SGR Repeal and Medicare Provider Payment Modernization Act
Although they have not yet determined how it will be paid for, the House (bill referred to Committee on Energy and Commerce et al) and Senate (bill referred to Senate Finance) have agreed on a permanent fix to the sustainable growth rate (SGR) formula that sets physician payment in the Medicare program.Under the deal Medicare will increase the amount it pays physicians by 0.5% each year for the next five years. The plan provides financial incentives for healthcare providers to participate in tests of alternative payment models (APMs). The deal also includes offers of bonuses to providers that agree to have their reimbursements based more on outcomes than on the volume of services they provide. The bill would also consolidate 3 different Medicare incentive programs, including the one for meaningful use of an electronic health record system (EHR).
Starting in 2018, payments under the new system would be adjusted based on performance in the new incentive system, the Merit-Based Incentive Payment System (MIPS), which consolidates three incentive programs: the Physician Quality Reporting System (PQRS), which provides incentives for physicians to report on the quality of care measures; the Value-Based Payment Modifier, which adjusts payment based on quality use of resources; and meaningful use of electronic health records. MIPS will assess performance in four categories:
Quality - In addition to measures used in the existing quality performance programs (PQRS, VBM, EHR MU) HHS will develop additional measures. Measures used by qualified clinical data registries may also be used to assess performance under this category.
Resource Use - The resource use category will include measures used in the current VBM program.
Meaningful Use - Current EHR meaningful use requirements, demonstrated by use of a certified system, will continue to apply in order to receive credit towards incentives in the new system. However, to prevent duplicative reporting, professionals who report quality measures through certified EHR systems for the MIPS quality category are deemed to meet the meaningful use clinical quality measure component.
Clinical Practice Improvement Activities - Professionals will be assessed on their effort to engage in clinical practice improvement activities. Incorporation of this new component gives credit to professionals working to improve their practices and facilitates future participation in APMs.
At the end of 2017 some incentive program penalties are sunset, including the 2 percent penalty for failure to report PQRS quality measures and the 3 percent (which would have increased to 5 percent in 2019) penalty for failure to meet EHR meaningful use requirements. The legislation would also require that EHRs be interoperable by 2017 and prohibit providers from deliberately blocking information sharing with other EHR vendor products. Another provision would require HHS to publish a list of clinical-decision support tools by April 1, 2016, that would be used in a program promoting the appropriate use of advanced diagnostic imaging. After Jan. 1, 2017, Medicare will pay only for images ordered by a clinician who has consulted one of these qualified systems and whose order adheres to what are called applicable "Appropriate Use Criteria."
There is flexibility to participate in MIPS in a way that best suits a particular practice environment. These options could include: use of EHRs, use of qualified clinical data registries maintained by physician specialty organizations, and the option to be assessed as a group, as a “virtual” group, or with an affiliated hospital or facility. Technical assistance would also be available to help practices with 15 or fewer professionals improve MIPS performance or transition to APMs. Overall, there will be very strong incentives to participate in APMs.
This bill will consolidate plans proposed last year by the Senate Finance, House Ways and Means, and House Energy and Commerce committees. How to pay for this new plan is still a big task ahead, although there seems to be enough momentum behind the effort to get this done. With the 0.5 percent increase, the cost for the SGR repeal comes to about $125 billion over 10 years, according to the Congressional Budget Office. A powerful array of provider organizations have expressed strong support including:
But the final product still needs to pass both houses of Congress and then be signed by the President. And hospital groups may be the first to try to guard their share of revenue. Already earlier this week the Federation of American Hospitals published a chart describing recent cuts on its blog entitled "Enough is Enough." There will be jockeying to determine funding, but I think we are closer than ever before to finally resolve this incredibly important issue, and at the same time make some smart moves in consolidating and simplifying programs while moving towards a payment system that rewards quality instead of quantity in healthcare.
