The American Recovery and Reinvestment Act of 2009 (ARRA), also known as Recovery Act, Public Law 111-5 or the Stimulus Bill, was signed into law by President Obama on February 17th, 2009. A chief component of this legislation provides major opportunities for the improvement of our nation's health care through health information technology (Health IT or HIT).

To say "there is a lot going on" behind the scenes in HIT would be the gross understatement of the year. The acronyms alone which represent the various entities/areas involved in this highly complex undertaking are enough to make the U.S. Navy blush. Because of this, those of us involved in the healthcare information arena who realize that "with change comes opportunity", may be having a hard time pinpointing just what these opportunities might be.

In order to move forward in our understanding, we need to take a close look at several criteria under the stimulus that will affect our industry and the problems and possible solutions for each:
- HITECH Act
- EHR and Interoperability
- Meaningful Use
- "Certified EHR"

HITECH Act

In order to recognize opportunity, you need to first understand the HITECH Act (Health Information Technology for Economic and Clinical Health), a $19 billion electronic health records funding provision within the stimulus, under which each physician is eligible to receive up to $44,000 total from 2011 through 2015 with 70% of that coming in the first 2 years for showing "meaningful use" of a "certified" EHR.

The HITECH Act is extremely vague and physicians may not comprehend all of the terminology of what a "certified EHR" or what a "meaningful user" entails; therefore, they may not understand how to receive the full reimbursement amount of $44,000 (per physician).

After 2015 there will be penalties levied on those who have not adopted and implemented an EHR. For office-based physicians who do not adopt such technology by 2015, Medicare payments will be reduced by the following factors in the years specified:
- 2015: One percent
- 2016: Two percent
- 2017 and beyond: Three percent
- 2018 and beyond: HHS Secretary may decrease one additional percent/year (max of 5%) if 75% of office-based physicians don't adopt technology by 2018

Will Any EHR System Work for Physicians? What is Interoperability?

There is not a "one size fits all" EHR solution and what an IT professional might call a "killer app" (i.e. Microsoft Office, Adobe Acrobat, Apple's iTunes, and Google Maps) does not yet exist in the world of the electronic health record. EHR's in some form have been around for some time however, the challenge of interoperability of these systems remains unresolved. Interoperability currently is and will likely continue to be a key requirement to receive any payments under the HITECH Act.

Scott Lavine, Marketing Director, Antek HealthWare (www.antekhealthware.com) advises that the practice should establish what their EHR implementation goals are prior to beginning the purchase process of an EHR system. "These goals should be set not only with input from the physicians but with front office staff and laboratory staff (if applicable). Once goals are established, the practice should research vendors who can help them attain their goals. Interoperability, which refers to connecting disparate software and hardware systems, should be included in a practices' EHR goal which will allow for connectivity among the EHR, Practice Management, LIS, and other diagnostic equipment. It is important to identify vendors that have experience working with the other software and hardware vendors who have products deployed in the practice."

"Finally, before making a commitment to a vendor, ask for references within the same specialty of medicine with like connectivity. Once an EHR vendor has been selected, an implementation process should be developed and all software and hardware vendors should be involved."

Interoperability: The ability of software and hardware on multiple machines from multiple vendors to communicate.

Meaningful Use

The term "Meaningful EHR User" in ARRA (Title IV, Subtitle A, Section 4104) is described as "an eligible professional" who meets the following criteria:
1. demonstrates that he/she is using certified EHR technology in a "meaningful manner, which shall include the use of electronic prescribing";
2. demonstrates that he/she uses the certified EHR technology to be "connected, in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination"; and
3. submits information on selected "clinical quality measures".

Certified EHR

One of the requirements under the HITECH Act calls for the use of a "certified EHR" if the provider is to qualify for incentives. Who then is the certifying body?

The Healthcare Information and Management Systems Society (HIMSS) believe that CCHIT (Certification Commission for Healthcare Information Technology) should be named as the certifying body for EHR technology. According to HIMSS, CCHIT has been in existence for several years; has demonstrated long-term commitment to an open and transparent process; much of its development was made possible through tax-payer dollars; and, it has proven itself to be an effective and reputable certifying body.

