but showed a smaller increase in their adoption rate after the Act.

In unreported regressions, ineligible providers affiliated with hospital systems were also found to increase adoption of advanced EHR following the passage of HITECH. This is important; system membership seems to be a big predictor of EHR adoption.

This analysis shows that hospitals and affiliated providers increased adoption of advanced EHR after the passage of the HITECH Act. We cannot be certain of causality, however, as there may have been other factors affecting adoption that arose at the same time. However, the fact that a similar increase in adoption of basic EHR was not identified confirms that a spurious trend is not being observed.

III. Modeling EHR Adoption

The goal of government incentive programs is to reduce the costs and/or increase the benefits of EHR adoption. In this section these costs and benefits are described in more detail so that a better understanding of how incentive programs may affect adoption can be obtained.

A. A Simple Example

A health care provider considering EHR would weigh the private costs against the private benefits. It would consider financial factors, such as the cost of installing and maintaining the EHR as well as any potential impact on efficiency. It may also consider the impact on quality, both because higher quality could translate into more demand and higher revenues, and because it might directly cares about quality independent of financial considerations. EHR may create positive spillovers to other providers; a provider that is part of an integrated organization may internalize these spillovers, making it more likely to adopt EHR.

A simple example captures these ideas. Note: the numbers included in this example do not bear any relationship to actual nursing home revenues or profits, or EHR costs for nursing homes. The numbers in this example are included only to illustrate some of the cost/benefit considerations that may inform a decision to invest in an EHR system, with or without incentives.

Consider an independent nursing home that has total revenues of $100m and expected profits of $40m. (All dollar amounts are expressed in terms of net present value.) Of this, 50 percent of its profits is derived from Medicare and Medicaid. This is based on estimated Medicaid/Medicare revenues of $60m and estimated costs of $40m. The nursing home is considering adopting EHR. The home estimates that the cost of adopting and maintaining EHR is $5m. It expects to enjoy cost savings equal to 2 percent of total revenues ($2m) and quality of care improvement that it "monetizes" at 1 percent of total revenues ($1m). Thus, the benefits or adoption are $3m while the cost is $5m. Because the costs outweigh the benefits, the home does not adopt EHR at this time.7

Suppose that a new program will augment Medicare and Medicaid reimbursements by 5 percent for nursing homes that adopt EHR. The nursing home in this example calculates that this bonus payment will amount to $3m, based on its Medicare/Medicaid revenues of $60m. The benefits of adoption increase to $6m while the costs remain at $5m. Therefore, the home adopts.

This simple example illustrates the some of the many factors that we must consider if we are to predict the number of providers that will adopt EHR regardless of incentives, and, more importantly, the extent to which incentives will accelerate EHR adoption. To predict adoption rates in the absence of incentives, we must consider the factors that will affect the costs and benefits of adoption.

B. Factors Affecting Costs and Benefits of Adoption

Factors affecting adoption costs

  • Size: Adoption costs tend to increase with the size of the provider, due to the need for greater system capacity and complexity as well as the need to train additional staff. However, fixed adoption costs increase less than proportionately with size, for two reasons. First, there is a substantial fixed component to EHR costs. Second, larger providers will likely have lower financing costs.

  • Access to capital independent of size: Providers that have superior access to capital can more easily finance the substantial costs of adoption. Thus, for-profit providers, nonprofits that enjoy favorable financial performance, and providers that are part of large systems may enjoy greater access to capital.

  • Presence of complementary labor inputs: EHR is a business process innovation and successful implementation requires access to labor that is skilled at working with information technology.

Factors affecting adoption benefits

  • Size: Adoption benefits are likely to increase proportionately with size.

  • System membership: To the extent that information exchange creates spillover benefits, providers in systems will internalize these benefits.

  • Patient severity: EHR may be more likely to improve outcomes for patients with complex conditions.

  • Market competitiveness: To the extent that EHR improves quality and this leads to higher demand, then a competitive EHR provider may value EHR more than a provider that faces little or no competition.

  • Provider objectives: Providers that value quality of care independent of profits may value EHR more highly than a purely profit driven provider.

Many of these considerations are borne out by the empirical analysis of the HITECH Act described earlier. Smaller hospitals, for-profit hospitals, and teaching hospitals are more likely to adopt EHRs when incentives are available. Hospitals that are part of smaller integrated delivery systems are more likely to adopt when incentives are available.

Factors affecting incremental adoption

Size, ownership, and system membership may predict EHR adoption, but do not necessarily predict incremental adoption from the incentive program. The model suggests that incremental adoption depends on the following:

  • The size of the incentives: This will be very dependent on the specific incentives under consideration. In our example, the size of the incentive is proportional to the total Medicare and Medicaid revenues.