We have known that the proposed rules for stage 2 meaningful use under the EHR Incentive Program were on their way. I had hoped that they would be released on Febraury 17, 2012, which was the third anniversary of the passage of the HITECH Act. Sadly, we did not get to read them prior to HIMSS. Nor did we get to read them prior to many of the learning sessions on stage 2 meaningful use scheduled at HIMSS the first two days. But, finally they are here (and sadly not even in time for Farzad Mostashari's keynote address as some had predicted). This will certainly be a major topic of conversation after the HIMSS conference (along with clouds, mobile and collaboration). There are two rules pertaining to stage 2 meaningful use: Medicare and Medicaid Electronic Health Record Incentive Program--Stage 2; and the New and Revised Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology which is not yet published. I will be posting some deeper analysis coming weeks on each of the rules once I have had some time to actually read them in more detail and the S&C rule is published.
Stage 2 Meaningful Use
First, let's look at the NPRM for Stage 2 meaningful use. The final rule for the Medicare and Medicaid EHR Incentive Programs, which was published in the Federal Register on July 28, 2010, specifies that CMS will expand on the criteria for meaningful use established for Stage 1 to advance the use of certified EHR technology by eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs). This proposed rule would establish the requirements for Stage 2. As stated in the July 28 final rule, "Our goals for the Stage 2 meaningful use criteria, consistent with other provisions of Medicare and Medicaid law, expand upon the Stage 1 criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results."
One of the significant changes is in the timing for implementation of stage 2 meaningful use. This change was expected and will become official under the final rule expected this summer. Under the current requirements, eligible doctors and hospitals that began participating in the Medicare EHR Incentive Programs in 2011 would have had to meet new standards for the program in 2013. If they did not participate in the program until 2012, they could wait to meet these new standards until 2014 and still be eligible for the same incentive payment. To encourage faster adoption the rule allows doctors and hospitals to adopt health IT in 2011, without meeting the new standards until 2014. The proposed rule would move all menu set items to core measures, and many of the percentages are increased, and some new menu objectives added.
Other significant aspects of the rule are around improving care transitions and patient engagement, including health information exchange and interoperability of EHRs. The requirement that patients have electronic access to their information is proposed to become that patients have used the capability to access and download their information and have communication preferences stated, as well as a requirement that 10% patients get reminders for preventive, follow-up care. Patients will have the right to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patients should be able to filter or organize information by date, encounter, etc. Patient engagement will be critical to allow patients to share accountability for their care and obtain better health. There is also a new requirement for Eligible Hospitals (EH)s that 80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. It will be required that data are available in human-readable and structured forms. (A web portal as defined as online access to health information. Therefore all web portals defined as such are subject to HIPPA rules and regulations.)
The requirement that a summary of care record must be transmitted between providers at transitions in care is ramped up and using paper is no longer an option. Secure messaging is a requirement, and there is a standards and certification requirement that Direct Project protocols are enabled in the EHR. The health information exchange requirement goes from merely performing one test to the ability to connect to at least three external providers in the primary referral network (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange organization. Sharing health data among providers is necessary to be accountable for care and the health of a patient population. The requirements for quality reporting in meaningful use are increasing at the same time that new reimbursement models are tied to performance. Quality reporting will eventually need to be in real time so that gaps in care can be avoided, rather than simply reported.
In order to successfully meet the requirements for meaningful use, hospitals and EPs must meet Stage 2 objectives and measures using “Certified EHR Technology.” Certified EHR Technology is defined as an EHR (either a Complete EHR or combination of EHR Modules) that has been certified against all applicable certification criteria adopted by ONC for a given payment year. With the delay of Stage 2 Meaningful Use implementation, this allows additional time for EHR vendors to design, develop and release new functionality, which was also cited as one of the reasons behind the recommended delay.
Below is the NPRM on Standards, Implementation Specifications, and Certification Criteria for stage 2 meaningful use. The final rule that established the initial set of standards, implementation specifications, and certification criteria was published in the Federal Register on July 28, 2010. The initial set represented the first round of an incremental approach to adopting future sets of standards, implementation specifications, and certification criteria to enhance electronic health record (EHR) interoperability, functionality, and utility. Under the authority provided by section 3004 of the Public Health Service Act (PHSA), this notice of proposed rulemaking would propose that the Secretary adopt revisions to the initial set as well as new standards, implementation specifications and certification criteria. The proposed new and revised standards, implementation specifications, and certification criteria would establish the technical capabilities that certified EHR technology would need to include to support meaningful use under the CMS Medicare and Medicaid EHR Incentive Programs.
