Demystifying 'Meaningful Use' for Anesthesiologists

Editor's note: This article by Tony Mira, president and CEO of Anesthesia Business Consultants, an anesthesia & pain management billing and practice management services company, originally appeared in Anesthesia Business Consultants eAlerts, a free electronic newsletter. Sign-up to receive this newsletter by clicking here.

The new calendar year is the last year in which "eligible professionals" (EPs) can begin to participate in the Medicare incentive program for electronic health records (EHRs) and receive the maximum available bonus payment, $44,000 over a five-year period. Although the final regulations on the EHR program appeared in mid-2010, there is still a fair amount of confusion over whether anesthesiologists can qualify for the bonus.

In this column, we will review the cumulative requirements for participation in a program whose summary is deceptively simple:

For calendar years 2011–2016, eligible professionals who demonstrate meaningful use of certified EHR technology can receive up to $44,000 over 5 years under the Medicare EHR Incentive Program.

1. You must be an eligible professional

The law defines "eligible professional" as:

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

who is legally authorized to practice under state law. The above list is exhaustive. Nurse anesthetists and other allied health professionals are not EPs for purposes of the Medicare EHR incentive program.

Hospital-based professionals who furnish substantially all their services in a "hospital setting" are not eligible for incentive payments. Hospital-based EPs are EPs who furnish 90 percent or more of their allowed services in a hospital inpatient setting, or hospital emergency department.

Although a majority of anesthesiologists might consider themselves "hospital-based," only a small minority provide 90 percent or more of their services on an inpatient basis. Outpatient procedures performed in the hospital or in an ambulatory surgery center are excluded from the 90 percent. If an anesthesiologist or other physician does 89 percent of his or her cases in the main hospital O.R. but performs the other 11 percent in the outpatient department, he or she will be considered an EP.

2. You must demonstrate meaningful use

A qualifying EP is one who successfully demonstrates meaningful use (of a certified EHR) for the reporting period. The Stage 1 criteria for meaningful use, which are applicable through the end of 2012, focus on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, and initiating the reporting of clinical quality measures and public health information. To demonstrate meaningful use, the EP must complete report the performance measures associated with:

1. 15 "core" objectives, and
2. 5 objectives out of 10 from the "menu" set, and
3. 6 total Clinical Quality Measures (CQMs), i.e.,
   • 3 core or alternate core CQMs,
   • and 3 out of 38 from the additional set

a) The 15 core objectives/measures that an EP must satisfy as part of demonstrating meaningful use are as follows:

1. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.
2. Implement drug-drug and drug-allergy interaction checks.
3. Maintain an up-to-date problem list of current and active diagnoses.
4. Generate and transmit permissible prescriptions electronically (eRx).
5. Maintain active medication list.
6. Maintain active medication allergy list.
7. Record [all of the following] demographics.
8. Record and chart changes in [the following] vital signs.
9. Record smoking status for patients 13 years old or older.
10. Report ambulatory clinical quality measures to CMS.
11. Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule.
12. Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, medication allergies) upon request.
13. Provide clinical summaries for patients for each office visit.
14. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
15. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

It is obvious that the core objectives do not fit anesthesia very well and that most, if not all, anesthesiologists will find it impossible to meet the requirements. The requirements are expressed as performance measures similar to those in the Medicare Physician Quality Reporting System (PQRS), with a numerator consisting of the number of patients who received the intervention, a denominator consisting of all patients in the measure group, and exclusions. Thus, for example, for Core Objective #12, "Provide patients with an electronic copy of their health information, upon request," the corresponding measure is: "More than 50% of all unique patients of the EP … who request an electronic copy of their health information are provided it within 3 business days." As the American Society of Anesthesiologists explained in a chart attached to correspondence with CMS dated February 18, 2011, this measure should not apply to anesthesiologists because "Patients rarely, if ever, request their health record from the individual anesthesiologist. Instead, requests generally go through the hospital."

b) The menu set from which the EP must select and complete an additional 5 measures is as follows:

1. Implement drug formulary checks.
2. Incorporate clinical lab-test results into EHR as structured data.
3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.
4. Send patient reminders per patient preference for preventive/follow-up care.
5. Provide patients with timely electronic access to their health information.
6. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.
7. The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.
8. The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.
9. Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.
10. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.

