Meaningful Use and Quality Improvement

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Continuing Medical Education — February 2014 

Tex Med. 2014;110(2):49-54.

By Shannon Vogel

The Texas Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. TMA designates this enduring activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This course has been designated by the Texas Medical Association for 1 credit of education in medical ethics and/or professional responsibility.

This credit is available for the period of Aug. 8, 2013, to Aug. 8, 2016.  

Disclosure of Commercial Affiliations

Policies and standards of the American Medical Association and the Accreditation Council for Continuing Medical Education require authors and planners for continuing medical education activities to disclose any significant financial interests, relationships, or affiliations they have with commercial entities whose products, devices, or services may be discussed. They also must disclose discussion of investigational or unlabeled uses of a product.

The content of this material does not relate to any product of commercial interest; therefore, there are no relevant financial relationships to disclose.

Learning Objectives

Upon completion of this publication, participants should be able to: 

  1. Summarize meaningful use and eligibility for federal electronic health record (EHR) incentives through the Medicare and Medicaid programs; 
  2. Discuss the quality of care, patient safety, and efficiency benefits of an EHR; and
  3. Explain potential for quality improvement through EHR quality reports, patient engagement, and care coordination.  

About the Author

Shannon Vogel is director of the Texas Medical Association's Health Information Technology Department. TMA has been advocating for and educating physicians about the adoption of health information technology (HIT) since creating a dedicated HIT department in January 2006 under Ms. Vogel's direction. Guided by a physician committee on HIT that meets three times annually, TMA provides physicians relevant education, guidance, and resources. 


This course is appropriate for physicians, nonphysician practitioners, and office staff in all specialties. 

CME Iinstructions  

  1. Read the course in its entirety. It is available online at
  2. Complete the online post-test with a minimum 70-percent passing score and the evaluation.
  3. CME credit will be recorded upon completion of the test. Documentation will be sent to the reader's email inbox, or you can print it directly from the website. 
  4. Direct questions or concerns to the TMA Education Center at (877) 880-1335 or

The Stimulus for Health Information Technology

The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009, promotes adoption of health information technology (HIT) throughout the health care industry. It offers physicians who treat Medicare or Medicaid patients monetary incentives to adopt and meaningfully use an interoperable electronic health record (EHR) system. Incentive payments for Texas physicians exceed $300 million and continue to grow.   

The HITECH Act also brought significant grant funding to Texas. The following grants total $91.7 million:  

  • $38 million for four regional extension centers (RECs),
  • $28.8 million for health information exchanges (HIEs),
  • $15 million for Strategic Health IT Advanced Research Projects,*
  • $5.4 million for HIT workforce education, and
  • $4.5 million for Medicaid HIT planning. 

The Office of the National Coordinator for HIT oversees activities related to the HITECH Act.

*The Strategic Health IT Advanced Research Projects program, under the auspices of the Office of the National Coordinator for HIT, is led by major collaborative efforts at The University of Texas at Houston (UT-Houston) and other institutions. UT-Houston is leading innovative cognitive research to harness the power of health IT to integrate and support physician reasoning and decisionmaking in the care of patients.

Physician Incentives: Who and How Much

Medicare and Medicaid each have an incentive program, as explained below. Physicians are eligible for both programs; however, they must choose only one. The eligibility for ancillary providers varies by program. 

For the Medicare program, physicians, dentists, podiatrists, optometrists, and chiropractors are eligible. Under Medicaid, eligibility applies to physicians, dentists, nurse practitioners, and certified nurse midwives, and to physician assistants who lead a rural health clinic (RHC) or federally qualified health center (FQHC).

Ineligible for incentives under either program are long-term care facilities such as nursing homes as well as physicians who perform more than 90 percent of their services in a hospital setting (based on claims reporting and place of service codes 21 and 23). Because hospitals receive incentives, physicians who practice in a hospital setting most likely benefit from them. 