The ONC has created a new certification called Certified EHR Technology that will replace current certification. This will begin at the implementation of Stage 2 Meaningful Use in 2014 (they are creatively calling this the 2014 edition). There will be two types of certification: a Base EHR and a Core EHR. Some of the baseline capabilities of a Base EHR are history and problem list, clinical decision support, CPOE, capture quality data and data query.
privacy and security, and health information exchange.
One of the requirements is the View and Download for patients certification criterion which combines several previous certification requirements:
Enable a user to provide patients with the ability to view and download their longitudinal health information online, and to electronically transmit this information directly to patients. Also, enable users to track transmission events and when information is viewed and downloaded. Information must include, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, procedures, clinical summaries and discharge instructions, and be provided in:
(i) Human readable format;
(ii) The standard (and applicable implementation specifications) specified in the new single standard and implementation guide and with data elements using applicable standards;
(iii) Track the number of patient online accesses (view and download) or transmission events.
Electronic access via online access is intended to include an online portal and/or PHR directly tied to the EHR or a third party patient portal and or PHR that is connected to the EHR. The third party solution (PHR and/or patient portal) may be directly connected to that EHR or through an HIE connection that offers electronic patient access. Similarly, the intention here is that the EHR needs to demonstrate one of these options for certification (not all of them). There is also the criteria that secure messaging is enabled that would allow a user to electronically send a secure message to a patient; and also receive a secure message from a patient. As mentioned previously Direct Project protocols must be enabled, which shows a continued emphasis on promoting these standards.
The Bipartisan Policy Center's (BPC) Task Force on Delivery System Reform and Health IT released a very timely set of recommendations for the most effective use of health IT dollars to support coordinated, accountable, patient-centered health care. The full report is available HERE. There was a webcast discussing the release of the report. Senators Tom Daschle and Bill Frist, Co-Leaders of BPC’s Health Project, and Governor Ted Strickland made remarks at the event. BPC Health IT Task Force members, including John Engler, President of the Business Roundtable, and Karen Ignagni, President and Chief Executive Officer of America's Health Insurance Plans, also provided insights on the findings and recommendations in the report.
The report recognizes that there remain several gaps in and barriers to achieving the health IT capabilities needed to support these common attributes of high performance and new models of care:
Misaligned Incentives New models of care, supported by the health IT capabilities required for their success, will not become the norm without transforming the nation’s primarily volume-based payment model to one that promotes higher quality, more cost-effective care.
Lack of Health Information Exchange While the exchange of information across the multiple settings where care and services are delivered is a central and necessary component of coordinated, accountable and patient-centered models of care, the level of health information exchange in the U.S. is extremely low.
Limited Level of Consumer Engagement Using Electronic Tools Health IT plays a critical role in supporting patient centered care, yet use of electronic tools to coordinate care, drive provider-patient communication, and empower patients to manage their health and health care
is not widespread.
Limited Levels of EHR Adoption While EHRs are a necessary foundational component for new models of care, the level of EHR adoption and Meaningful Use among physicians, hospitals and other provider organizations remains low.
Privacy and Security Concerns Consumers expect that their health information will be kept private and secure. Solidifying public trust in health IT and electronic health information exchange initiatives will require assurance about the processes used to protect the privacy and security of health information.
Multiple Federal Priorities Require Focus and Attention Health care organizations are faced with numerous requirements associated not only with health IT, but also with delivery system and payment reforms, health care coverage and access challenges, administrative improvements, and program integrity brought about by the Patient Protection and Affordable Care Act (ACA) of 2010, HITECH and other federal, state and private sector programs.
But just as importantly the report lays out solutions that could be implemented in a bipartisan way to address these gaps. The full report goes into great detail on how to address each the key issues raised. One important recommendation regarding EHR adoption is to improve the usability and safety of EHRs and accelerate the maturation of the EHR market. They propose that vendors, clinicians, hospitals and other providers should collaborate to identify common challenges and issues related to usability, including those with implications for patient safety, and develop and execute strategies to overcome them. I believe that usability should be a component of the standards and certification criteria for future stages of meaningful use.
They also make some suggestions to increase engagement of consumers using technology tools. They urge that the consumer awareness campaign initiated by ONC be built upon, and that both the public and private sectors should take additional steps to demonstrate how electronic tools can help consumers manage their health and engage further with their providers. This should be an encouragement to Lygeia Ricciardi, the ONC's Consumerista.
