Properly implemented electronic health records (EHRs) can inform clinical decision-making and improve patient outcomes.1,2 In 2009, Congress passed the U.S. Health Information Technology for Economic and Clinical Health Act (HITECH) to facilitate and hasten hospital and clinician EHR adoption through incentive payments expected to total $27 billion over a 10 year period.

EHR implementation is not just a matter of creating digital versions of paper medical records. It is intended to transform how medical information is created, organized, shared and utilized.

“This involves fundamental shifts in how clinicians create, access and utilize patient records, and that represents a major shift in clinical workflow and habits,” William Chin, MD, executive medical director of HealthCare Partners in Torrance, Calif., told Clinical Advisor.

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This shift in workflow is referred to as meaningful use, the goals of which include improving the quality, efficiency and safety of health care; reducing health disparities; improving coordination of care and public health outreach; and engaging patients in their own health — all while maintaining patient privacy.

The main advantage of EHRs is improved patient access to medical records, and more thorough patient engagement with healthcare providers, particularly NPs and PAs. “NPs and PAs are active participants in the online patient portal in place in our healthcare system, in which patients can access lab results, make primary-care provider (PCP) appointments, e-mail their PCP and update their insurance information,” Chin said.

Other benefits of EHR systems include the ability to conduct sophisticated analyses of patient data, “in stark contrast” to paper records, which enables hospitals and clinicians to identify and address quality-of-care problems across patient populations.

“The EHR allows analysis to define areas for improvement where the paper chart is intractable,” Chin said. “Strong EHR support and training leads to improved analytics, and clinical and operational improvements.”

Meaningful use incentives

Although EHR participation in the United States is currently voluntary, hospitals and clinics that do not meet EHR meaningful use requirements by 2015 will face escalating penalties starting with a 1% reduction in Medicare and Medicaid payments, which will increase to 2% in 2016 and 3% in 2017.3,4

HITECH incentives are intended to help overcome the natural reluctance and resistance to such changes, reflecting increasing support among policymakers and the public for the increased efficiency, reduction in medical errors and cost savings believed to be achievable through EHR.

Although NPs and PAs are likely to be tasked with helping clinics and hospitals in EHR implementation and meaningful use processes, many are not eligible to receive incentive payments under the HITECH act, according to Tricia Marriott, director of reimbursement for the American Academy of Physician Assistants in Alexandria, Va.

PAs frequently attend EHR education programs and return to train colleagues at the hospitals and clinics where they work, according to Marriott, but including provisions in the HITECH law for midlevel health-care providers was likely overlooked “due to a lack of understanding about the roles they play.”

Under Medicare, NPs and PAs are not eligible for EHR incentive program payments, but Medicaid’s EHR incentive program includes MDs, DOs, NPs, certified nurse-midwives, and under certain circumstances, PAs.

A PA is eligible for incentive payments if he or she is the primary health-care provider handling the majority of a services at a federally qualified health center (FQHC) or rural health clinic (RHC), or is the clinical or medical director at the clinic in question or owner of a RHC.

Current EHR incentives specify that physicians can earn up to $44,000 through Medicare, whereas, qualifying NPs and PAs can earn up to $63,750 in Medicaid incentive payments. To qualify for Medicaid EHR incentives, at least 30% of patient volume at a hospital or clinic must be Medicaid patients. Pediatric offices with 20% Medicaid patient volume are also eligible, but patients insured through the Children’s Health Insurance Program (CHIP) may not be counted toward this threshold.4

Registration for the incentives program remains open for 2012.

