arra & hit in rural america

Rural WisconsinRural WisconsinHealth CooperativeHealth Cooperative

ARRA & HIT in Rural AmericaARRA & HIT in Rural America

Louis WenzlowLouis WenzlowDirector of HITDirector of HITRWHC for theRWHC for the

WORH Financial WORH Financial WorkshopWorkshop

August. 18th, 2009August. 18th, 2009


American Recovery & Reinvestment ActAmerican Recovery & Reinvestment Actand Health Information Technologyand Health Information Technology

in Rural Americain Rural America

Presentation OverviewPresentation Overview

II - Medicare HIT Incentives in ARRA- Medicare HIT Incentives in ARRA

IIII - Certified Expense and Meaningful Use- Certified Expense and Meaningful Use

IIIIII -- Rural HIT Challenges and StrategiesRural HIT Challenges and Strategies

IVIV - Preparing for ARRA Now- Preparing for ARRA Now


Overview of RWHCOverview of RWHC

• Founded 1979Founded 1979

• Non-profit coop owned Non-profit coop owned by 35 rural hospitals (net by 35 rural hospitals (net rev ≈ $3/4B; ≈ 2K rev ≈ $3/4B; ≈ 2K hospital & LTC beds)hospital & LTC beds)

• ≈ ≈ $7M RWHC budget $7M RWHC budget (≈70% member fees, (≈70% member fees, 20% fees from others, 20% fees from others, 5% dues, 5% grants)5% dues, 5% grants)

• 6 PPS & 29 CAH; 24 6 PPS & 29 CAH; 24 freestanding; 11 system freestanding; 11 system owned or affiliated owned or affiliated

• Founded 1979Founded 1979

• Non-profit coop owned Non-profit coop owned by 35 rural hospitals (net by 35 rural hospitals (net rev ≈ $3/4B; ≈ 2K rev ≈ $3/4B; ≈ 2K hospital & LTC beds)hospital & LTC beds)

• ≈ ≈ $7M RWHC budget $7M RWHC budget (≈70% member fees, (≈70% member fees, 20% fees from others, 20% fees from others, 5% dues, 5% grants)5% dues, 5% grants)

• 6 PPS & 29 CAH; 24 6 PPS & 29 CAH; 24 freestanding; 11 system freestanding; 11 system owned or affiliated owned or affiliated


I - HIT Incentives in ARRAI - HIT Incentives in ARRA• Give 70% of Americans an electronic health record Give 70% of Americans an electronic health record

(EHR) within 5-10 years.(EHR) within 5-10 years.• Use Medicare to incentivize the adoption of EHRs to Use Medicare to incentivize the adoption of EHRs to

improve quality, provide data portability, and allow improve quality, provide data portability, and allow for performance evaluation.for performance evaluation.

• Eventually penalize non-adopters by reducing Eventually penalize non-adopters by reducing reimbursement.reimbursement.

• Some rural providers will also be eligible for Some rural providers will also be eligible for Medicaid incentives. Medicaid incentives.

Last year was “not if but when.” This year “not when Last year was “not if but when.” This year “not when but now.” ARRA presents tremendous challenges for but now.” ARRA presents tremendous challenges for small and rural providers. small and rural providers.


Physician Medicare IncentivesPhysician Medicare Incentives

• Those that are meaningful users will receive 75% of Those that are meaningful users will receive 75% of estimated allowed charges limited to the following estimated allowed charges limited to the following maximums: Year 1- $15,000; Year 2 - $12,000; Year maximums: Year 1- $15,000; Year 2 - $12,000; Year 3 - $8,000; Year 4 – $4,000; and Year 5 -$2,000.3 - $8,000; Year 4 – $4,000; and Year 5 -$2,000.

• If first adopting in 2011 and 2012, maximum Year 1 If first adopting in 2011 and 2012, maximum Year 1 incentive increased to $18,000.incentive increased to $18,000.

• Up to $44,000 in payments per physician.Up to $44,000 in payments per physician.

• Penalties for non-users starting in 2015 (start at 1% Penalties for non-users starting in 2015 (start at 1% fee schedule reduction and go to 3% reduction). fee schedule reduction and go to 3% reduction).