  • The size of the provider: Larger providers are likely to perceive larger gaps between benefits and costs, whether positively or negatively, simply because the stakes are higher. Thus, it will take bigger incentives to motivate a given number of large providers relative to a given number of small providers.

  • The number of fence sitters: The number of providers for whom the costs of adoption exceed the benefits in the absence of incentives but for whom the benefits exceed the costs with incentives. In other words, we need to know the number of "fence sitters."

  • Decision-making: The extent to which the provider's decision to adopt EHR is based on financial rather than medical considerations.

Most of these considerations are supported by the empirical analysis of HITECH. No empirical evidence outlines the relationship between the size of the incentives and the adoption rate, as there have been no experiments in which the size of the incentives have varied. Smaller hospitals responded more strongly to HITECH, which could indicate that smaller hospitals were more likely to be fence sitters. Finally, for-profits responded more strongly to HITECH, likely because they placed more weight on financial considerations.

The biggest unknown when forecasting incremental adoption is identifying the fence sitters. Ideally, one would obtain such information from a carefully constructed survey. Absent survey data, simple statistical theory can be used to conjecture about incremental adoption rates. Noting that there is likely to be a distribution of providers with a range of benefit/cost ratios for EHR adoption. Like most distributions, this is likely to be bell-shaped with disproportionate number of providers "in the middle" of the distribution. This helps account for the classic "S-curve" of new technology adoption, whereby there are a few early adopters, adoption accelerates, and then slows.

If there is a bell curve of benefit/cost ratios, then there are more fence sitters when about half of all providers have chosen to adopt EHR than when either 10 percent or 90 percent have chosen to adopt. Put another way, when very few providers have adopted, then most are probably far away from choosing to adopt and an incentive program may not change many minds. When most have adopted, there are few providers left whose minds need changing. Thus, the biggest impact of any incentive program will come when some but not all providers have adopted. Referring to Table S1, which lists adoption rates of basic EHR by provider categoryshows a wide range of reported adoption rates. If these adoption rates are valid, then for those classes of ineligible providers, including rehabilitation hospitals and long-term care hospitals, where less than 10 percent have adopted EHR, then large incentives may be necessary to encourage substantial additional adoption in these categories. On the other hand, about half of providers in categories such as nursing homes and home health care have adopted basic EHR. Small incentives might be sufficient to generate substantial additional adoption. However, these conclusions are dependent on the availability of reliable and valid data regarding EHR adoption rates for these providers.

IV. Comparing Different Approaches to Encouraging Incremental Adoption

A. Caveats

Although it is difficult to forecast with any degree of confidence the impact of incentives on incremental EHR adoption, the CBO and other organizations have made such forecasts in conjunction with the HITECH Act and a proposed extension to mental health providers. Unfortunately, it is difficult to determine whether they have forecasted overall growth in EHR adoption or incremental growth attributable to the incentives in the legislation. Nor has there been any retrospective review to ascertain the accuracy of these forecasts.

Rather than attempt to provide specific forecasts of the impact of extending the EHR Incentive Program on adoption, we believe it is more reasonable to use the ideas developed above to compare the relative effectiveness of different incentive programs.

B. Comparing Incentives

When evaluating a specific program to encourage EHR adoption, there are many considerations.

  • How large are the incentives?

  • Are the incentives larger for some providers than for others? Which providers get the largest benefits from adoption? Which enjoy the largest cost reductions?

  • How large are the benefits relative to the incentives?

  • Does the program target "fence sitters?"

  • Will the program pay for adoption by providers that have already adopted and/or would have adopted in the absence of incentives?

We bear these in mind as we consider three different programs: Payment incentives, Financing, and Information technology consulting.

Payment Incentives

The HITECH Act creates incentive payments under Medicare and Medicaid for hospitals that meet a range of criteria for EHR adoption. Incentive payments have several advantages. The government can stipulate precisely what providers must do to be eligible. Providers can easily understand these requirements and easily compute the financial benefits from compliance. Incentive payments also have disadvantages. They tend to be broad based, so that the government must reimburse providers that would have adopted EHR and complied with the stipulations even if no incentive payments were forthcoming. And the strict requirements for payment can strait-jacket providers into EHR solutions that are not optimal for their particular circumstances. Our research evidence suggests that HITECH's incentives had a powerful effect on EHR adoption.

