Certified EHR for Behavioral Healthcare: The Path to Payment

Posted by Kerry Bailey, Feb 16, 2011.
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Certified EHR for Behavioral Healthcare: The Path to Payment
Core Solutions, Inc.

It’s in the newspaper and on TV. It has enthusiastic advocates and fervent opponents. The web is inundated with debates and discussions surrounding its benefits, drawbacks, and everything in between. It is virtually impossible not to hear about it or be affected by it.

Healthcare reform.

Whether or not people agree on the government’s strategy, it has been set in motion with the hope that it will improve the system of delivering care to individuals who need it. And for those working in the behavioral healthcare industry, these individuals – the social workers, clinicians, therapists, addiction treatment specialists – work with some of the most vulnerable citizens in the population.

n important part of this legislation is the improvement of health information technology (health IT), which will inevitably have a large impact on every sector of healthcare – including behavioral health. The push for national adoption of electronic health record (EHR) technology is fully underway with tight deadlines and a lengthy list of criteria.

There are many keywords out there, and perhaps the most important are meaningful use, certification, and incentives. It is clear that providers must prove that they are meaningfully using their certified EHR system in order to be eligible for incentives, but for many, it is difficult to sift through the extensive amount of information on these topics to discern how exactly to accomplish this.

While information technology is just one facet of healthcare reform, it is one of the most innovative ways to improve quality of care and streamline the way data is recorded and reported. With a bill on the table (H.R. 5040) that would extend incentives to behavioral healthcare providers, it is important they know what is required in order to receive them and why it is necessary to act now.

Being a Part of the HITECH World

Technology has the power to help organizations grow, but it also has the ability to leave some behind if they are not properly informed or financially equipped. Recognizing this, the federal government enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act of 2009 (ARRA). This provision promotes the adoption and meaningful use of heath information technology.

After this was signed into law, the real work began for the Office of the National Coordinator for Health Information Technology (ONC), led by Dr. David Blumenthal. This office was charged with establishing the criteria for what exactly meaningful use is.

The product: a Final Rule published in the July 28, 2010 Federal Register describing in detail what providers must do to be eligible to receive a chunk of the $34 billion allocated for the meaningful use of certified EHRs.

The criteria has since been critiqued and tweaked, and despite the hefty amount of information contained in the Final Rule, there are many informative resources available that break down the objectives and measures that healthcare providers must achieve in order to prove that they are meaningfully utilizing a certified EHR.


The path to utilizing certified EHR technology is actually a three-step process. First, organizations must be designated as an Authorized Certifying Body to certify the EHR vendor, known as an ONC-ACB. Then, software vendors must become certified through this certifying body. Last, healthcare providers must purchase and utilize a certified EHR, which will fulfill the criteria set by the ONC.

According to ONC, this will help make providers and patients confident that EHR systems are secure, confidential, and able to share information with other authorized healthcare entities.

Certifying the Certifiers

On Jan. 3, 2011, ONC issued the final rule that establishes the permanent certification program – Establishment of the Permanent Certification Program for Health Information Technology. According to the HHS press release, this will eventually replace the temporary certification program established last June, which will continue to be in effect until it ends on December 31, 2011.

This rule requires certification bodies authorized by the National Coordinator (ONC-Authorized Certification Bodies or ONC-ACBs):

  • To first be accredited in order to test and/or certify health information technology;
  • To conduct post-certification surveillance; and
  • To perform follow-up surveillance and  “gap certification” 

Vendor Certification

Without software vendors’ first receiving certification, healthcare providers would not have a menu of certified technology from which to choose. Each vendor must send its system through rigorous testing, which is performed by an ONC-ATCB. The testing ensures that the
EHR technology has the capabilities necessary to support their efforts to meet the goals and objectives of meaningful use.

There are two ways that vendors may choose to seek certification:

  1. Vendors can submit its software to be tested in full. If certified, it is considered a Complete EHR.
  2. Vendors can submit several modules. Providers can purchase multiple modules from multiple vendors.

Alternatively, for providers who have developed in-house systems, they can go directly to a certification body for certification testing.