Medicare incentives. Table 1 shows the incentives physicians may earn through the Medicare EHR incentive program. 2014 is the last year physicians can begin the program and still receive the incentive, which is diminishing. The incentive amount is calculated for the individual physician, not the practice, and is 75 percent of the physician's Medicare allowed charges up to a maximum. Physician who practice in a federal health professional shortage area are eligible for an additional 10-percent bonus. 

Physicians who choose not to meaningfully use an EHR will pay a Medicare penalty: 1 percent in 2015 and 2 percent in 2016, with a cap of 3 percent in 2017 and beyond. There is one caveat to the penalty. If at least 75 percent of office-based physicians do not demonstrate meaningful use by 2018, the U.S. Department of Health and Human Services secretary has the authority to increase the penalty an additional 1 percent for the next two years.  That could mean a 4-percent penalty in 2018 and a 5-percent penalty in 2019. 

To receive the incentives, physicians must register for the Medicare EHR incentive program at Each year of participation, they also must attest to the Centers for Medicare & Medicaid Services (CMS) to meeting the meaningful use measures; separate attestation pages are required for each measure. 

In their first year of participation, physicians must demonstrate meaningful use for a 90-day EHR reporting period; in years two through five, they must demonstrate meaningful use for a full-year EHR reporting period. However, in 2014, everyone, regardless of their stage of meaningful use, will be required to demonstrate meaningful use for only 90 days. A physician must be enrolled with the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to receive the incentives.  

Medicaid incentives. The Medicaid program is different in that eligibility is based on patient volume. Medicaid must account for at least 30 percent of the patients seen in the practice, unless the physician is a pediatrician. Pediatricians are eligible if the volume is 20 percent. 

Physicians must reestablish their eligibility each year, basing patient volume on either patient encounters or patient panel for a sample 90-day billing period from the previous calendar year.

FQHC or RHC physicians can participate if 30 percent of their patient volume is attributed to "needy" individuals who qualify for sliding-scale or free care, or for the Children's Health Insurance Program.

The incentive payment is a fixed amount for each year of participation. Eligible physicians with at least 30-percent Medicaid volume could receive up to $63,750 over six years. 

Eligible pediatricians with at least 20-percent Medicaid volume could receive up to $42,500 over six years. 

Medicaid incentives roll out over six years instead of five as in the Medicare program. Medicaid pays out until 2021, so physicians could start in 2016 and still receive the full incentive. Also, physicians can skip years. One warning to those whose participation is lagging: Should Congress repeal the EHR incentive funding, physicians waiting too long may miss out on some of the incentives. 

For Medicaid, physicians do not need to meet meaningful use in their first year. They simply must have a certified EHR. Year two of the program requires 90 days of meaningful use, and years three through six require demonstrating meaningful use for the full calendar year (except, as noted above, in 2014, everyone will be required to demonstrate meaningful use for only 90 days). No penalties are associated with the Medicaid program.

When registering for Medicaid, physicians who plan to participate in the Medicaid EHR incentive program must first register on the CMS website at CMS will alert Texas Medicaid, which will email the physician instructions on how to register for the Texas Medicaid EHR incentive program. PECOS enrollment is not required for the Medicaid program. Physicians must attest every year of participation.

Attestation. Physicians attest to meeting meaningful use on the CMS website at All technical questions about registration and attestation pages may be directed to the EHR Information Center by telephone at (888) 734-6433.

Stages of Meaningful Use

Meaningful use is being rolled out in three stages: 

  •  Years 2011 through 2013 constitute Stage 1. This is the data-capture and sharing stage.
  • The second stage demonstrates advanced clinical processes. Stage 2 began on Jan. 1, 2014. 
  • The Stage 3 rules are not yet released but are expected in late 2014 or early 2015. Stage 3 is meant to focus on improved outcomes in patient care.  

Starting in 2014, all physicians must use an EHR certified for Stage 2, even if they are participating in Stage 1. Because every physician EHR user in the country must upgrade in 2014, CMS is allowing 90 days of meaningful use for 2014. Everyone gets two years of Stage 1, with the exception of those who started in 2011, before having to move to Stage 2.  