Demonstrating meaningful use

The Centers for Medicare and Medicaid Services (CMS) have identified three basic requirements to show that eligible health-care providers are achieving EHR meaningful use. These include: demonstrated use of certified EHR technology; demonstrated EHR connectivity to promote care coordination through electronic sharing of health information; and submission of information on clinical quality measures to the U.S. Department of Health and Human Services (HHS). 4

In order to demonstrate that they meet these three requirements, healthcare providers must achieve 25 meaningful-use objectives during a continuous 90-day reporting period within one calendar year. These consist of 15 mandatory core objectives, plus five additional objectives that clinicians are allowed to select from a menu list of 10 items.4

The 15 mandatory core objectives for establishing meaningful use are summarized below:

  • Recording at least one entry as structured data for either an up-to-date problem list or current list of active diagnoses; an active medication allergy list; or an active medication list for more than 80% of patients
  • Recording structured EHR demographic data, including sex, race, ethnicity, date of birth, preferred language and (for hospitals) date and cause of death for more than 50% of patients
  • Recording weight, height and BP data for more than 50% of patients aged 2 years or older
  • Recording smoking status for more than 50% of patients aged older than age 12 years
  • Recording clinical summaries within three business days for more than 50% of all office visits
  • Providing electronic copies of discharge instructions upon request to more than 50% of patients discharged from the ER or inpatient departments
  • Providing electronic copies within three days of a visit for more than 50% of patients who request diagnostic test results, medication lists, allergies, and problems and hospital discharge summaries and instructions.
  • Electronically transmitting more than 40% of prescriptions (hospitals are exempt)
  • Ordering at least one medication through computer provider order entry (CPOE) for at least 30% of patients
  • Enabling functionality of drug-drug and drug-allergy interaction checks throughout the entire 90-day reporting period
  • Performing at least one test to determine EHR system capacity for electronic exchange of patient data
  • Establishing at least one clinical decision support rule
  • Implementing the ability to track compliance with that rule during the reporting period
  • Conducting a review of security risks and implementing security updates and deficiency corrections to protect patient privacy
  • Electronically submitting clinical quality measures to CMS or state Medicaid program agency (state criteria available, here)

The five additional items necessary for meaningful use include options such as generating a list of patients with a specific condition and performing drug formulary checks, but vary slightly by practice setting and clinician eligibility. Full details are available in the CMS list of EHR incentive objectives.

Challenges to successful implementation

Despite this guidance, EHR implementation has proven challenging for some early-adopters.5  “EHR allows patient information to be available 24 hours a day, seven days a week, but often slows clinicians’ productivity. This presents a challenge for all team members, but one that can be overcome with training and time,” Chin explained.

Relatively few public domain case studies have been published describing early adopters’ experiences with EHR implementation, but some have suggested that centralization and hospital-wide coordination through a dedicated office of clinical transformation may significantly improve odds for success.6

EHR vendors can also help ease the transition with proprietary internal lessons-learned analyses from experiences with previous clients. Some vendors even offer guarantees that incentive goals will be met.7

Selecting a vendor for guidance in implementing EHR and securing incentive payments should be a carefully considered step, and depend on the company’s ability to understand and address the client’s clinical practice and routine. “Any EMR purchase requires an assessment of the vendor’s ability to create the work flow to meet the needs of the clinician,” Chin emphasized.

Bryant Furlow is a freelance medical writer based in Albuquerque, New Mexico.


1. Cebul RD, Love TE, Jain AK, Hebert CJ. “Electronic health records and quality of diabetes care.” New Engl J Med. 2011;365(9):825-833.

2. Blumenthal D, Tavenner M. “The ‘meaningful use’ regulation for electronic health records.” New Engl J Med. 2010;363(6):501-504.

3. Harrison RL, Lyerla F. “Using nursing clinical support systems to achieve meaningful use.” Comput Informat Nurs. 2012; doi: 10.1097/NCN.0b013e31823eb813.

4. Centers for Medicare & Medicaid Services (CMS). EHR Incentive Program. Accessed April 30, 2012.

5. Crosson JC, Schueth AJ, Isaacson N et al. “Early adopters of electronic prescribing struggle to make meaningful use of formulary checks and medication history documentation.” J Am Board Fam Med. 2012;25(1):24-32.

6. Banas CA, Erskine AR, Sun S et al. “Phased implementation of electronic health records through an office of clinical transformation.” J Am Med Inform Assoc. 2011;18:721-725.

7. AthenaHealth. “How to get paid for meaningful use: 7 tips from the EHR trenches.” March 2012. Accessed April 30, 2012.