PPS Hospital Medicare IncentivesPPS Hospital Medicare Incentives

• Those that are meaningful users by 2013 are eligible Those that are meaningful users by 2013 are eligible for full 4 years of incentive payments (e.g., about for full 4 years of incentive payments (e.g., about $4 million average for Wisconsin hospitals).$4 million average for Wisconsin hospitals).

• ($2 million base + volume adjustment) x (Medicare ($2 million base + volume adjustment) x (Medicare Share with charity adjustment). Payment reduced by Share with charity adjustment). Payment reduced by 25% each of Years 2, 3, and 4. 25% each of Years 2, 3, and 4.

• Penalties for non-users starting in 2015. Penalties for non-users starting in 2015.

• Early adopters rewarded, since $$ are paid regardless Early adopters rewarded, since $$ are paid regardless of their costs or timing prior to 2013.of their costs or timing prior to 2013.


CAH Medicare IncentivesCAH Medicare Incentives

• CAHs that are meaningful users by 2011 are eligible CAHs that are meaningful users by 2011 are eligible for 4 years of enhanced Medicare payments (20% for 4 years of enhanced Medicare payments (20% over Medicare Share* with charity adjustment) with over Medicare Share* with charity adjustment) with immediate full depreciation of certified EHR costs, immediate full depreciation of certified EHR costs, including including undepreciatedundepreciated costs from previous years. costs from previous years.

• Penalties for non-users start in 2015 (0.33% reduction Penalties for non-users start in 2015 (0.33% reduction in Medicare increases to 1% in 2017).in Medicare increases to 1% in 2017).

• Depreciated investments by “early adopters” are not Depreciated investments by “early adopters” are not eligible for any incentive paymentseligible for any incentive payments

* Definition for ARRA “Medicare Share” adds about * Definition for ARRA “Medicare Share” adds about 30% to definition in cost report + 20% in ARRA formula.30% to definition in cost report + 20% in ARRA formula.


What This Means to CAHs (1 of 2)What This Means to CAHs (1 of 2)• CAHs must become meaningful EHR users between CAHs must become meaningful EHR users between

2011 and 2015 to qualify for bonus structure and 2011 and 2015 to qualify for bonus structure and avoid penalties.avoid penalties.

• For CAHs that qualify, new and undepreciated For CAHs that qualify, new and undepreciated “certified EHR costs” will get a roughly 50%* bump “certified EHR costs” will get a roughly 50%* bump in Medicare Reimbursement (with 100% Maximum). in Medicare Reimbursement (with 100% Maximum).

• Bonus incentives initiate only after most of the Bonus incentives initiate only after most of the investments need to be made; the issue of investments need to be made; the issue of capital/financing is left unaddressed.capital/financing is left unaddressed.

* Definition for ARRA “Medicare Share” adds about * Definition for ARRA “Medicare Share” adds about 30% to definition in cost report + 20% in ARRA formula.30% to definition in cost report + 20% in ARRA formula.


What This Means to CAHs ( 2 of 2)What This Means to CAHs ( 2 of 2)• Maximizing incentive bonus will involve strategy to Maximizing incentive bonus will involve strategy to

leave as much “Certified EHR Expense” as possible leave as much “Certified EHR Expense” as possible undepreciated at the time of reaching “Meaningful undepreciated at the time of reaching “Meaningful User” designation.User” designation.

• Definition of “Certified EHR” will ultimately Definition of “Certified EHR” will ultimately determine (and could significantly reduce) the value determine (and could significantly reduce) the value of the incentive.of the incentive.

• Definition of “Meaningful Use” will ultimately Definition of “Meaningful Use” will ultimately determine whether the incentive is reasonably determine whether the incentive is reasonably attainable by rural providers.attainable by rural providers.


II - “Certified EHR Expense” II - “Certified EHR Expense” and “Meaningful EHR Use”and “Meaningful EHR Use”


What is a “Certified EHR Expense”? What is a “Certified EHR Expense”?

• CAHs, unlike PPS Hospitals, will only receive an CAHs, unlike PPS Hospitals, will only receive an ARRA incentive for “Certified EHR Expenses.”ARRA incentive for “Certified EHR Expenses.”