Eligible Provider Certification

Financial incentives for the "meaningful use" of certified EHR technology

The last step in the road to certification is for eligible professionals (EPs) to demonstrate that they are meaningful users of an EHR system.  So who exactly is an eligible provider?

An EP is one who meets certain criteria established by the Centers for Medicare & Medicaid Services (CMS).  There are certain types of healthcare professionals who have been selected for eligibility for financial incentives:

Medicaid EPs: Include only physicians, nurse practitioners, certified nurse-midwife, and dentists. Physicians Assistants practicing in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) that is led by a Physician Assistant are also considered eligible professionals.

They must also meet one of the following requirements:

  • Have a minimum 30% Medicaid patient volume
  • Have a minimum 20% Medicaid patient volume, and is a pediatrician
  • Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals

Medicare EPs: Medicare eligible professionals include Doctors of Medicine or Osteopathy, Dental Surgery or Dental Medicine, Podiatric Medicine, or Optometry. Chiropractors are also eligible.

An EP must also choose to participate in one of two programs: the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program. These programs define the minimum requirements EPs must meet while using certified EHR technology in order to qualify for incentive payments.

According to the CMS website, EPs must choose to participate in either one of these programs – not both – although CMS does make an exception for some hospitals that meet all eligibly criteria. For both programs, EPs may start registering in 2011.

Some key differences are outlined in the table below:

Medicare EHR Incentive Program

Medicaid EHR Incentive Program

Must comply with Meaningful Use requirements for at least 90 days in first year.

Given until Year 2 to comply with Meaningful Use requirements for at least 90 days.

Last year to begin is 2012

Last year to begin is 2016

Program runs through 2012

Program runs through 2021

Payment adjustments (see chart below) in Medicare reimbursements for EPs that do not successfully demonstrate meaningful use by 2015.

No payment adjustments under the Medicaid EHR Incentive Program.

EPs can receive up to $44,000 over 5 years.

EPs can receive up to $63,750 over the 6 years during participation.

It is important to note that after 2015, if an EP does not successfully demonstrate meaningful use of certified EHR technology, the EP’s Medicare fee schedule amount for covered professional services will be adjusted reduced by the following amounts specified in ARRA beginning in 2015. The payment adjustments will be as follows:

Medicare Payment Adjustments







Source: National Council Presentation

Behavioral Healthcare Certified Technology

While CMS must verify that a provider is a meaningful user of certified EHR, the system must logically have the stamp of approval from an ONC-ACB. One of these certifying bodies, the Certification Commission for Health Information Technology (CCHIT) has developed a certification called “CCHIT Certified 2011 Behavioral Health.” The testing process for Behavioral Health EHRs contains requirements for functionality, interoperability and security. 

Examples from their 29-page chart of requirements include:

  • System must support the use of electronic signatures.
  • System must provide the ability to associate individual encounters with diagnoses.
  • System must provide the ability to create prescription or other medication orders with sufficient information for correct filling and dispensing by a pharmacy.
  • System must provide authorized administrators with the capability to read all audit information from the audit records.

This certification is available as both an add-on to the Ambulatory EHR certification as well as a standalone certification for EHRs used in other outpatient settings. Although this requires testing for the vendor, it is vital to keep this in mind when selecting an EHR. After all, certification yields incentives.

For those who opted for the Medicaid EHR Incentive Program, an EP must legally state through the state’s Medicaid agency website that he or she has met all eligibility requirements. For more information, check out CMS’ page on the “Path to Payment.”

Here is an example of how this could impact an organization. A drug rehabilitation center employs 25 psychiatrists, all of whom choose to participate in the Medicare EHR Incentive Program. The facility purchases an EHR that has been certified by an ONC-ACB, i.e. CCHIT. These EPs must then prove that they are meaningful users of this certified technology by meeting the federal government’s set of criteria.  Once this is done, they may receive up to $63,750 each, totaling almost $1.6 million.

