Certified EHR technology. For  example, a Medicare professional that first demonstrated meaningful use  in 2011 must report the Stage 1 meaningful use measures for 2011,  2012, and 2013 to receive incentive payments for those years and must  report the Stage 2 meaningful use measures beginning in 2014 to receive   The Stage 3 requirements have not  an incentive payment for that year.yet been developed but are expected to be finalized in 2015 and to apply  beginning in 2017. Clinical quality measures (CQM). For example, one CQM for  professionals measures the use of high-risk medications in the elderly. Participation in the EHR Programs Has Increased, but Program Changes Make It Difficult to Estimate Future Participation

Participation in CMS’s EHR programs increased substantially from 2011  to 2012, but some providers who participated in 2011 did not continue in  2012. For hospitals, participation increased from 45 percent of those  eligible for 2011 to 64 percent of those eligible for 2012. For  professionals, participation increased from 21 percent of those eligible for  2011 to 48 percent of those eligible for 2012. 4.) The increased stringency of these Stage 2  requirements for demonstrating meaningful use may slow participation in  the EHR programs. Providers Exceeded Meaningful Use Requirements for Most Stage 1 Measures, but May Face Challenges with Certain More Stringent Stage 2 Measures

The meaningful use measures reported by providers for 2011 and 2012  indicate that providers used their certified EHR systems more often than  required and suggest that many providers who have already reported  certain Stage 1 measures will be able to meet most of the more stringent  reporting thresholds for similar measures in Stage 2. For both 2011 and 2012, Medicare hospitals  reported using computerized provider order entry for medication orders  for over 84 percent of patients—about 2.8 times the required threshold for  Stage 1. Other measures not related to the electronic exchange of information may also be  problematic for providers. HHS Lacks a Comprehensive Strategy to Help Ensure Reliability of EHR Data Collected to Improve Quality of Care

The lack of a comprehensive strategy limits HHS’s ability to ensure that  the department can reliably use the CQMs collected in certified EHRs for  quality measurement activities. providers may report CQMs based on and tested to different  requirements. However, although HHS, CMS, and ONC have established important  performance measures for the goals related to adoption and meaningful  use of EHRs, they have not established measures linked to the second  category of goals, which would help them to track program outcomes  such as health care quality, efficiency, and patient safety. CMS and ONC may lack critical information  necessary to establish program priorities and subsequently make  program adjustments based on progress toward these outcomes. We describe several issues regarding the reliability of CQM  data—for example, providers may be reporting CQMs based on and  tested to different specifications. CMS and ONC lack a comprehensive strategy that  would allow them to ensure the reliability of CQM data collected using  EHRs, in accordance with the internal control standard requiring an  agency to have relevant and reliable information to achieve its mission  and goals. Although HHS expects that EHRs can  help achieve improved outcomes as well as support various other health  care reform efforts that are also intended to improve care, that result is  not yet assured. To ensure that CMS and ONC can effectively monitor the effect of the  EHR programs and progress made toward goals, the Secretary of Health  and Human Services should direct the agencies to take the following two  actions:
Develop performance measures to assess outcomes of the EHR  programs—including any effects on health care quality, efficiency, and  patient safety and other health care reform efforts that are intended to  work toward similar outcomes—and
Use the information these performance measures provide to make  program adjustments, as appropriate, to better achieve program  goals. HHS agreed that  data reliability and performance monitoring are important, but neither  agreed nor disagreed with our recommendations. Appendix I: Effect of the HITECH Act on Health Insurance Premiums

The Health Information Technology for Economic and Clinical Health  (HITECH) Act mandates us to report on, among other things, the impact  of the HITECH Act on health insurance premiums. Analysis of participation in the Medicare and Medicaid EHR  programs. Appendix V: Strategic Goals and Associated Performance Measures Relevant to the EHR Programs

We reviewed Department of Health and Human Services (HHS), Centers  for Medicare & Medicaid Services (CMS), and Office of the National  Coordinator for Health Information Technology (ONC) strategic goals and  categorized them into one of two major categories particularly relevant to  the Electronic Health Record (EHR) programs—(1) adoption and  meaningful use of EHRs; and (2) improving quality, efficiency, and patient   The first category of goals is focused on program processes, and  safety.the second is focused on program outcomes.
Why GAO Did This Study