They also make detailed recommendations on how to build a business case for health information exchange. Aside from encouraging expansion of requirements for meaningful use they also recommend that Federal, state and private sector purchasers and payers should require that data standards adopted by the secretary be reflected in the specifications associated with clinical quality measures required by their payment or incentive programs. Health information exchange is a critical component of any strategy to use health IT to improve care and lower costs. I know that policy makers are taking these recommendations into serious consideration. I strongly recommend anyone interested in using technology to improve health care read this report.
Federal Investment in Electronic Health Records Likely to Reap Returns in Quality of Care
Healthcare is one of the last industries in the United States to universally incorporate technological advancements. While most sectors have made significant investments in information technology to improve efficiency and consumer relationships, America’s health care system is still largely paper-driven. As a result the healthcare system is plagued by inefficiency and poor quality. Delivery is slower, more prone to errors, and harder to measure and coordinate than it should be. Investments in health information technology can help improve this situation. Research published in the New England Journal of Medicine (FREE FULL TEXT) gives cause for optimism that efforts to increase adoption of electronic health records (EHRs) will provide major benefits in better patient care and health outcomes. Perhaps we can finally move away from using a dead tree medical recod system in this country.
To start with take a look at this video from a 1961 study that concluded that one day it is going to be possible to relieve the nurses and doctors of some of their paperwork, it is going to be possible to have correlation of diseases which we have not had before, and it is going to be possible to eliminate errors in medications and tests which would have been harmful to the patient:
“We were not surprised by these results,” said Randall D. Cebul, M.D., a professor of medicine at Case Western Reserve University and the study’s lead author who I was able to speak with earlier today. “They were influenced by several factors, including our public reporting on agreed-upon standards of care and the willingness of our clinical partners to share their EHR-based best practices while simultaneously competing on their execution.”
The research involved more than 500 primary care physicians in 46 practices that are partners in a region-wide collaborative known as Better Health Greater Cleveland (Better Health). This alliance of providers, businesses and other stakeholders is dedicated to enhancing the value of care for patients with chronic medical conditions in the region. Launched in 2007, the organization is one of 16 that the Robert Wood Johnson Foundation chose to support in its nationwide initiative, called Aligning Forces for Quality. This initiative is the foundation’s signature effort to lift the overall quality of health care in targeted communities as well as reduce racial and ethnic disparities and provide models that will help propel national reform. Common themes across the communities include public reporting of performance and community-wide initiatives to improve care.
As important as electronic health records are, Dr. Cebul said, their greatest value merges when used in conjunction with other approaches, such as the sharing of best practices and coaching offered through collaborations such as Better Health Greater Cleveland. "We've been doing summits twice yearly and will continue in the future so that we can identify and share best practices among providers. We also will provide ongoing coaching to practices that wish to continue to improve clinical outcomes," he said. The patient centered medical home is built on the foundation of electronic health records, and Better Health is working with employers and payers in the region to develop medical homes as well as exploring opportunities to participate in new payment models.
I asked Dr. Cebul what impact health information exchange will have on continuing improvements, particularly in the area of clinical care coordination. "I think that HIE will have a big benefit and it's value will be as much in cost reductions as it will in improving quality of care. For the smaller practices it will be very valuable in providing data from outside providers and specialists. HIE will enable us to reduce unnecessary emergency room visits and hospital readmission, as well as reducing duplicate testing. This will also accelerate the process of clinical evaluation and save money."
The authors did caution that they could not conclude that EHRs were the only explanation for quality differences. Other potential causes could be "the participation of exceptional EHR-based organizations, a nonrepresentative sample of paper-based organizations and inadequate adjustment for patient characteristics," they stated. Their study also would have provided even more compelling evidence for an advantage to EHR use if they had measured before-and-after performance for groups that had switched away from paper-based to using an EHR. But this study absolutely provides a basis for determining that digitizing medical records can have a substantial impact on quality of care.
The study involved more than 27,000 adults with diabetes and found that those in physician practices using EHRs were significantly more likely to have health care and outcomes that align with accepted standards than those where doctors rely on paper records. Improvements in care and outcomes over a three-year period also proved greater among patients in EHR practices. The study’s findings remained consistent for patients regardless of insurance type, including the uninsured as well as patients insured by Medicare, Medicaid, and commercial payers.
