EHRs: Incentives and Implementation


The final rules for meaningful use were published in the Federal Register on July 28, 2010. They became official 60 days later. There has been a lot of misinformation in blogs, online forums, and professional journals about the ability (or inability) of eye care providers to become “meaningful users of certified EHR [electronic health record] technology” and thus qualify for the Medicare or Medicaid incentive payments. This article discusses some common questions about qualifying for meaningful use (see More Than Incentives).WHO ISSUED AND CONTROLS THE FINAL RULE(S) FOR MEANINGFUL USE?

There are actually two final rules. One is from the Centers for Medicare & Medicaid Services, and the other is from the Office of the National Coordinator (ONC) for Health Information Technology.

The Centers for Medicare & Medicaid Services are responsible for the rules related to the EHR incentive programs, one for Medicare providers and one for Medicaid providers. The ONC is responsible for the rules related to software certification criteria and the process of certifying EHR software applications.

The rules for meaningful use and certification are separate but closely related. For example, even though you will not have to meet all of the measures for meaningful use, software vendors must demonstrate that their applications can meet all of the certification criteria.


The Medicare program offers up to $44,000 per provider, and the Medicaid program offers up to $64,000 per provider. You may only get one or the other, but you may switch from one program to the other once.

Before you get too excited about the Medicaid incentive, you should know that 30% of your patients must be on Medicaid for you to qualify for the program. That requirement rules out about 95% of all providers. If you think you might qualify for the Medicaid incentive, you should be familiar with two of its nicest features:

  1. You do not have to be a meaningful user in your first year of payment, and you must only adopt, implement, or upgrade a certified EHR technology. After year 1, you must be a meaningful user.
  2. You may begin the Medicaid EHR program until 2016, and the maximum reimbursement will not decrease. The Medicare program pays you a 75% bonus on your Medicare-allowed charges up to an annual maximum. As evident in Table 1, the maximum payment during your first year of payment (which does not have to be 2011) is $18,000, so you only need $24,000 in allowed charges in your first payment to earn the full first-year incentive payment. The annual maximum incentive payment decreases each year after your first year of payment.


You must be a meaningful user (more on this later) of a certified EHR technology. Your first step, therefore, is to select and begin using an EHR application that is certified by an ONC-approved body.

Many EHR software vendors are now certified. The first ones received their certification in October 2010. For a list of certified vendors, visit


You must demonstrate that you are a meaningful user of the certified EHR technology. You cannot just install an EHR system; you must actually use it and meet specific criteria. Most of the requirements for meaningful use are things that you probably already do or that will require only minor changes to your business and clinical processes, so do not worry too much. The rules also allow you to exclude measures that do not fit your practice. Here is what the final rule says about exclusions: “An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply.”

There is a core set of 15 rules on meaningful use that you must meet in order to be eligible for the incentive payments. Chances are that at least four of them are part of your normal clinical documentation:

  1. Maintain a list of problems for more than 80% of all unique patients seen by the eligible professional (EP).
  2. Maintain an active list of medications for more than 80% of all unique patients seen by the EP.
  3. Maintain an active list of allergies to medications for more than 80% of all unique patients seen by the EP.
  4. Record demographics (preferred language, gender, race and ethnicity, and date of birth) for more than 50% of all unique patients. Other items on the list of rules may require some minor modifications to your normal documentation:
  5. Record vital signs (height, weight, blood pressure), calculate body mass index, and display or print growth charts for more than 50% of all unique patients aged 2 and older seen by the EP. Any EP who believes that all three vital signs have no relevance to his or her scope of practice may exclude this measure.
  6. Use Computerized Physician Order Entry for 30% of your medication orders. You are probably already recording most orders (referrals to specialists, laboratory tests, etc.), and the final rule only requires that orders of medication be recorded. EPs who write fewer than 100 prescriptions during the EHR reporting period may exclude this measure.
  7. Record smoking status for more than 50% of all unique patients 13 years of age or older seen by the EP. (You merely need to indicate one of three choices.)
  8. Generate and transmit permissible prescriptions electronically for 40% of all permissible prescriptions. Any EP who writes fewer than 100 prescriptions during the reporting period may exclude this measure.
  9. Implement checks for drug-drug and drug-allergy interactions.
  10. Provide clinical summaries to patients for more than 50% of all office visits within 3 business days. Although you probably are not doing this now, the clinical summary is something that your EHR software will have to generate. Meeting the requirements of the other core set measures is certainly not an insurmountable hurdle:
  11. Implement one clinical decision support rule.
  12. Become capable of electronically exchanging key clinical information (eg, lists of problems, medications, or allergies to medications; diagnostic testing results) among providers of care and patient-authorized entities.
  13. Provide patients with an electronic copy of their health information (including diagnostic testing results and lists of problems, medications, or allergies to medications) for at least 50% of those who request it within 3 business days. Any EP who has no such requests during the EHR reporting period may exclude this measure.
  14. Report clinical quality measures. This is the requirement that will give practitioners and their staff the most fits, especially those who have not participated in the Physician Quality Reporting Initiative.
  15. Perform a Health Insurance Portability and Accountability Act security risk analysis.