Financing Programs

Low interest loan programs allow providers lacking access to capital to obtain low interest loans to finance EHR adoption. These tend to be low stakes programs for the government -- in the long run the cost of these programs is equal to the discount on the interest rate afforded to the providers. But these programs can have a high return because they target the types of providers that seem to be most responsive to financial incentives -- small and unaffiliated with larger systems. We are aware of a few loan programs that make available low interest loans to support EHR acquisition and use, such as the financial program offered by North Dakota, but we are unaware of any studies documenting whether these programs have been effective.

Information Technology Consulting

Dranove et al. (2012) showed that the EHR is more effective when adopting providers are located in a community rich with information technology expertise. Government might consider programs that provide information technology training to providers that lack this necessary complement to EHR adoption. These programs could target information technology-poor communities, both by reducing the costs and increasing the benefits of EHR implementation and use. But these programs cannot be short term -- they must provide enduring local information technology knowledge.

V. Programs to Improve Interoperability

This comparison of incentive programs has largely ignored a key criterion for incentive payments under HITECH and a key success factor for EHR: Interoperability. To date, information exchange across different EHR platforms is difficult. With just a few exceptions, such as with the Epic system, exchange among providers using the same platforms is also difficult. Such exchange creates positive externalities for patients that may not be captured by providers; thus, providers may not give proper weight to interoperability when choosing an EHR vendor. This is one of the reasons that interoperability is a key criterion for meaningful use under HITECH.

The meaningful use criteria in HITECH do seem to be influencing platform choices, as evidenced by the sharp increase in adoption of EPIC. Note, however, that while EPIC offers has high interoperability among EPIC users, it is not especially interoperable with other platforms. It remains to be seen whether providers interpret the interoperability requirement as a de facto endorsement of Epic, thereby driving providers towards a single platform.

Financial incentives can be a powerful tool for promoting interoperability, as evidenced by the growth of Epic subsequent to HITECH. Incentives to promote interoperability can be thought of as being quite distinct from incentives for EHR adoption, as the latter affect the costly decision to adopt any EHR platform whereas the former merely affect the choice of platform. Given the ongoing rise in EHR adoption, it might be cost effective to focus on promoting interoperability. This focus would satisfy the goal of achieving the maximum benefit at minimal cost to the government. Indeed, a key focus of the Stage 2 Meaningful Use EHR Incentive Program includes a focus on interoperable health information exchange.

Before the government invests too heavily in further promoting interoperability, it should take stock of ongoing changes in the provider landscape, specifically the growth of formally integrated provider systems as well as the growth of "virtual" provider systems such as Accountable Care Organizations. These systems can internalize the benefits of health information exchange. Ongoing system growth is likely to further promote EHR adoption and interoperability among eligible and ineligible providers.

References

Agha, L. 2012. The Effects of Health Information Technology on the Costs and Quality of Medical Care. Working Paper, Boston University.

Bassett, J. "Wired for Success." Advance for Physical Therapy & Rehab Medicine. http://physical-therapy.advanceweb.com/Archives/Article-Archives/Wired-for-Success.aspx.

Borzokowski, R. 2009. Measuring the Cost Impact of Hospital Information Systems: 1987-1994. Journal of Health Economics 28: 938-49.

Buntin, M., M. Burke, M. Hoagline, & D. Blumenthal. 2011. The Benefits of Health Information Technology: A Review of the Recent Literature Shows Predominately Positive Results. Health Affairs 30(3): 464-471.

Chaudhry, B., J. Wang, S. Wu, M. Maglione, W. Mojica, E. Roth, S. Morton, & P. Shekelle. 2006. Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. Annals of Internal Medicine 144(10): 742-752.

Congressional Budget Office. 2008. "Evidence on the Costs and Benefits of Health Information Technology."

Dranove, D., C. Forman, A. Goldfarb, & S. Greenstein. 2012. "The Trillion Dollar Conundrum: Complementarities and Health Information Technology." NBER Working Paper.

Fuji, K., K. Galt, M. Siracuse, & J.S. Christofferson. 2011. "Electronic Health Record Adoption and Use by Nebraska Pharmacists." Perspectives in Health Information Management (Summer): 1-11.

Furukawa, M., T. Raghu, & B. Shao. 2010. Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence from California Hospitals, 1998-2007. Health Services Research45(4): 941-962.

Hillestad, R., J. Bigelow, A. Bower, F. Girosi, R. Meili, R. Scoville, & R. Taylor. 2005. Can Electronic Medical Record Systems Transform Healthcare? An Assessment of Potential Health Benefits, Savings, and Costs. Health Affairs 24(5): 1103-17.

Lee, J., J.S. McCullough, & R.J. Town. 2012. The Impact of Health Information Technology on Hospital Productivity. NBER Working Paper #18025.

Maine Rural Research Center. RHCs At The Crossroads. 2012.