The data shows a staggering difference in performance among practices with EHRs as compared to those without: 51 percent of diabetes patients in EHR practices received all the care they needed as compared to only 7 percent in practices with paper records. A similar variation was also reported for diabetes patient outcomes—how well patients and their doctors were able to effectively manage their condition. For both care and outcomes, patients treated at practices with EHRs far outpaced those in paper practices across all insurance types—whether patients were on Medicare, Medicaid, a commercial plan or uninsured. Breaking the data down further shows that for practices using EHRs, the percentages of patients meeting standards for diabetes care were higher for making sure hemoglobin A1c tests were performed, kidney management was maintained, eye examinations were made than for those practices using paper records.
The Better Health study focused on a 12-month window spanning 2009 and 2010, and also followed trends over a three-year period. The study also measured achievement by age, gender and racial and ethnic categories as well as language preference and estimated patient income and education. The locally vetted national standards for care included timely measurements of blood sugar, management of kidney problems, eye examinations, and vaccinations for pneumonia. Outcome measures included meeting national benchmarks for blood sugar, blood pressure and cholesterol control, as well as achieving a non-obese Body Mass Index and avoidance of tobacco use. Patients who made at least two visits to the same primary care practice within a single year were included. The researchers reported results for individual standards as well as separate composite standards for care and outcomes. In the future they will be also developing metrics for patient satisfaction, as well as possibly adding childhood obesity and hypertension.
The study’s findings were striking – even after researchers statistically accounted for differences between EHR and paper-based practices in the characteristics of their patients.
Standards of Care: Nearly 51 percent of patients in EHR practices received care that met all of the endorsed standards. Only 7 percent of patients at paper-based practices received this same level of care – a difference of 44 percentage points. After accounting for differences in patient characteristics, EHR patients still received 35 percent more of the care standards.
Patient Outcomes: Nearly 44 percent of patients in EHR practices met at least four of five outcome standards, while just under 16 percent of patients at paper-based practices had comparable results. After accounting for patient differences, the adjusted gap was 15 percent higher for EHR practices.
Trends Over Time: After accounting for patient differences, EHR practices had annual improvements in care that were 10 percent greater than paper-based practices as well as 4 percent greater annual improvements in outcomes.
Performance Across Insurance Types: Patients in EHR practices showed better results, including improvements over time, in both standards of care and outcomes across all insurance categories – commercial, Medicare, Medicaid and uninsured.
“These results support the expectation that federal support of electronic health records will generate quality-related returns on our investments,” said David Blumenthal, M.D., M.P.P., professor of medicine and health care policy at Harvard Medical School and past National Coordinator for Health Information Technology. “I am especially pleased that the benefits reported in this investigation spanned all insurance types, including Medicaid and uninsured patients, since it is essential that the modern information technologies improve care for all Americans, including our most vulnerable citizens.”
“Cleveland stands as a pioneer in the burgeoning movement to leverage local resources and federal reform opportunities to improve health care quality,” said Anne F. Weiss, M.P.P., who leads efforts to improve the quality of American health care at the Robert Wood Johnson Foundation. “Electronic health records alone cannot solve the nation’s health care quality problems, but they are an important part of the fix. Cleveland’s use of electronic health records is a model for all health care organizations working to implement health reform.”
“Better Health seeks to improve the value of health care for all of the region’s residents and those who pay for their care,” said David L. Bronson, MD, FACP, president of Cleveland Clinic Regional Hospitals and President-elect of the American College of Physicians. “As the program moves forward, we expect that EHR-based sharing of information across different health care systems, and with our patients, will help us to keep our patients healthier and foster more discriminating use of expensive resources, such as our emergency departments and hospitals.”
This perspective is also echoed by other national leaders as well. Not only do such collaborations enhance care and outcomes, but they also provide rich opportunities to test the impact of different approaches and innovations. As Dr. Carolyn Clancy, M.D., director of the federal Agency for Healthcare Research and Quality, explained: “The results of this study support both the value of electronic health records and community-based partnerships to improve quality of care.”