• Current certification programs cover only a fraction Current certification programs cover only a fraction of the systems that make up an EHR. of the systems that make up an EHR.

• PACS, hardware, network infrastructure, and many PACS, hardware, network infrastructure, and many other aspects of EHR other aspects of EHR do notdo not have certification have certification programs.programs.

• Not currently clear what costs associated with EHR Not currently clear what costs associated with EHR implementation can be applied to the CAH bonus.implementation can be applied to the CAH bonus.

• A timetable for answering the above not known.A timetable for answering the above not known.


Physician Meaningful EHR Use?Physician Meaningful EHR Use?

ARRA requirements:ARRA requirements:

• Implement certified physician practice EMRImplement certified physician practice EMR

• Participation in Information ExchangeParticipation in Information Exchange

• Quality reporting participationQuality reporting participation

• E-prescribingE-prescribing

• Meet function and reporting requirements as Meet function and reporting requirements as determined by ONC and ultimately CMSdetermined by ONC and ultimately CMS


ARRA Requirements:ARRA Requirements:

• Use of certified vendorsUse of certified vendors

• Participation in Information ExchangeParticipation in Information Exchange

• Quality reporting participationQuality reporting participation

• Meet function and reporting requirements as Meet function and reporting requirements as determined by ONC and ultimately CMSdetermined by ONC and ultimately CMS

Hospital Meaningful EHR Use?Hospital Meaningful EHR Use?


HIT Policy Committee RecommendationsHIT Policy Committee Recommendations• CMS expected to make final rules by end of 2009.CMS expected to make final rules by end of 2009.• ““Adoption year” 2011 is 1/1/11 to 12/31/12. Adoption year” 2011 is 1/1/11 to 12/31/12. • ““Adoption year” 2013 is 1/1/13 to 12/31/14 with more Adoption year” 2013 is 1/1/13 to 12/31/14 with more

rigorous outcomes to be eligible. The Committee’s rigorous outcomes to be eligible. The Committee’s “concession” to rural concerns for providers at early “concession” to rural concerns for providers at early stage of adoption is to allow the first “adoption year” stage of adoption is to allow the first “adoption year” metrics to slide into 2013; specifics unknown.metrics to slide into 2013; specifics unknown.

• But “Adoption year” 2015 is in fact 2015; at this time But “Adoption year” 2015 is in fact 2015; at this time penalties are expected to kick in for non-adopters.penalties are expected to kick in for non-adopters.

• The Certification Commission of Health Information The Certification Commission of Health Information Technology initially to be the certifying body.Technology initially to be the certifying body.


HIT Policy Committee Recommendations to CMS on HIT Policy Committee Recommendations to CMS on Quality & Efficiency Quality & Efficiency by 2011-12 two year cycle: by 2011-12 two year cycle:

•10% of all orders entered by authorized providers 10% of all orders entered by authorized providers through CPOEthrough CPOE

•Drug contraindication checksDrug contraindication checks

•Up-to-date problem lists of current/active diagnoses Up-to-date problem lists of current/active diagnoses

•Active medication and allergy listsActive medication and allergy lists

•Demographic information & advance directivesDemographic information & advance directives

•Record vital signs & smoking statusRecord vital signs & smoking status

Hospital Meaningful EHR Use? (1 of 5)Hospital Meaningful EHR Use? (1 of 5)


HIT Policy Committee Recommendations to CMS on HIT Policy Committee Recommendations to CMS on Quality & Efficiency Quality & Efficiency by 2011-12 two year cycle: by 2011-12 two year cycle:

•Lab results available in EHRLab results available in EHR

•Ability to generate patient lists by conditionAbility to generate patient lists by condition

•Report quality measures to CMSReport quality measures to CMS

•Implement one decision support rule for priority Implement one decision support rule for priority conditioncondition

•Electronic insurance eligibility checksElectronic insurance eligibility checks

•Electronic claims submissionElectronic claims submission



HIT Policy Committee Recommendations to CMS on HIT Policy Committee Recommendations to CMS on Patient Engagement Patient Engagement by 2011-12 two year cycle: by 2011-12 two year cycle:

•Provide patients with electronic copy of lab results, Provide patients with electronic copy of lab results, problem lists, meds and allergies upon request (could problem lists, meds and allergies upon request (could be on CD or USB drive)be on CD or USB drive)

•Provide patients with electronic copy of discharge Provide patients with electronic copy of discharge instructions upon request instructions upon request

•Provide patient specific educational resourcesProvide patient specific educational resources



HIT Policy Committee Recommendations to CMS on HIT Policy Committee Recommendations to CMS on Care Coordination Care Coordination by 2011-12 two year cycle: by 2011-12 two year cycle:

•Capability to exchange key clinical information among Capability to exchange key clinical information among providers of careproviders of care

•Medication reconciliation at relevant encounters and Medication reconciliation at relevant encounters and care transitionscare transitions

Population and Public HealthPopulation and Public Health::

•Submit data to immunization registriesSubmit data to immunization registries

•Submit lab results and syndromic surveillance data to Submit lab results and syndromic surveillance data to public health public health



HIT Policy Committee Recommendations to CMS on HIT Policy Committee Recommendations to CMS on Security & Privacy Security & Privacy by 2011-12 two year cycle: by 2011-12 two year cycle:

•Compliance with HIPAACompliance with HIPAA

•Compliance with fair data sharing practices Compliance with fair data sharing practices

Note: There is more to come after the first two year Note: There is more to come after the first two year cycle: eg real-time patient portals, closed loop medicine cycle: eg real-time patient portals, closed loop medicine management, etc…management, etc…

Note: Reporting of measures will be required to confirm Note: Reporting of measures will be required to confirm all “meaningful use outcomes/priorities.all “meaningful use outcomes/priorities.



Eligible Physician IssuesEligible Physician Issues

HIT Policy Committee Recommendations to CMS for HIT Policy Committee Recommendations to CMS for physicians by 2011-12 two year cycle are similar to those physicians by 2011-12 two year cycle are similar to those noted for hospitals as well as: noted for hospitals as well as:

•CPOE for all orders CPOE for all orders

•Generate permissible prescriptions electronically Generate permissible prescriptions electronically

•Send reminders to patients for follow-up/preventive careSend reminders to patients for follow-up/preventive care

•Document a progress note for each encounterDocument a progress note for each encounter

•Provide clinical summaries for patients per encounterProvide clinical summaries for patients per encounter


Impact on Rural ProvidersImpact on Rural Providers

• Rural providers have lower than average levels of Rural providers have lower than average levels of adoption.adoption.

• They are starting from farther behind with fewer They are starting from farther behind with fewer resources to devote to EHRs.resources to devote to EHRs.

• AHA, RUHIT, NRHA and other provider and quality AHA, RUHIT, NRHA and other provider and quality groups are concerned that the Committee groups are concerned that the Committee recommendations are too aggressive to be reasonably recommendations are too aggressive to be reasonably achievable for the average small and rural provider.achievable for the average small and rural provider.


HIMSS EHR Adoption ModelHIMSS EHR Adoption ModelStage Cumulative Capabilities

0 Laboratory, Radiology & Pharmacy Not Installed

1 Laboratory, Radiology & Pharmacy All Installed

2 Clinical Data Repository, Controlled Medical Vocabulary, Clinical Decision Support System (CDSS), may have Document Imaging

3 Clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

4 Computerized Physician Order Entry, CDSS (clinical protocols)

5 Closed loop medication administration

6 Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS

7 Medical record fully electronic; ability to contribute Continuity of Care Document as byproduct of EMR; Data warehousing in use

HIMSS = (Healthcare Information and HIMSS = (Healthcare Information and Management Systems Society)Management Systems Society)


44thth Quarter 2008 Adoption Rates Quarter 2008 Adoption Rates (Data Provided by HIMSS)(Data Provided by HIMSS)

Hospital Type Median Adoption Rate Score

Academic/Teaching 3.2520

Non-Academic 2.1690

General Medical/Surgical 2.2820

Others 2.0450

Rural 1.0905

Urban 2.2820

IDS 2.2420

Independent Hospital 2.0935

Critical Access Hospital 1.0860


Impact on Rural ProvidersImpact on Rural Providers

• Committee recommendations for 2011 roughly Committee recommendations for 2011 roughly correspond to reaching 4.0 on HIMSS scale.correspond to reaching 4.0 on HIMSS scale.