On April 29, 2009, CCHIT's chair, Mark Leavitt, MD, PhD testified at the National Committee for Vital and Health Statistics (NCVHS) Executive Subcommittee hearings on the topic of "EHR Product Certification" and "meaningful use" as they apply to the American Recovery and Reinvestment Act (ARRA). CCHIT believes that in their initial years, certification served as a confidence-booster for providers concerned about buying EHRs that lacked the needed functionality, security, and interoperability. Financial incentives for EHRs then began to emerge, but they pale in comparison to the bold goals and nationwide scale of the Recovery Act.

"Now, as health leaders, we must make progress on three tightly interdependent paths at the same time. Promoting EHR adoption and use is just one track. The second is to develop and sustain health information exchange. Finally, we must reform - and ultimately transform - the health system. Because the journey is long and complex, we will need to assess and reward progress at incremental steps along the way. Certification must step up to fulfill a more strategic role, serving not only to reduce risks, but as a dynamic coupling mechanism between advancing policies and the real-world development, marketing, adoption, and use of health IT."

EHR vs. EMR - They Are Not the Same

Since 2004 we've heard the two terms 'EMR' and 'EHR' and have used them interchangeably. Is this correct? Do they mean the same thing?

Absolutely not.

The National Alliance for Health Information Technology (NAHIT) recently established definitions for the Electronic Medical Record (EMR) and the Electronic Health Record (EHR).

EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual's health and care.

EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual's health and care.

So what does this mean in simpler terms?

The Electronic Medical Record (EMR) is a record that is created, kept and maintained within a physician's practice for the purpose of keeping track of the conditions, treatments and notes for each individual patient, usually by encounter or diagnosis.
The Electronic Health Record (EHR) is a cumulative (from the cradle to the grave) record of the complete health, history, procedures, diagnosis, treatment, prescription, etc. for an individual. This record is not confined to a physician's practice and can be viewed across more than one health care organization.

EHR/EMR Adoption Rate Low - Failure Rate High

In 2007 we have seen reports indicating that, although only a small portion of physician's offices adopted and implemented EMR/EHR, the failure rate of these systems was in the area of 50%. The consensus among physicians is that today's EHRs and EMRs are hard to use and are invasive both to workflow and finances. While high cost is a significant barrier to physician adoption, workflow disruption remains the killer deterrent.

There are IT professionals who compare an interoperable EHR system to social networks such as Facebook, MySpace and Twitter who ask, "If they can do it, why can't we?" In a recent interview with HIMSS, Mark Leavitt, CCHIT chair explains, "We are not playing in a social game such as Facebook where the information is not private or of any particular value. Someone isn't going to die if we leave off a tweet." Mr. Leavitt states that he has seen shining examples of success with current EHR's and the solution lies in training and education of these systems. "The problem isn't that the systems are too hard to use, the problem is that people are too hard to change", says Mr. Leavitt.

Pinpointing the Opportunity

According to Bradley Lund, Executive Director of HBMA (Healthcare and Billing Management Association - www.hbma.org), "The introduction of electronic health records to a physician practice offers significant opportunity and risk. Selection and implementation must start with a well designed EHR/EMR application fitted to particular practice needs, along with training and implementation programs, otherwise we will continue to see high failure rates. A complete understanding of how the billing functions will interface with the clinical record is essential in achieving maximum value of EHR."

"HBMA continues to design resources for our members that allow them to function as the technology expert for physician practices beginning with EHR selection, through implementation and ongoing maintenance. The ultimate goal of EHR implementation is to achieve both clinical efficiencies and appropriate reimbursement for services provided", states Mr. Lund.

Those of us who are providing services to physicians that involves HIT (practice managers, billing outsourcing agencies, consulting firms, IT professionals) need to engage and align ourselves with reputable sources of information and associations/support systems that will provide us the ability to recognize the opportunities that are coming our way. We are in the "solutions" business. Just as we found solutions and provided guidance to changes in the past (electronic claims, E/M Requirements, HIPAA), we will do the same with EHR.

Tammy Harlan is the CEO of Medical Billing Course, LLC (www.medicalbillingcourse.com), a leading online Medical Billing Course Certificate Program for Employment or Business. Tammy is also the CEO of Medical Billing Business Resources (www.medicalbillingbusinessresources.com), a company which assists and supports those entering into Medical Billing Business ownership. tammy@medicalbillingcourse.com. (865) 286-9124.