McCormick, D., D. Bor, S. Woolhandler, & D. Himmelstein.2012. Giving Office-Based Physicians Electronic Access to Patients' Prior Imaging and Lab Results Did Not Deter Ordering Of Tests. Health Affairs 31(3): 488-496.

McCullough, J., S. Parente, & R. Town. 2012. "Health Information Technology on Patient Outcomes: The Role of Organizational and Informational Complementarities." Unpublished Working Paper. University of Minnesota.

Miller, A. & C. Tucker. 2012. Can Healthcare Information Technology Save Babies? Journal of Political Economy 119(2): 289-324.

Pizzi, R. Ambulatory Surgery Centers Short on IT Healthcare IT News http://www.healthcareitnews.com/news/ambulatory-surgery-centers-short-it?page=0,0.

RCHN Community Health Foundation Research Collaboration. 2011. Policy Research Brief #27: Results from the 2010-11 Readiness for Meaningful Use of HIT and Patient Centered Medical Home Recognition Survey.

Resnick, H.E., & M. Alwan. 2010. Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007. Journal of the American Medical Informatics Association (JAMIA) 17: 389-395.

Resnick, H.E., B.B. Manard, R.I. Stone, & M. Alwan. 2009. Use of Electronic Information Systems in Nursing Homes: United States, 2004. Journal of the American Medical Informatics Association (JAMIA) 16: 179-186.

Sidorov, J. 2006. It Ain't Necessarily So: The Electronic Health Record and the Unlikely Prospect of Reducing Health Care Costs. Health Affairs 25(4): 1079-85.

Winsten, D., & H. Weiner. 2010. Improve Outreach Performance by Leveraging the Internet. CLMA Thinklab '10 Session 504.

Wolf, L., J. Harvell, & A. Jha.2012. Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates of Electronic Health Records. Health Affair, 31(3).

TABLE S1. EHR Adoption Rates by Ineligible Providersa
Ineligible Provider Adoption Rates for Basic EHR System for Some Clinical Processes
  1. This summary provides the limited available information regarding adoption rates by ineligible providers for basic level EHRs (some functionality to support clinical needs. It is difficult to compare values among providers due to a lack of uniform definitions. Adoption estimates should be interpreted with caution due to "significant variability in breadth and depth of survey content, data item construction, terminology, and definitions (when definitions are provided at all), as well as issues of sample size and representativeness. http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm#assess.
  2. Resnick, H.E., Alwan, M. "Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007." Journal of the American Medical Informatics Association (JAMIA), 2010, 17: 389-395.
  3. Ibid Resnick.
  4. Resnick, H.E., Manard, B.B., Stone, R.I., Alwan, M. "Use of Electronic Information Systems in Nursing Homes: United States, 2004." Journal of the American Medical Informatics Association (JAMIA), 2009, 16: 179-186.
  5. Wolf, L., Harvell, J. and Jha, A. "Hospitals Ineligible for Federal Meaningful-Use Incentives Have Dismally Low Rates of Electronic Health Records." Health Affair, 2012, 31(3).
  6. Ibid Wolf.
  7. Ibid Wolf.
  8. "HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health." National Council for Community Behavioral Healthcare. June 2012. http://www.thenationalcouncil.org/galleries/business-practice%20files/HIT%20Survey%20Full%20Report.pdf. This study on health IT adoption for community behavioral health organizations reports that 21% of organizations have EHRs at all of their sites; 65% of the behavioral health organizations surveyed reported having adopted some form of an EHR at some of their sites. Only 2% of responding community behavioral health organizations reported adopting technology that could meet the base requirements of the Meaningful Use Program.
  9. RCHN Community Health Foundation Research Collaboration. Policy Research Brief #27: Results from the 2010-11 Readiness for Meaningful Use of HIT and Patient Centered Medical Home Recognition Survey. November 2011.
  10. Maine Rural Research Center. RHCs At The Crossroads. 2012. http://muskie.usm.maine.edu/Publications/rural/RHCs-at-the-crossroads_Gale-NRHA-2012.pdf.
  11. Pizzi, R. Ambulatory Surgery Centers Short on IT Healthcare IT News http://www.healthcareitnews.com/news/ambulatory-surgery-centers-short-it?page=0,0.
  12. Fuji, K., Galt, K., Siracuse, M., Christofferson, J.S. "Electronic Health Record Adoption and Use by Nebraska Pharmacists." Perspectives in Health Information Management (Summer 2011): 1-11.
  13. Winsten, D. and Weiner, H. "Improve Outreach Performance by Leveraging the Internet." CLMA Thinklab '10 Session 504 (May 2010).
  14. Bassett, J. "Wired for Success." Advance for Physical Therapy & Rehab Medicine. http://physical-therapy.advanceweb.com/Archives/Article-Archives/Wired-for-Success.aspx.
Long-Term & Post-Acute Care
Home Health 43%b
Hospice 43%c
Nursing Facility 43%d
Rehabilitation Hospital 4%e
Long Term Acute Care Hospital 6%f
Intermediate Care Facilities/Mentally Retarded Unknown
Community Residential Home Unknown
Behavioral Health
Psychiatric Units and Hospitals 2%g
Substance Abuse Treatment Facilities Unknown
Community Mental Health Center 65%h (2% could meet meaningful use)
Psych/BH Out-pt Clinic Unknown
Partial Day-Treatment Center/Hospital Unknown
Psychologist Unknown
Clinical Social Worker Unknown
Licensed Counselor Unknown
Psychiatric Advanced Practice Nurse Unknown
Safety Net Providers
Federally Qualified Health Center 68.5%i
Rural Health Clinic 42%j (limited study n=65 of 3950 providers)
Health Care Related
Ambulatory Surgery Center 18%k
Renal Dialysis Facilities (ESRD Benefit) Unknown
Ambulance (EMS) Unknown
Pharmacy 12%l *NE
Laboratory 24.2%m can post to an EHR via interface
Blood Center Unknown
Therapists (PT, OT, SLP) PT=28%n
Dieticians and Nutritionists Unknown