• While the Committee recommendations may be While the Committee recommendations may be achievable by providers at 3.0 on the HIMSS scale, it achievable by providers at 3.0 on the HIMSS scale, it is unclear, if not unlikely, they are achievable by is unclear, if not unlikely, they are achievable by those at 1.0 or lower on the scale.those at 1.0 or lower on the scale.

• With providers being forced to rush, we may see a With providers being forced to rush, we may see a high rate of failed implementations, as well as high rate of failed implementations, as well as setbacks in quality and efficiency. setbacks in quality and efficiency.

• From provider perspective, important to move From provider perspective, important to move quickly but not at the expense of implementation quickly but not at the expense of implementation success.success.


III - Rural HIT Implementation III - Rural HIT Implementation Challenges and StrategiesChallenges and Strategies


Hospital EHR Modules & FunctionsHospital EHR Modules & FunctionsFacility ManagementFacility Management Medical RecordsMedical Records Inpatient ClinicalsInpatient Clinicals1. Data Repository1. Data Repository 1. HIM Core Module1. HIM Core Module1. Inpatient Charting1. Inpatient Charting2. Master Patient Index2. Master Patient Index 2. Chart & Film Tracking2. Chart & Film Tracking 2. Multidisciplinary2. Multidisciplinary3. Database Reporting3. Database Reporting 3. Chart deficiency tracking3. Chart deficiency tracking 3. e-MAR3. e-MAR4. Registration/ADT4. Registration/ADT 4. Release of Info. Tracking4. Release of Info. Tracking 4. Barcoding4. Barcoding5. Billing5. Billing 5. Coding & abstracting5. Coding & abstracting 5. Patient Education5. Patient Education6. General Ledger6. General Ledger 6. Reg. Scanning 6. Reg. Scanning 6. Physician Portal6. Physician Portal7. Accounts Payable7. Accounts Payable 7. HIM Scanning 7. HIM Scanning 7. CPOE7. CPOE8. Fixed Assets8. Fixed Assets 8. Electronic Signature8. Electronic Signature 8. Decision Support8. Decision Support9. Materials Management9. Materials Management10. Payroll/HR 10. Payroll/HR Departmental SystemsDepartmental Systems Other ModulesOther Modules11. Time & Attendance11. Time & Attendance 1. Pharmacy1. Pharmacy 1. Long Term Care1. Long Term Care12. Executive Information12. Executive Information 2. Lab2. Lab 2. QI2. QI13. Budgeting13. Budgeting 3. Radiology3. Radiology 3. Physician EMR3. Physician EMR14. Enterprise Scheduling14. Enterprise Scheduling 4. Other Ancillaries4. Other Ancillaries 4. Practice Management4. Practice Management15. Order Entry15. Order Entry 5. ER5. ER 5. Contract Management5. Contract Management

6. OR6. OR 6. PACS6. PACS


Challenge: Underestimating ScopeChallenge: Underestimating Scope

Strategies:Strategies:

• This is transformative culture change, not simply This is transformative culture change, not simply putting in new systems.putting in new systems.

• Recognize every department will be impacted.Recognize every department will be impacted.

• Focus on improving workflow and quality.Focus on improving workflow and quality.

• Understand that many small and rural facilities Understand that many small and rural facilities have experienced the same challenges and have have experienced the same challenges and have come out of the process better off.come out of the process better off.


Challenge: Limited HIT ExpertiseChallenge: Limited HIT Expertise


• Invest in someone capable of leading the charge.Invest in someone capable of leading the charge.

• HIT leadership requires healthcare, project and HIT leadership requires healthcare, project and change management expertise.change management expertise.

• The new federally funded Regional Extension The new federally funded Regional Extension Centers may help.Centers may help.

• Use consultants strategically without creating a Use consultants strategically without creating a dependency relationship.dependency relationship.


Challenge: Normal Resistance to ChangeChallenge: Normal Resistance to Change


• Solicit user feedback from early stages.Solicit user feedback from early stages.