Meaningful Use Goals

Each of the meaningful use criteria falls under one of these five goals:  

  1. Improve quality, safety, and efficiency, and reduce health disparities; 
  2. Engage patients and family; 
  3. Improve care coordination; 
  4. Improve population and public health; or
  5. Ensure adequate privacy and security protections for personal health information. 

Stage 1 Meaningful Use Criteria

All physicians must meet a core set of 14 meaningful use measures. A 15th measure is no longer required for physicians reporting in 2013 and beyond for Stage 1. Additionally, there is a menu set of 10 measures. Physicians must choose five from the set of 10, and one of them must be one of the two public health measures.  

Exclusions. Thirteen of the now 24 meaningful use criteria allow "exclusions" for physicians to report that the objective or measure is not applicable. For example, a physician who writes fewer than 100 prescriptions during the EHR reporting period is excluded from reporting on the drug formulary checks. 

►For a list of the meaningful use measures and details about each, go to

Product certification. Physicians must use "certified" EHR technology, i.e., the current product and version number must be certified for meaningful use. A product certification number is required for attestation. 

►A product list is available at

Meaningful use products are either "complete" or "modular." Modular products require additional technology. For example, the EHR may not have an e-prescribing component, precluding a complete certification. The physician would have to install an add-on e-prescribing product to meet certification requirements. 

Quality and Safety Benefits of EHRs

EHRs enable health monitoring in regard to quality and safety. They provide drug alerts and recommended preventive services and immunizations, and allow physicians to track and trend a patient's blood pressure and body mass index. Physicians can run reports on their patients who have specific conditions or need follow-up care or preventive services.  Extracting this type of data is not feasible with paper records. 

Quality-improvement measures. These meaningful use criteria are designated as quality-improvement measures: 

From the core set: 

  • Computerized physician order entry (CPOE),
  • Drug alerts,
  • E-prescribing,
  • Demographics,
  • Problem list of active diagnoses,
  • Medication list,
  • Medication allergy list,
  • Vital signs,
  • Smoking status,
  • Decision support, and
  • Clinical quality measures (CQMs). 

From the menu set: 

  • Drug-formulary checks,
  • Lab results, and
  • Reporting by condition. 

Clinical quality measures. To meet the criteria for CQMs, physicians must track a minimum of six CQMs or a maximum of nine: three from the core set, three from an alternate core set if needed, and three from a set of 38. 

Clinical quality measures align with the CMS Physician Quality Reporting System (PQRS).

Core set:  

  1. NQF 0013: Hypertension: Blood pressure Measurement
  2. NQF 0028: Preventative Care and Screening Measure Pair: (a) Tobacco Use Assessment and (b) Tobacco Cessation Intervention
  3. NQF 0421/PQRI 128: Adult Weight Screening and Follow-up  

No percentage is required for Stage 1 meaningful use. Physicians should place in the numerator whatever the EHR calculates for these measures. If all of the core measures have a zero numerator, the physician will be prompted to report on the alternate core set:  

  1. NQF 0024: Weight Assessment and Counseling for Children and Adolescents
  2. NQF 0041/PQRI 110: Preventive Care and Screening for Influenza Immunization for Patients 50 Years Old or Older
  3. NQF 0038: Childhood Immunization Status 

Engaging Patients/Proving Value

Proving quality is not just for meaningful use and government programs. Employers, too, want to know they are getting the best value for their cost. It's not enough to practice quality medicine; physicians must prove quality medicine as well. 

Part of meaningful use is about engaging patients and families in their own health care. These five meaningful use criteria are related to engaging patients and families: 

From the core set: 

  • Copy of health information, and
  • Clinical summaries. 

From the menu set: 

  • Patient reminders,
  • Timely access to patient's health information, and
  • Patient education. 