 

TABLE S2. Hospital Adoption of Basic EHR (CDS, CDR, OER)
  Year     N of Facilities   % Using at
  Least 1 Application  
% Using All
  3 Applications  
% Using EPIC
  for Any Application  
2001 4,013 91.4 37.5 0.2
2002 3,985 93.3 43.1 0.7
2003 4,005 93.7 45.4 1.6
2004 3,989 94.3 46.4 2.0
2005 4,010 94.3 54.0 3.8
2006 5,082 77.5 45.7 4.9
2007 5,073 88.6 57.4 5.6
2008 5,168 91.2 63.0 5.6
2009 5,237 93.0 77.3 6.2
2010 5,315 94.6 80.9 9.5
2011 5,339 95.5 83.8 10.9

 

TABLE S3. Hospital Adoption of Advanced EHR (CPOE, PD)
  Year     N of Facilities   % Using at
  Least 1 Application  
% Using All
  3 Applications  
% Using EPIC
  for Any Application  
2005 4,010 47.5 12.9 6.78
2006 5,082 41.6 17.6 7.99
2007 5,073 49.3 26.4 8.71
2008 5,168 52.9 29.8 8.67
2009 5,237 55.3 33.7 9.71
2010 5,315 68.2 50.1 12.7
2011 5,339 73.6 54.8 13.68

 

TABLE S4. Subacute Facility Adoption of Basic EHR (CDS, CDR, OER)
  Year     N of Facilities   % Using at
  Least 1 Application  
% Using All
  3 Applications  
% Using EPIC
  for Any Application  
2001 3,508 73.7 33.35 0.2
2002 3,546 80.1 38.01 0.4
2003 3,380 80.0 32.1 0.7
2004 3,007 90.4 40.94 1.0
2005 2,875 92.9 46.47 2.1
2006 3,017 89.4 45.81 2.7
2007 2,940 94.3 52.21 3.2
2008 2,733 94.6 58.95 3.8
2009 2,665 94.5 68.22 4.4
2010 2,521 95.0 70.92 7.4
2011 2,422 95.5 75.14 8.9

 

TABLE S5. Subacute Facility Adoption of Advanced EHR (CPOE, PD)
  Year     N of Facilities   % Using at
  Least 1 Application  
% Using All
  3 Applications  
% Using EPIC
  for Any Application  
2005 2,875 41.2 10.3 3.7
2006 3,017 41.9 15.9 4.8
2007 2,940 46.2 22.5 5.2
2008 2,733 50.1 27.3 5.9
2009 2,665 51.6 29.5 7.6
2010 2,521 60.0 42.5 11.2
2011 2,422 66.4 47.4 12.4

 

TABLE S6. Ambulatory Care Provider Adoption of EHR
  Year     N of Facilities     Adoption Rate  
(%)
  Adoption Rate  
of EPIC ($)
2005 17,837 24.8 5.2
2006 19,714 35.6 7.6
2007 20,458 43.7 8.8
2008 21,796 47.7 10.6
2009 22,870 52.6 12.4
2010 25,290 59.3 15.6
2011 26,090 61.5 16.5

 

