Summary

While discussing a separate, ongoing study on the extent of documentation vulnerabilities of evaluation and management (E/M) services using electronic health record (EHR) systems, officials from the Office of the National Coordinator (ONC) for Health Information Technology expressed interest in getting additional information about physicians’ reported use of EHR systems. ONC officials also wanted to know how many and which EHR systems were being used and whether the Medicare physicians in our study were using certified EHR systems to document E/M services. Additionally, CMS may find this information helpful as it continues administering its EHR incentive program.

Methodology

Using Medicare claims data, the reviewers drew a random sample of 2,000 physicians from a population of 441,990 who provided at least 100 E/M services in 2010. These Medicare physicians were asked whether they currently used an EHR system at their primary practice location and whether they used EHR systems to document E/M services. They were also asked which EHR system they used to document E/M services and whether their system was certified.

Findings

This study found that 57 percent of Medicare physicians used an EHR system at their primary practice location in 2011. Twenty-two percent of physicians first began using EHR systems to document E/M services in 2011, the year that CMS commenced its incentive program. Additionally, three of every four Medicare physicians with an EHR system used a certified system to document E/M services. Finally, although many EHR systems can assist physicians in assigning codes for E/M services, reviewers found that most Medicare physicians manually assigned E/M codes.

This report does not contain recommendations.

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