Clinical summaries. What's in a clinical summary? This is a frequently asked question from TMA members. The list of what is required is rather extensive:   

  • Patient name;
  • Provider's office contact information;
  • Date and location of visit;
  • Updated medication list;
  • Updated vitals;
  • Reason(s) for visit;
  • Symptoms;
  • Problem list, procedures, and instructions based on office visit;
  • Immunizations or medications administered during visit;
  • Summary of topics covered/considered during visit;
  • Time and location of next appointment, scheduled testing, and follow up;
  • List of other appointments, tests, and contact information the patient needs for follow-up care;
  • Laboratory and other diagnostic test orders; and
  • Test/laboratory results (if received 24 hours after visit).  

Meaningful use requires that you offer the clinical summary to at least 50 percent of all patients. If the patient refuses it, you can still count it. Some EHRs use the "print to screen" function to capture the count. Check with your vendor for specifics on how to track this measure. 

Personal health records (PHRs) can help. Physicians can send patient information directly to the patient's PHR by using the Direct Secure Messaging protocol. This standard allows the sending of HIPAA-compliant encrypted emails. Physicians typically can get a Direct email address through their local health information exchange (HIE). Patients can get a Direct email address from their PHR company.

PHRs may be better than patient portals for various reasons. Most EHR vendors charge for patient portals. Portals are silos of patient information, and patients may have multiple portals at multiple clinic locations. By securely using the Direct email and communicating via a patient PHR, physicians don't have to pay for or administer the patient portal connected with the EHR. 

The goal of care coordination is about improving quality and increasing patient safety by having the right information at the right time to enhance decisionmaking. This also helps physicians know where else the patient is receiving care — for example, if the patient has been hospitalized recently.   

Health Information Exchanges 

Exchanges are in various stages of development throughout Texas thanks to the $28.8 million grant from the Office of the National Coordinator for HIT. The Health and Human Services Commission, with support from the Texas Health Services Authority (THSA), is overseeing grant dissemination for regional HIEs in Texas; details are available from THSA at

Counties that do not have HIE coverage are referred to as "white space." At the very least, physicians have the option of using Direct protocol email in these areas. White-space counties do not have a way to query patient information unless they are part of a hospital-based, private HIE. 

Improving Population and Public Health

Physicians must choose at least one of the two public health measures from the menu set. There are exclusions for both, but physicians need to choose at least one even if only to claim the exclusion.  

  • Immunization registry: Perform one test of EHR's capability to submit electronic data to immunization registries and perform follow-up submission if test is successful. Exclusion: Does not perform immunizations.
  • Syndromic surveillance data: Perform one test to provide electronic syndromic surveillance data to public health agencies, and perform follow-up submission if successful. Exclusion: Public health department does not accept syndromic surveillance data from ambulatory practices.  


Five of the meaningful use measures are related to e-prescribing and medications. The CMS e-prescribing program is winding down, as the EHR program includes e-prescribing measures.

Privacy and Security

Practices must ensure that protected health information is HIPAA-compliant at all times. Practices must conduct a security risk analysis, taking appropriate action to correct any privacy or security shortfalls they identify and adopting ongoing privacy and security procedures. Having a designated compliance officer will help the practice regulate and monitor these actions. The Office of the National Coordinator for HIT has created a risk analysis tool accessible through the TMA HIPAA Resource Center at

Stage 2 of Meaningful Use

In Stage 1, physicians must meet 14 core objectives plus five of 10 menu objectives, for a total of 19 objectives. 

Stage 2 will require meeting 17 core objectives (Table 2) plus three of six menu objectives (Table 3), totaling 20. 

Getting Help

Physicians needing help should consider the federally funded regional extension centers (RECs). RECs help with selection, implementation, meaningful use requirements, and meaningful use attestation of EHRs. 

More information is available in the Texas Medical Association's Texas Regional Extension Center Resource Center at

CME Instructions

Remember to visit to complete an online post-test and evaluation to receive CME credit. 

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