The Health Information Technology for Economic and Clinical Health (HITECH) Act provides the U.S. Department of Health and Human Services (HHS) with the authority to establish programs to improve health care quality, safety and efficiency through the promotion of health information technology (HIT), including electronic health records and private and secure electronic health information exchange. Under HITECH, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified electronic health record (EHR) technology and use it to achieve specified objectives, otherwise known as "meaningful use" criteria. Two regulations have been released, one of which defines the "meaningful use" objectives that providers must meet to qualify for the bonus payments, and the other which identifies the technical capabilities required for certified EHR technology:

1. Incentive Program for Electronic Health Records: Issued by the Centers for Medicare and Medicaid Services (CMS), this final rule defines the minimum requirements that providers must meet through their use of certified EHR technology to qualify for the payments.
2. Standards and Certification Criteria for Electronic Health Records: Issued by the Office of the National Coordinator (ONC) for Health Information Technology, this rule identifies the standards and certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they adopt are capable of performing the required functions.

In conforming to meaningful use criteria, there are several items to keep in mind.

1. Determine how to measure successful technology adoption;
2. Describe how to measure return on investment (ROI) for various technologies; and
3. Model technology implementation on best practices.

It is also important to determine what will make a successful technology adoption. These include: 

• Eliminate or minimize transcription costs
• Reduce medical records staff (no more chart hunting)
• Accommodate fast access to patient information
• Data mine for drug recalls
• Determine easy and accurate identification of patients overdue for follow up care or screenings, eliminate chart used daily in the practice
• Allow the physicians to leave the office on time most days
• Reduce staffing and supply costs
• Increase charge capture and/or improved coding support for billing
• Eliminate legibility issues
• Allow for remote access to patient information such as medications, test results and the last note
• Be able to track outstanding orders for results
• Reduce phone calls from pharmacies
• Address patient phone calls without taking messages and playing phone tag
• Gather clinical information to participate in pay for performance programs

Determining your ROI timeline for EHR adoption is easier said than done. However, keeping a chart (Figure 1) to aid in the ROI estimates can be helpful. Determine a measure of the annual physician work relative value units (WRVU) before and after EHR adoption. WRVUs capture three components of patient care, including physician work RVUs (the relative level of time, skill, training and intensity to provide a given service), practice expense RVU (the costs of maintaining a practice including rent, equipment, supplies and non-physician staffing costs), and malpractice RVUs (represents payment for the professional liability expenses). It is also important to determine how long invoices stay in accounts receivables (A/R) as well as the ratio of support staff to physician staff, including a breakdown of these costs before and after EHR adoption.

Figure 1

For illustrative purposes, let's fabricate a common scenario as it relates to EHR adoption that is currently being played out in hospitals and group practices all across the United States. If a facility began its conversion to EHR in 2002, realized a spike in increased costs during this year, and a dip in costs below pre-conversion 2 years later, an overall break-even can be recognized 3 years from the conversion initiation date.

A 1-year conversion case study was cited at the Medical Group Management Association (MGMA) 2010 Annual conference in New Orleans, LA as follows: chart pulls from 1,600 per day to almost 0, shredding up to 20 tons of paper, and 55 thousand charts available online containing millions of scanned documents. As is implied here, the EHR payoff will be recognized from the average higher fee-for-service collections per patient visit through automated charge capture and integrated coding compliance features, a dramatic reduction in office supply expenses by eliminating chart materials, charge tickets and other pre-printed forms, and a reduction in labor costs.¹

Now that we've uncovered the generous cost savings from EHR adoption and are on our way to profitability, it will be important to maximize your system to meet the meaningful use criteria. These will allow any hospital or practice to report quality initiatives, exchange information and e-prescribe. On July 1, 2010, the ONC for Health Information Technology began accepting applications from entities who would like to be approved as an ONC Authorized Testing and Certification Body (ATCB).² ONC-ATCBs will use ONC established criteria to approve EHRs, and EHR products that were previously certified by CCHIT will not be grandfathered in. ONC has projected that entities will be approved by early fall and EHRs will begin to be certified by the end of 2011. Only ONC-ATCBS will be able to certify an EHR. Additionally, as privacy and security is of paramount importance, technology standards final rule requires organizations to perform risk analyses and correct security deficiencies (for assistance a free tool can be found at http://www.hipaasecurityassessment.com). Requirements to EHR technology are to include encryption capabilities, auditing capabilities including read-only access to patient records, automatic log-off capabilities, and file and message integrity checking.

U.S. government incentives (Figure 2) will be paid out to physicians that adopt EHR and adhere to meaningful use criteria. If you are still not convinced to optimize to meaningful use, or lose out as the rest of the healthcare field advances, Medicare incentive payments to physicians are well known, but penalties will be recognized in part by a reduction in the physician fee schedule.³ A bonus will be provided to physician practices that are in a designated health professional shortage area, as they will recognize a 10 percent increase in the designated fee schedule.

There are three stages (Figure 3) to satisfying Meaningful Use.⁴ Beginning in 2011, stage 1 mandates that there are 15 core objectives/measures plus five additional tasks from a menu of 10 for eligible providers. It will be imperative to focus on the capture of health information in coded format, use that information to track key clinical conditions, communicate that information for care coordination purposes, and initiate reporting of clinical quality measures and public health information. Stage 2 will mandate that practices and hospitals make improvement from Stage 1, including use of evidenced-based order sets, electronic medication administration record (eMAR), be able to record physician notes in the EHR, and contribute data to a personal health record (PHR) for patients to access through a patient portal. Stage 3 is still yet to be determined.

Figure 3