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.

Eligible Hospitals

Eligible Professionals

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.

$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.

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.

Pediatricians: 20% Medicaid Patient Volume

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

Children's: no patient volume requirement

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.

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

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

Calendar Year

Federal Fiscal Year

Calendar Year

Federal Fiscal Year

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'

Critical Access Hospitals

• 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

Children's hospitals

• Preferred language
• Sex
• Race
• Ethnicity
• Date of birth

• 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

• 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

• 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

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.

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.

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.

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.

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.

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.

"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."

(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."

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."

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."

(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."

(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."

(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.

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)).

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

§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.

§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 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.

• Federally qualified health center (FQHC) (see below)
• Rural health clinic (RHC) descriptions (see below)

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

• Community Mental Health Centers (CMHCs)

§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...

• End Stage Renal Dialysis Facilities (ESRD Facilities)

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.

• Blood Centers

SSA §1833(i)

§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

• Ambulatory Surgical Centers (ASCs)

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."

• Emergency medical service providers, including Medicare ambulance providers

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.

• FQHCs
• RHCs

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

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

§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.

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.

• Pharmacist

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

• Pharmacy

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.

• Laboratory

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...

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.

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 incentive payments are not available to:

• Clinical Social Workers
• Clinical Psychologists
• Registered Dieticians/nutrition professionals

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.

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.

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...

• RHCs

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.

• Drug manufacturers participating in the 340B Drug Pricing Program

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.

• Physical therapy Occupational therapist
• Qualified speech-language pathologist

• 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: 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.

• 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

• 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

• 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: SSA §1842(b)(18)(C)
• Clinical Social Worker §1861(hh)(1)
• Clinical Psychologist §1861(ii)
• Registered Dietitian or Nutrition professional

• 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

• 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

• 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.

• SSA §1833(i)(1)
• See: §1832(a)(2)(F)

EHR incentives/other funding NOT available for ASC.

• SSA §1881
• See: SSA §1881(b)(1)

EHR Incentives/Other Funding NOT available for ESRD Facilities.

Nephrologists are eligible as a physician.

• No commonly accepted definition
• Ambulance: SSA §1861(s)(7) title XVIII

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

• Registered Dietician/Nutritional Professionals)

(Psychologist and Clinical Social Worker in Behavioral Health Cluster)

• 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

• Physical Therapist
• Occupational Therapist
• Qualified Speech
• Pathologist)

• 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: 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.

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

• 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.

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

93.6% freestanding

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

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

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

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.

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

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

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

1749 (MH)⁴⁸
748 (SA)⁴⁹

1,894,000 (MH)⁵⁰
15,238 (SA)⁵¹

Substance abuse--see note⁵³

$2.5B (MH)⁵⁴
$46M (SA)⁵⁵

$20.18B (MH)
$2.88B (SA)⁵⁶

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

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

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

90% freestanding
10% hospital-based¹⁰⁴

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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

•  
• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• Patient Demographic, Health Information and Problem Lists
• Clinical Decision Support

• Physician Order Entry
• Privacy, Security and Integrity Features

• 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)

• 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

• Patient Demographic, Health Information and Problem Lists
• Clinical Decision Support

• Physician Order Entry
• Privacy, Security and Integrity Features

• 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)

• 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

• Patient Demographic, Health Information and Problem Lists
• Clinical Decision Support

• Physician Order Entry Privacy, Security and Integrity Features

• 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)

• 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

• Patient Demographic , Health Information and Problem Lists
• Clinical Decision Support

• Physician Order Entry (small segment can prescribe)

• 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

• Admission, discharge and transfer (ADT)
• Appointments
• Clinical notes
• Assessments
• Care Plan

• Condition specific documentation
• Medication and treatment records Patient Portals
• Patient eligibility determinations
• Billing

• Patient Demographic , Health Information and Problem Lists
• Clinical Decision Support

• Privacy, Security and Integrity Features

• 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

• 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

• 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

• Cost to adopt/lack of capital/lack of incentives

• Workforce limitations to implement and maintain an EHR

• 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

• 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

• Cost to adopt/lack of capital/lack of incentives

• Workforce limitations to implement and maintain an EHR

• 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

• 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

• 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

• 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

• Patient Demographic, Health Information and Problem Lists
• Clinical Decision Support

• Physician Order Entry
• Privacy, Security and Integrity Features

• 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

• Admission, discharge and transfer (ADT)
• Appointments
• Clinical notes
• Medication and treatment records

• Assessments
• Care Plan
• Condition specific documentation
• Lab information system

• Patient Demographic, Health Information and Problem Lists
• Clinical Decision Support

• Privacy, Security and Integrity Features

• 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

• 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

• Patient Demographic, Health Information and Problem Lists
• Clinical Decision Support

• Privacy, Security and Integrity Features

• 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

• Order entry and management
• Pharmacy information system

• Patient eligibility determinations

• 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

• 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

• Order entry and management
• Pharmacy information system

• Patient eligibility determinations

• 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

• 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

• Order entry and management
• Lab information system

• Patient eligibility determinations

• Patient Demographic, Health Information and Problem Lists

• Exchange health information (send, receive and integrate)
• Privacy, Security and Integrity Features

• Lack of awareness of the need to implement an EHR
• Lack of demand for an EHR

• Lack of a certified vendor for provider specialty

• Clinical notes

• Patient Demographic, Health Information and Problem Lists
• Support Clinical Quality Measures

• Privacy, Security and Integrity Features

• 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

• Patient Demographic , Health Information and Problem Lists
• Support Clinical Quality Measures

• Privacy, Security and Integrity Features

• Lack of a certified vendor for provider specialty

"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.

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

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.

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

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.

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

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]

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.

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

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

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.

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.

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.

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.

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.

See FAQ.⁷

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

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

Parallels in Sec. 2302.

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.

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.

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

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.

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

Participation of LTCFs and state HIE program

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

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

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

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

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.

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 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.

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

• Danville, PA
• Tulsa, OK
• RI
• Southeast MN
• HI
• S. Piedmont, NC
• Brewer, ME
• Western NY

• 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

• CO
• MA
• MD
• OK

CO extending grants for LTPAC organizations to connect to HIE

• MA: $1,717,610
• CO: $1,718,783
• MD: $1,683,171
• OK: $1,719,086

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

• 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)

• AL
• FL
• KY
• MI
• NM

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.

• OH: Community MH Centers
• MI: PHIP

• OH: Up to $50,000 per Community MH Center
• MI: $130,000 per PHIP

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.

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.

• 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.

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.

• North Dakota
• Maine
• Minnesota

Hospital and multi-professional entities

Entities with 3 or more commonly owned facilities

$625,000

$1,250,000

• 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.

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).

MN's QIO (Stratis Health) developed and health IT toolkits for EHR implementation for nursing homes^a and home health agencies^b with the support of local trade associations.

• 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

ONC posted to the toolkit on their State HIE website.

AHIMA also posted a briefing and the toolkit.^e,f