TABLE S7. Home Health Care Provider Adoption of EHR
  Year     N of Facilities     Adoption Rate  
(%)
  Adoption Rate  
of EPIC ($)
2002 2,087 76.1 0.1
2003 1,953 78.4 0.2
2004 1,842 80.2 0.0
2005 1,853 83.2 0.2
2006 2,054 81.4 0.6
2007 2,128 82.8 0.8
2008 2,293 83.7 1.3
2009 2261 85.8 1.6
2010 2302 88.3 1.7
2011 2324 89.1 1.9

 

TABLE S8. Hazard Regression Results -- Adoption of Advanced EHR1
Variable Hazard Ratio
  1. A coefficient of 1 indicates that the variable does not affect the hazard ratio b.IHDS size is the number of hospitals in the same Integrated Health Delivery System (IHDS) as the hospital.

* Significantly different from 1 at p<0.10
** Significantly different from 1 at p<0.05
*** Significantly different from 1 at p<0.01

Log(Beds) 1.277***
For-Profit Dummy 0.131***
IHDS Sizeb 1.015***
Academic Hospital Dummy 1.196*
Post-HITECH 3.242***
Log(Beds)*Post_HITECH 0.920**
For-Profit*Post_HITECH 3.097***
Academic*Post_HITECH 1.376*
IHDS Size *Post_HITECH 0.992***
No. of Observations 8161

Notes

  1. Adoption estimates should be interpreted with caution due to "significant variability in breadth and depth of survey content, data item construction, terminology, and definitions (when definitions are provided at all), as well as issues of sample size and representativeness." http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm#assess.

  2. Chaudry et al. state that they study Health Information Technology and they do not indicate if they distinguish between health IT and EHR.

  3. For recent studies of the impact of EHR on patient outcomes, see McCullough, Parente, and Town (2012) and Miller and Tucker (2012).

  4. For related work on the implications of HIT for hospital productivity, see Lee, McCullough, and Town (2012).

  5. CBO cost estimate for HITECH on January 21, 2009. Federal Costs for Extending EHR Incentive Payments to Behavioral Health Providers. October 15, 2010. Avalere Health LLC.

  6. Over time, this gap will decrease as more hospitals would adopt EHR with or without the incentives in HITECH.

  7. Note that a rational decision maker might not follow this simple go/no-go adoption decision if the benefits appear to outweigh the costs but there is uncertainty about benefits or costs that will be resolved over time. The decision maker may prefer to wait for the uncertainty to be resolved before adopting.

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APPENDIX T. CIO CONSORTIUM EMR COST STUDY DATA

TABLE T1. CIO Consortium Report: Electronic Medical Records (EMR) Cost Study -- Final Report, Implementing and Operating Electronic Medical Records in Long-Term and Post-Acute Care Environment
CIO Consortium -- Original Data from Report.
EMR*Care -- Facts and Statistics
Type of Organization: For-Profit
State of Operation: North Carolina, Florida
Types of Facilities: Skilled Care
Number of Facilities: Total 25 (10 in NC and 15 in FL)
Range in Bed Size: 80 - 240
  NC FL TOTALS
Average Licensed Bed: 120 120 120
Averaged Total Licensed Beds: 1200 1800 3000
Average Total Patient Days: 1044 2069 3133
Average Total Occupancy: 87% 87% 87%
Average Medicare Occupancy: 16% 20% 18.40%
Average Medicaid Occupancy: 67% 58% 61.60%
Average Occupancy -- All Other: 17% 22% 20%
Number of Employees (assume 60 overhead): 1127 2270 3457
Average Medicare Rate: 463.5 420 441.75
Average Medicaid Rate: 203.5 166.5 185
Average Rate - All Other: 197 141 169
Annual Revenue $261,919,833

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APPENDIX U. ABBREVIATIONS AND ACRONYMS

Abbreviations and Acronyms

Abbreviations and Acronyms
AA Alcohol Abuse
AAHSA American Association for Homes and Services for the Aging (now known as LeadingAge)  
AAP American Academy of Pediatrics
ACA Patient Protection and Affordable Care Act (same as PPACA or Affordable Care Act)
ACO Accountable Care Organization
ADATP Alcohol and Drug Abuse Treatment Program
ADL Activity of Daily Living
ADT Admission, Discharge and Transfer
Affordable Care Act   Patient Protection and Affordable Care Act (same as ACA or PPACA)
AHA American Hospital Association
AHCA American Health Care Association
AHIMA American Health Information Management Association
AIU Adopt, Implement or Upgrade
AKS Anti-Kickback Statute
AMDA American Medical Directors Association
APPN Advanced Practice Psychiatric Nurse
AO Accrediting Organization
ARD Assessment Reference Date
ARRA American Recovery and Reinvestment Act
ASC Ambulatory Surgical Center
ASPE HHS Office of the Assistant Secretary for Planning and Evaluation  
AT Active Treatment
ATL Accredited Testing Laboratory
 