In addition to the 15 measures just described, there is also a “menu set” of 10 measures of meaningful use. You may pick the five that you feel will be most advantageous to your practice, but two must be public health measures (number 6 or 7 in the following list). Just as with the core set, the menu set includes some noteworthy exclusions:

  1. Incorporate the results of clinical laboratory testing into EHRs as structured data. An EP who orders no laboratory tests having results that are either in a positive/ negative or numerical format during the EHR reporting period may exclude this measure.
  2. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.
  3. end reminders to patients according to their preferences for preventive/follow-up care. An EP who has no patients aged 65 years or older or 5 years or younger with records maintained using certified EHR technology may exclude this measure.
  4. Provide patients with timely electronic access to their health information (including laboratory results and lists of problems, medications, or allergies to medications) within 4 business days of when the information becomes available to the EP.
  5. Perform a medication reconciliation if you are the EP who receives a patient from another setting of care or provider of care or if you believe an encounter is relevant. An EP who was not the recipient of any transitions of care during the EHR reporting period may exclude this measure.
  6. Submit electronic data on immunization (related to public health). This measure merely requires a test of submission, and a failed attempt meets the measure. An EP who does not give any immunizations during the EHR reporting period may exclude this measure.
  7. Submit electronic data on syndromic surveillance (related to public health). Again, this measure simply requires a test of submission, and a failed attempt meets the measure. An EP who does not collect any reportable syndromic information on his or her patients during the EHR reporting period or who does not submit such information to any public health agency that has the capacity to receive the information electronically may exclude this measure.
  8. Check drug formularies. Your e-prescribing module probably includes this function. Any EP who writes fewer than 100 prescriptions during the EHR reporting period may exclude this measure.
  9. Use certified EHR technology to identify patientspecific educational resources and provide them to the patient if appropriate.
  10. Provide a summary-care record for each transition of care or referral if you, the EP, transition your patient to another setting of care or provider of care or refer your patient to another provider of care.

As with the core set, the menu set offers more than enough flexibility for nearly any practitioner to pick measures with which he or she is comfortable and/or to reduce significantly the number of objectives that he or she must meet through exclusions.


Among the certified EHR systems, look for ones with ophthalmology-specific templates and the ability to integrate all aspects of a typical ophthalmic practice, including an optical shop, multiple providers, device interfaces, and practice management.

Choose an EHR application that is fully customizable. You can then mold the software to the way the doctors and staff at your practice work, instead of forcing them to conform to the software. Bear in mind that all EHR vendors will say that their EHR system is “customizable.” The important capabilities that many do not offer include being able to actually change the look and layout of the examination template(s), add triggers/rules that automate data entry, modify all output, modify the underlying database itself, etc.

Put together an implementation team. Ensure that all staff members and physicians can voice their concerns and fears about implementing an EHR system so that these matters can be taken into consideration.

Regularly communicate your expectations or plan to deal with fear, uncertainty, and doubt down the line.

Pay attention not only to how the examination screens look but also to how well the vendor can train and support you and your staff during the transition. Follow your vendor’s advice on the amount of training necessary. Seldom do a practice’s physicians and staff finish implementing an EHR system feeling like they were trained too much.

Take the time to thoroughly review your current processes and understand exactly what happens in your office now (people’s processes, the movement of papers and patients, etc.). Many of these processes will need to be re-engineered for your new “digital” practice. View this as an opportunity to improve on the things that you have “always done that way.”

Establish a specific timeline that everyone can access or view so that each person knows where your practice is in the process and what he or she is supposed to be doing. Without a timeline, how can anyone know if the practice is on track and making acceptable progress?

Finally, before going live, all doctors and technicians must practice using real charts or scenarios that you have created. Their level of comfort with live patients will be in direct proportion to their practice and preparation.


Now, you have an understanding of the incentives. You know how much they are worth to you, and you know more about how to successfully implement an EHR system. Focus on the benefits to your practice and your patients from the use of a proven and fully vetted EHR application. Any federal EHR incentives you receive are “gravy.”

Jeff Grant is the founder of HCMA, Inc., in Shell, Wyoming. The company specializes in managerial, operational, and information technology consulting for medical practices, and it offers revenue-cycle managerial services. Mr. Grant may be reached at