Three Stages

Because of the size and scope of this national initiative, HHS has decided to divide the deadlines to meet criteria into three phases. This way, adoption, implementation, or upgrade of an EHR system will be more manageable and will ensure that organizations are eligible for the financial incentives available through HHS.

For Stage 1, the criteria have been set and providers are able to register to begin the process in January 2011. HHS expects to update the criteria every two years. Stage 2 criteria are expected to be finalized by the end of 2011 and Stage 3 criteria by the end of 2013.

 The ROI of EHR and Reporting


Electronic health record systems can be a costly and time-consuming endeavor, so it is not unheard of that some providers may be overwhelmed at this point. With all the timelines and expectations, there is a lot at stake – especially when the planned payment reductions set in. However, the movement towards electronic data does not lack returns on investment (ROI).

The Health Information and Management Systems Society (HIMSS) published a study that outlined the hard and soft ROI of EHRs, which they also presented to the Obama Administration and Congress. While hard ROI contains quantifiable measurements that would suggest cost savings; soft ROI are “transformative” in nature.

The chart below includes data found in the HIMSS study.

Hard ROI

Soft ROI

Billing improvements

-          Billing cycle improvements

-          Improved reimbursement

-          Improved “patient responsibility” cash collection

Reduces medical errors

Decreases paper costs

Reduces health disparities and improves population & public health

Decreases claim rejections

Improves patient safety

-          Adverse drug reaction avoidance

-          Improved nursing documentation

-          Eliminates problems associated with illegible orders and medical orders

-          Addressing “high alert medications”

Increases patient volume à more revenue and profitability

Improves communication

-          Legible documentation

-          Decision support

-          Documentation sharing

Materials and staffing reductions

Regulatory compliance

-          HIPAA

-          JCAHO

-          CMS

-          State agencies

Improves AR and cash flow

Process improvement

-          Common user interface

-          Eliminates duplicate records

-          Electronic charting, discharge, and signatures

-          Chart pull requests decrease

Quality Improvement


The survey noted that calculating hard ROI is difficult because of the nature of the healthcare. Providers do not measure metrics like other industries, and this often makes it easier to see the soft ROI. Additionally, installation of EHR systems is fairly new, so there is not extensive hard data from which to derive conclusions. However, some behavioral health EHR software providers report that they can reduce rejected claims by up to 98 percent.

Of course, the biggest and most beneficial ROI for organizations are the incentives. While simultaneously attaining all of these positive outcomes, providers are also very likely to meet the federal requirements that determine eligibly to receive financial incentives.


Providers are also expected to begin to improve their reporting methods, which includes capturing and reporting clinical quality measures (CQMs) using certified EHR technology. According to an article by the American Health Information Management Association (AHIMA), this requires EPs to clearly define their measure specifications to support automated analysis.

Examples from the CMS chart that contains all of 44 CQMs include:

  • Weight Assessment and Counseling for Children and Adolescents
  • Childhood Immunization Status
  • Preventive Care and Screening: Influenza Immunization for Patients who are 50 and older
  •  Asthma Pharmacologic Therapy
  • Breast Cancer Screening
  • Smoking and Tobacco Use Cessation
  • Diabetes: Eye Exam

These criteria may seem more specific to physical and ambulatory healthcare providers. However, three reporting systems – NOMs, SOMMS, and TEDS – may be more relevant to certain behavioral health organizations.

According to SAMHSA, National Outcome Measures (NOMs) track and measure real-life outcomes for people in recovery from mental health and substance abuse disorders. States must collect this data across 10 domains, which can be a cumbersome task when client information is first recorded on paper or if organizations are utilizing disjointed computer software. When selecting an EHR, it would be advisable to look for systems that incorporate this method of reporting.

Another benefit of EHR is the ability to view real-time data without having to wait until the end of the month or quarter to perform an analysis. With a simple click of a button, administrators can export a wide range of data, depending upon the type of reports offered by each EHR vendor. Before purchasing, decision makers should see the report catalog of each prospective technology provider.