BCP Beacon Community Program
BH Behavioral Health
BHIP Behavioral Health Integration Project
BIP Balancing Incentives Program
 
C-CDA   Consolidated CDA
CAH Critical Access Hospital
CARE Continuity Assessment Record and Evaluation
CAST Center for Aging Services Technology
CBA Cost-Benefit Analysis
CBHC Community Behavioral Health Center
CBO Congressional Budget Office
CCD Continuity of Care Document
CCHIT Certification Commission for Health Information Technology
CCTP Community-Based Care Transitions Program
CDA Clinical Document Architecture
CDR Clinical Data Repository
CDS Clinical Decision Support
CDSS Clinical Decision Support System
CDT Clinical Documentation Tool
C-EHR Certified Electronic Health Record
CEHRT Certified Electronic Health Record Technology
CHADIS Child Health and Development Interactive System
CHAP Community Health Accreditation Program
CHF Congestive Heart Failure
CHIP Children’s Health Insurance Program
CIHS Center for Integrated Health Solutions
CIOC CIO Consortium
CIP Capital Improvement Project
CITL Center for Information Technology Leadership
CLIA Clinical Laboratory Improvement Amendments
CMCS Center for Medicaid and CHIP Services
CMMI Center for Medicare and Medicaid Innovation
CMHC Community Mental Health Center
CMS HHS Centers for Medicare and Medicaid Services  
CNA Certified Nursing Assistant
CNS Clinical Nurse Specialist
COPD Chronic Obstructive Pulmonary Disease
CoP Condition of Participation
CORHIO   Colorado Regional Health Information Organization
CPOE Computerized Provider Order Entry
CQM Clinical Quality Measurement
CRISP Chesapeake Regional Information Systems for Our Patients  
CSAT Center for Substance Abuse Treatment
CY Calendar Year
 
DA Drug Abuse
DOH Department of Health
DRG Diagnosis-Related Group
DURSA   Data Use and Reciprocal Support Agreement
 
ED Emergency Department
EH Eligible Hospital
EHR Electronic Health Record
EHRT EHR Technology
eMAR Electronic Medication Administration Record
EMR Electronic Medical Record
EMT Emergency Medical Technician
EP Eligible Professional
eRx Electronic Prescription
ESRD End-Stage Renal Disease
 
FCC Federal Communications Commission
FDA HHS Food and Drug Administration
FFP Federal Financial Participation
FICEMS   Federal Interagency Committee on Emergency Medical Services  
FQHC Federally-Qualified Health Center
FY Fiscal Year
 
GAO U.S. Government Accountability Office
GWU George Washington University
 
H&P History and Physical
HAC Hospital-Acquired Condition
HCBS Home and Community-Based Services
HCBW Home and Community-Based Waiver
HCCN Health Center Controlled Network
HCP Health Care Provider
HCTAA Home Care Technology Association of America
health IT Health Information Technology (same as HIT)
HH Home Health
HHA Home Health Agency
HHS U.S. Department of Health and Human Services
HI Health Information
HIE Health Information Exchange
HIEI Health Information Exchange and Interoperability
HIMSS Healthcare Information and Management Systems Society
HISP Health Information Service Provider
HISPC Health Information Security and Privacy Collaboration
HIT Health Information Technology (same as health IT)
HIT IAPD Health Information Technology Implementation Advance Planning Document
HIT PAPD   Health Information Technology Planning Advance Planning Document
HITECH Health Information Technology for Economic and Clinical Health Act
HL7 Health Level 7
HMO Health Maintenance Organization
HRSA HHS Health Resources and Services Administration
 
ICD International Classification of Diseases
ICF/IID Intermediate Care Facility for the Intellectually Disabled (previously known as ICF/MR)  
ICF/MR Intermediate Care Facility for the Mentally Retarded (now known as ICF/IID)
IH Integrated Healthcare
IHDS Integrated Health Delivery System
IHS HHS Indian Health Service
IMD Institution for Mental Diseases
IPPS Inpatient Prospective Payment System
IRF Inpatient Rehabilitation Facility
IT Information Technology
 
JAMIA Journal of the American Medical Informatics Association
JABFM Journal of the American Board of Family Medicine
JCAHO Joint Commission for Accreditation of Healthcare Organization
 