The Health Information Technology for Economic and Clinical Health (HITECH) Act established the EHR programs, which provide incentive payments for—and later are expected to apply penalties to—certain providers, such as hospitals and professionals, to encourage them to demonstrate meaningful use of certified EHR technology and meet other program requirements. For example, one measure of meaningful use requires providers to implement checks for potential drug interactions with patients' other drugs and allergies.
As mandated by the HITECH Act, GAO (1) assessed the extent of current and expected participation in the EHR programs, (2) examined information reported by providers and others to measure meaningful use in the EHR programs, (3) evaluated HHS efforts to ensure that EHR data can be reliably used to measure quality of care, and (4) evaluated HHS efforts to assess the effect of the EHR programs on program goals related to adoption and meaningful use of EHRs and improved outcomes. GAO analyzed data from CMS and other sources; reviewed applicable statutes, regulations, and guidance; and interviewed officials from HHS and stakeholder groups.

What GAO Found

Based on the number of providers awarded incentive payments, participation in the Department of Health and Human Services' (HHS) Medicare and Medicaid Electronic Health Record (EHR) programs increased substantially from their first year in 2011 to 2012. For hospitals, participation increased from 45 percent of those eligible for 2011 to 64 percent of those eligible for 2012. For professionals, such as physicians, participation increased from 21 percent of those eligible for 2011 to 48 percent of those eligible for 2012. While increases occurred, a substantial percentage of providers that participated in 2011 did not participate in 2012. Officials who oversee the programs at the Centers for Medicare & Medicaid Services (CMS) noted there could be several reasons for this, such as challenges in demonstrating meaningful use, and are monitoring the issue. Various program changes make future participation difficult to estimate. For example, increased stringency of requirements for the programs' second phase beginning in 2014—Stage 2—may slow participation, while the introduction of penalties in 2015 for some providers may motivate participation.
Reporting on meaningful use for 2011 and 2012 indicates that providers who have already participated in the programs' first phase—Stage 1—used their certified EHR systems more often than required. For example, for both 2011 and 2012, Medicare hospitals reported using computerized provider order entry for over 84 percent of patients—in excess of the required threshold for Stage 1 of 30 percent. However, some meaningful use measures may be more challenging for providers, including measures involving the electronic exchange of information. For example, less than 15 percent of professionals reported on an optional Stage 1 measure to provide a summary of care document at each care transition or referral, which is mandatory in Stage 2. A CMS official said the agency is taking steps to help providers prepare for Stage 2 meaningful use measures.
The lack of a comprehensive strategy limits HHS's ability to ensure the department can reliably use the clinical quality measures (CQM) collected in certified EHRs for quality measurement activities. Reliability issues persist, although CMS and HHS's Office of the National Coordinator for Health Information Technology (ONC) have made efforts to address concerns. For example, different providers may report CQMs based on and tested to different requirements depending on whether their EHRs have incorporated technical updates. Without a comprehensive strategy, efforts to address reliability issues (in accordance with the internal control standard requiring relevant and reliable information) and improve quality and efficiency may be limited.
Consistent with law and GAO guidance on assessing agency performance, HHS, CMS, and ONC have established some performance measures for the EHR programs that are tied to strategic goals regarding adoption and meaningful use of EHRs; however, they have not established measures that would help them to track progress toward program outcomes such as health care quality, efficiency, and patient safety. Although HHS expects that the use of EHRs can help achieve improved outcomes and support other efforts that are also intended to improve care, that result is not yet assured. CMS and ONC may lack critical information necessary to establish program priorities and subsequently make program adjustments based on progress toward outcomes.

What GAO Recommends

GAO recommends that HHS develop a comprehensive strategy to better ensure the reliability of CQM data collected using EHRs and develop and use outcome-oriented performance measures to monitor progress toward goals. HHS agreed data reliability and performance monitoring are important but neither agreed nor disagreed with GAO's recommendations.