Again, the nature of anesthesiology practice is inconsistent with a number of the measures. According to ASA, in the CMS correspondence referenced above, Menu Set Measure #10, "Capability to submit electronic syndromic surveillance data," is not applicable because "This would be a function of a hospital's EHR. The only reportable data related to anesthesiology practice would be reporting malignant hyperthermia episodes or difficult airway to a registry but these are not public health repositories." Although anesthesiologists may be able to report some of the measures, they run a clinical and/or legal risk in recording data that they typically do not collect or that is not relevant to the services that they provide to their patients.

The third and final set of measures that an EP must complete in order to qualify for the EHR incentive is the Clinical Quality Measures. In 2012, EPs seeking to demonstrate meaningful use must electronically submit clinical quality measures selected by CMS directly to CMS through certified EHR technology. (In 2011, attestation was sufficient.)

c) The set of 6 CQMs, of which an EP must report on 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures (selected from a set of 38 CQMs):

1. 3 required core CQMs:
   • Hypertension: Blood Pressure Measurement
   • Preventive Care and Screening Measure Pair: a)Tobacco Use Assessment , b) Tobacco Cessation Intervention
   • Adult Weight Screening and Follow-Up
2. 3 alternate core CQMs:
   • Weight Assessment and Counseling for Children and Adolescents
   • Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older
   • Childhood Immunization Status

Given that anesthesiologists will be unable to complete the requisite number of core objectives/measures, "menu set" objectives/measures and 3 out of the 6 core CQMs because counseling, follow-up and immunization are not within the scope of services normally provided, we refer readers to the CMS website for information on the 38 additional CQMs from which they must report 3 measures.

Participation threshold: Yet another obstacle comes from the requirement that 50 percent of the EP's patient encounters take place in practice locations equipped with certified EHR technology. Also, some of the measures listed above require that 80 percent of the EP's patients have records in the certified EHR technology. Many anesthesiologists practice in multiple locations and even if some of their hospital ORs or ASCs have certified EHRs, others may not. It may be impossible to satisfy the EHR utilization threshold.

3. Your EHR must be certified

Anesthesiologists must be EPs, and they must meaningfully use certified EHR technology. To quality for the incentive, an EHR system must be "meaningful use" certified by an "authorized testing and certification body" approved by the Office of the National Coordinator (ONC) in the Department of Health and Human Services. EHR technologies may be certified as complete systems, or as modules.

Because the meaningful use requirements preclude the vast majority of anesthesiologists from qualifying for the bonus, claims that a particular EHR is certified for use in this specialty and will produce a Medicare EHR incentive payment for the purchaser should be thoroughly checked out. ONC maintains an up-to-date, authoritative listing of complete EHRs and EHR modules that have been tested and certified.

Last July, the following appeared under the heading "ASA Update on Electronic Health Records and Meaningful Use" on the ASA website:

During a recent meeting with ASA, ONC acknowledged that Stage 1 meaningful use requirements will not be modified for any specialty including anesthesiologists; however, it did state that the needs of specialties may be addressed in the Stage 2 requirements. The fact that the ONC is going to address the needs of specialty societies is a direct testament to the persistent lobbying by ASA members and staff. ASA will continue to lobby to ensure the actual practice of anesthesiology is considered when Stage 2 meaningful use requirements are written. Given this new development, anesthesiologists deemed eligible under the EHR incentive program should work with their electronic health record (EHR) vendor and information technology department to assess whether Stage 1 or Stage 2 certification is feasible.

We hope that the foregoing has helped to demystify the complex issues encompassed by the term "meaningful use."

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