LCCWG Longitudinal Coordination of Care Workgroup
LOINC Logical Observation Identifiers Names and Codes
LPN Licensed Professional Nurse
LTACH Long-Term Acute Care Hospital (same as LTCH)
LTC Long-Term Care
LTCF Long-Term Care Facility
LTCH Long-Term Care Hospital (same as LTAC)
LTPAC Long-Term Post-Acute Care
LTSS Long-Term Services and Supports
 
M+C Medicare+Choice
MA Medicare Advantage
MacPAC   Medicaid and CHIP Payment and Access Commission
MA-PD Medicare Advantage Prescription Drug Program
MBES Medicaid Budget and Expenditure System
MDCH Michigan Department of Community Health
MDCN Medicare Data Communication Network
MDS Minimum Data Set
MedPAC Medicare Payment Advisory Commission
MFP Money Follows the Person
MH Mental Health
MHBG Mental Health Services Block Grant
MHSA Mental Health and Substance Abuse
MIPPA Medicare Improvements for Patients and Providers Act
MITA Medicaid Information Technology Architecture
MU Meaningful Use
 
N-SSATS National Survey of Substance Abuse Treatment Services
NAHC National Association of Home Care
NAICS North American Industry Classification System
NAPHS National Association of Psychiatric Health Systems
NASMD State Medicaid Directors Association
NASMHPD   National Association of State Mental Health Program Directors  
NCAL National Center for Assisted Living
NCCBHC National Council for Community Behavioral Healthcare
NCHS National Center for Health Statistics
NEMSIS National EMS Information System
NF Nursing Facility
NH Nursing Home
NHE National Health Expenditures
NHPCO National Hospice and Palliative Care Organization
NHTSA National Highway Traffic Safety Administration
NP Nurse Practitioner
NTDHA New York Digital Health Accelerator
NYeHC New York eHealthCollaborative
 
OASIS Outcome and Assessment Information Set
OBHITA Open Behavioral Health Information Technology Architecture
OBQI/M Outcome-Based Quality Improvement/Monitoring
ODMH Ohio Department of Mental Health
OHIET Oklahoma Health Information Exchange
OIG Office of Inspector General
ONC HHS Office of the National Coordinator for Health Information Technology (same as ONCHIT)  
ONC-ACB ONC-Authorized Certification Body
ONC-ATCB   ONC Authorized Testing and Certification Body
ONCHIT HHS Office of the National Coordinator for Health Information Technology (same as ONC)
OOP Out-Of-Pocket
OT Occupational Therapy
OTP Opioid Treatment Program
 
P&P Policies and Procedures
PA Physician Assistant
PAC Post-Acute Care
PACE Program of All-Inclusive Care for the Elderly
Part D Medicare Part D (prescription drug program)
PBM Pharmacy Benefit Manager
PCMH Patient Centered Medical Home
PD Physician Documentation
PECOS   Provider Enrollment, Chain and Ownership System
PHR Personal Health Record
PHS Public Health Services
PHSA Public Health Services Act
PIHP Prepaid Inpatient Health Plan
PPACA Patient Protection and Affordable Care Act (same as ACA or Affordable Care Act)  
PPD Post-Partum Depression
PPS Prospective Payment System
PRTF Psychiatric Residential Treatment Facility
PT Physical Therapy
 
QIO Quality Improvement Organization
QSOA Qualified Service Organization Agreement
 
RAI Resident Assessment Instrument
REC Regional Extension Center
REM Reference Electronic Health Record Model
RHC Rural Health Center
RHIO Regional Health Information Organization
RIQI Rhode Island Quality Institute
RN Registered Nurse
RTC Residential Treatment Center
 
S&I Standards and Interoperability
SA Substance Abuse
SAMHSA   HHS Substance Abuse and Mental Health Services Administration  
SBIR Small Business Initiated Research
SCIC Significant Change in Condition
SDE State Designated Entity
SEC Securities Exchange Commission
SHIE State Health Information Exchange
SHIN-NY Statewide Health Information Network of New York
SLP Speech Language Pathology
SMHP State Medicaid Health Information Technology Plan
SMPC State Health Policy Consortium
SNF Skilled Nursing Facility
SNOMED Systematized Nomenclature of Medicine
SPA State Plan Amendment
SPBC Southern Piedmont Beacon Community
 
TA Technical Assistance
TAG Technical Advisory Group
TAP Technical Assistance Publication
TEDS Treatment Episode Data Set
TRICARE   U.S. Department of Defense Health Care Program (provides health care for the seven uniformed services: Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, and the National Oceanic and Atmospheric Administration)
 
UM-HIE Upper Midwest Health Information Exchange
USRDS United States Renal Data System
 
VA Veterans Administration

[Return to the Table of Contents]

 

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