• EPs who participate in the Medicare EHR Incentive Program.
• EPs who can participate in either the Medicare or Medicaid EHR Incentive Programs.
• These payment adjustments will be applied beginning on January 1, 2015, for Medicare EPs.

• Medicaid EPs who can only participate in the Medicaid EHR Incentive Program and do not bill Medicare.

How much are the payment adjustments and how are they applied?

The payment adjustment will be applied to the Medicare physician fee schedule (PFS) amount for covered professional services furnished by the EP during the year (including the fee schedule amount for purposes of determining a payment based on the fee schedule amount).

The payment adjustment is 1% per year and is cumulative for every year that an EP is not a meaningful user. Depending on the total number of Medicare EPs who are meaningful users under the EHR Incentive Programs after 2018, the maximum cumulative payment adjustment can reach as high as 5%.

• Infrastructure - EPs must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).
• New EPs - Newly practicing EPs who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Thus EPs who begin practice in calendar year 2015 would receive an exception to the penalties in 2015 and 2016, but would have to begin demonstrating meaningful use in calendar year 2016 to avoid payment adjustments in 2017.
• Unforeseen Circumstances - Examples may include a natural disaster or other unforeseeable barrier.
• Patient Interaction - Lack of face-to-face or telemedicine interaction with patients; Lack of follow-up need with patients.
• Practice at Multiple Locations - Lack of control over availability of CEHRT for more than 50% of patient encounters
  

• A patient who had to be transferred to the intensive care unit due to delays in care caused by the computer.
• A nurse who was not able to obtain needed blood for an emergent medical emergency.
• Insulin orders set erroneously by the software.
• Missed orders for lab tests for newborn babies and an inability for RNs to spend time teaching new mothers how to properly breast feed babies before patient discharge.
• Lab tests not done in a timely manner.
• Frequent short staffing caused by time RNs have to spend with the computers.
• Orders incorrectly entered by physicians requiring the RNs to track down the physician before tests can be done or medication ordered.
• Discrepancies between the Epic computers and the computers that dispense medications causing errors with medication labels and delays in administering medications.
• Patient information, including vital signs, missing in the computer software.
• An inability to accurately chart specific patient needs or conditions because of pre-determined responses by the computer software.
• Multiple problems with RN fatigue because of time required by the computers and an inability to take rest breaks as a result.
• Inadequate RN training and orientation.

• Stakeholder buy-in - This dispute between Sutter and its nurses is a great reminder of the importance of getting user buy-in when implementing new technology. When users desires are not carefully considered and addressed, the on-boarding process becomes significantly more complicated and leads to animosity and hurt feelings on both sides.

• Disaster Training - No technology is fool-proof. Technology is not perfect and crashes should be expected, whether they are due to a software error, natural disaster, or some other reason. Employees must be adequately trained and knowledgeable about the steps that need to be taken in the event of an EHR or other critical software system malfunction. Otherwise, hospital systems and doctors leave themselves open to greater liability in the event of an adverse patient outcome. A Disaster Recovery Plan is required under HIPAA and employee training should be considered in any Disaster Recovery and Business Continuity plan.
  

• Adequate Backup - Critical systems must have adequate backup. Yes, this can be costly, but "critical" indicates that the information technology resources are essential to the function of the particular business. In the case of an EHR system, it is critical in the sense that lives are literally on the line. As such, backup services in these circumstances should be looked at as the cost of doing business and accounted for in annual cost allocations. A Data Backup Plan is a requirement element of HIPAA.
  

• Erin McCann, Setback for Sutter after $1B EHR crashes, Healthcare IT News, Aug. 28, 2013
• California Nurses Association, Press Release, Sutter’s $1 Billion Boondoggle-New Electronic Records System Goes Dark, Aug. 27, 2013
  
• California Nurses Association, Press Release, Sutter’s New Electronic System Causes Serious Disruptions to Safe Patient Care at E. Bay Hospitals, July 11, 2013
  

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