In fact, CCHIT has 18 reporting/data exporting conditions in order for an EHR vendor to meet the requirements for the CCHIT Certified 2011 Behavioral Health EHR Certification. This includes the ability to add customizable data fields and to report on any data elements that are held discretely; the system must also support the use of third-party reporting tools through either direct access to the database or through exported data.

Hopping on Board

Health IT is moving at an alarming rate, and it is imperative for behavioral health organizations to keep abreast of the changes and opportunities involved with ARRA funding, certified EHR, and meaningful use. There are many online media publications that are resources to aid providers in understanding this complex system. For starters, take a look at Healthcare Technology Online, Government Health IT, and Behavioral Healthcare

The ability to schedule appointments, track encounters, prescribe electronically, and store and report data has clear-cut benefits that will result in more patient flow and more revenue. But the improvement of overall patient care is invaluable.

Behavioral health is an indispensible part of the healthcare industry, without which many individuals would not get the help and support they need. When a clinician, the billing coordinator, and a senior executive have the same software (albeit different permission levels), they are able to better communicate and better serve the community. An EHR system allows healthcare providers to make sounder decisions about which medicine to prescribe to patients based on the easily viewable patient history, examine client assessments, and create treatment plans.

But while technology is the tool which will get providers the incentives, it is the end users who will truly transform the face of healthcare. Organizations must empower themselves through thorough research, viewing multiple demonstrations by vendors, and asking the tough questions. Once the decision is made, working closely with the vendor will set providers on the path to payment.

Frequently Used Terms

  • Certified EHR System: To be a certified EHR system, it must receive approval of certification by an ONC-Authorized Testing and Certification Bodies (ONC-ATCB). This includes CCHIT, the Drummond Group, ICSA Labs, SLI Global Solutions, and InfoGard Laboratories.
  • Eligible Professional (EP): Also referred to as Eligible Provider. In order to be eligible to receive payments under the incentive programs provided through the Recovery Act, an EP must be able to demonstrate meaningful use of a certified EHR system.
  • H.R. 5040: Also known as the Health Information Technology Extension for Behavioral Health Services Act of 2010, this is the bill introduced in April 2010 that would extend health IT assistance eligibility to behavioral health, mental health and substance abuse professionals and organizations.
  • Meaningful Use: The central concept behind this is that providers seeking incentives must not only show that they are utilizing EHR technology, but that they are meaningfully using the technology. Through the efforts of workshops and focus groups, the federal government established a comprehensive set of criteria that providers must meet to be eligible. This is separated into three phases.
    • For more information about Meaningful Use, check out the CMS Meaningful Use Fact Sheet
  • ONC-ATCB:  Organizations authorized to perform Complete EHR and/or EHR Module testing and certification.
    • Certification by an ONC-ATCB will signify to eligible professionals, hospitals, and critical access hospitals that an EHR technology has the capabilities necessary to support their efforts to meet the goals and objectives of meaningful use.

    Important Dates


  • October 1, 2010 – Reporting year begins for eligible hospitals and CAHs.
  • January 1, 2011 – Reporting year begins for eligible professionals.
  • January 3, 2011 – Registration for the Medicare EHR Incentive Program begins.
  • January 3, 2011 – For Medicaid providers, states may launch their programs if they so choose.
  • April 2011 – Attestation for the Medicare EHR Incentive Program begins.
  • May 2011 – EHR Incentive Payments expected to begin.
  • July 3, 2011 – Last day for eligible hospitals to begin their 90-day reporting period to demonstrate meaningful use for the Medicare EHR Incentive Program.
  • September 30, 2011 – Last day of the federal fiscal year. Reporting year ends for eligible hospitals and CAHs.
  • October 1, 2011 – Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 for the Medicare EHR Incentive Program.
  • November 30, 2011 – Last day for eligible hospitals and critical access hospitals to register and attest to receive an Incentive Payment for Federal fiscal year (FY) 2011.
  • December 31, 2011 – Reporting year ends for eligible professionals.
  • February 29, 2012 – Last day for eligible professionals to register and attest to receive an Incentive Payment for calendar year (CY) 2011.

Source: CMS Incentive Programs  Overview


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