There has been much discussion and debate on the use of electronic health records and whether they are capable of improving the quality of care. In the recent Stanford University study by researchers Max Romano and Randall Stafford, MD, PhD, there was not much indication of quality improvement. In another study from Britain they were likewise unable to find empirical evidence of quality and safety improvement. However, my conclusion, unlike the headlines which blared "EHR Systems Do Not Improve Quality," is that while the technology itself will not automatically improve quality or safety the "meaningful use" of this technology can and will improve clinical outcomes and the quality of care. My concerns on the EHR Incentive Programs are not centered on this debate, but rather on components of the legislation and regulations.
I'm trying to remain optimistic about these programs, but there are some issues that I would like to highlight as potential roadblocks to success. Unfortunately, many of these problems are written into the legislation and can not be fixed by future rulemaking, but will require Congress to act. And the amount of incentive payments are too low and will not cover the transition costs for providers that are still on paper, although hospitals and health systems that have already made significant investments in health IT will see some return on their investment. I'm not much concerned that HR 408 the Spending Reduction Act of 2011, which would defund the HITECH Act incentive program, will become law. However, I would like to see checks make it to providers before future stages of meaningful use become a political football.
There are potentially some serious difficulties that rural providers and small hospitals will have being able to fund these projects within their limited resources, considering that the incentive payments will barely, if at all, cover the costs of implementation. I fear that billions of taxpayer dollars will pass right through the hands of hospitals and physicians and go straight to the bottom line of health IT vendors. Healthcare providers could end up having a very hard time maintaining the meaningful use of their EHRs with a dwindling revenue stream. The CBO estimated in 2008 that EHR implementation costs for hospitals amount to approximately $14,500 per bed for implementation. Annual operating costs amount to $2,700 per bed per year. For physician groups, the CBO reported that total implementation costs for office-based EHRs ranged from $25,000 to $45,000 per physician, with annual operating, licensing, and maintenance costs ranging between $3,000 and $9,000 per physician. These figures are conservative at best and costs have certainly risen since then in any event. The costs will continue to increase due to market pressures and vendor workforce shortages.
There are also eligibility problems that some providers in a Rural Health Clinic (RHC) setting are facing. The HITECH Act created an EHR incentive payment for an Eligible Professional (EP) under Medicare based on the allowed charges for covered professional services furnished by the EP. Only services billed under the Part B physician fee schedule meet the HITECH Act definition of "covered professional services." This means services provided in an RHC would not be included in the calculation for the Medicare EHR incentive. These providers may still qualify under their states Medicaid requirements, but only EPs who meet the 30 percent threshold for "needy individuals" as defined in statute and other program requirements will qualify for payments. This section of the law will cause some providers in rural and underserved settings to be unable to participate in the program at all.
This same section of the legislation also precludes Medicare Advantage providers from participating directly in the program since they do not bill Part B. Under the Medicare Advantage EHR Incentive Program, payments are made only to Medicare Advantage organizations that are licensed as HMOs, or in the same manner as HMOs, by a state. It seems that the legislation was crafted with particular lobbying interests at the table, and while no bill is perfect the HITECH Act was rushed through rather quickly and mistakes were made which are unlikely to be addressed in the current political environment.
Another group that is left out are Physician Assistants (PA)s, unless they are working in a RHC led by a PA. There are many PAs working in settings that will disqualify them from participating in the incentive program and this already having an effect on recruitment strategies. Why would a practice hire a PA who is ineligible instead of a Nurse Practitioner who is eligible? This can also create difficulty and confusion for EHR adoption strategy by clinics attempting to create a patient-centered medical home. The wise use of mid-level practitioners can be an important key to success. Addressing the primary care physician shortage is not helped by this provision in the legislation.
Finally, the Medicaid program is being approached in a wide variety of ways by the states, and some may be trying to use the incentive program as a policy lever to accomplish other goals. I am concerned that in some states the roll out of the incentive program may have lost sight of the economic stimulus side of the equation. Money continues to be poured into government run programs like the State Cooperative Agreements for health information exchange and the Regional Extension Centers to help with adoption, but few of these dollars are making it into the private sector. I like the "adopt, implement or upgrade to certified EHR technology (AIU)" provision in the Medicaid EHR Incentive Program. This will enable some to springboard to future stages of meaningful use. If this were expanded then perhaps there would not be so many rural providers and critical access hospitals left at the station...