• Provide lots of opportunities to learn.Provide lots of opportunities to learn.

• Advertise anticipated system benefits.Advertise anticipated system benefits.

• Administration/Directors lead by example.Administration/Directors lead by example.

• Stress that soon EMR will be the status quo.Stress that soon EMR will be the status quo.


Challenge: Physician AcceptanceChallenge: Physician Acceptance


• Bend over backwards to involve physicians in Bend over backwards to involve physicians in selecting the systems that will impact them.selecting the systems that will impact them.

• ARRA will require significant physician HIT use, ARRA will require significant physician HIT use, which may help motivate engagement.which may help motivate engagement.

• Again, provide educational opportunities to help Again, provide educational opportunities to help physicians overcome what will be a steep learning physicians overcome what will be a steep learning curve.curve.


Challenge: Interdepartmental TensionChallenge: Interdepartmental Tension


• Recognize that implementation process is stressful. Recognize that implementation process is stressful.

• View this as an opportunity: make it a goal to fix View this as an opportunity: make it a goal to fix dysfunctional workflow between departments.dysfunctional workflow between departments.

• Provide non-threatening forum for stakeholders to Provide non-threatening forum for stakeholders to discuss resolution strategies. discuss resolution strategies.

• Interdepartmental cooperation and communication Interdepartmental cooperation and communication are critical in an EMR environment. are critical in an EMR environment.


Challenge: Staff BurnoutChallenge: Staff Burnout

Strategies: Strategies:

• Provide staff with the time and resources they Provide staff with the time and resources they need to successfully navigate the change events.need to successfully navigate the change events.

• Accept that implementation and Go Live Accept that implementation and Go Live activities will necessitate higher staff/patient activities will necessitate higher staff/patient ratios. ratios.

• Find opportunities to celebrate implementation Find opportunities to celebrate implementation milestones.milestones.


Challenges: Ongoing CostsChallenges: Ongoing Costs

StrategiesStrategies

• Pursue cost effective strategies, but make sure Pursue cost effective strategies, but make sure they will lead to the goals of meaningful use.they will lead to the goals of meaningful use.

• Find return on investment where possible, though Find return on investment where possible, though this is a challenge for small facilities.this is a challenge for small facilities.

• Consider collaborative opportunities.Consider collaborative opportunities.


IV - Preparing for ARRA NowIV - Preparing for ARRA Now


First Three Key QuestionsFirst Three Key Questions

1.1. Are you currently using a certified vendor?Are you currently using a certified vendor?

http://www.cchit.org/choose/inpatient/2007/http://www.cchit.org/choose/inpatient/2007/

http://www.cchit.org/choose/ambulatory/08/http://www.cchit.org/choose/ambulatory/08/

2.2. If yes, will that vendor likely provide you with a If yes, will that vendor likely provide you with a migration path to meaningful use?migration path to meaningful use?

3.3. If yes, are you strategically committed to staying If yes, are you strategically committed to staying with your current vendor?with your current vendor?


Recommendations If Yes to All ThreeRecommendations If Yes to All Three

• Continue an HIT Planning Workgroup.Continue an HIT Planning Workgroup.

• Educate key stakeholders on ARRA & meaningful use.Educate key stakeholders on ARRA & meaningful use.

• Determine what vendor modules will likely need to be Determine what vendor modules will likely need to be implemented by 2011 to achieve meaningful use.implemented by 2011 to achieve meaningful use.

• Determine what 3Determine what 3rdrd party products may be required to party products may be required to fill primary vendor gaps and begin selection process.fill primary vendor gaps and begin selection process.

• Work with vendors to identify likely scheduling issues Work with vendors to identify likely scheduling issues and challenges.and challenges.

• Continue assessing workflow and change goals at the Continue assessing workflow and change goals at the department level.department level.


Recommendations If No to Any of ThreeRecommendations If No to Any of Three• Convene an HIT Planning Workgroup.Convene an HIT Planning Workgroup.

• Educate key stakeholders on ARRA and meaningful Educate key stakeholders on ARRA and meaningful use issues.use issues.

• Set goals and develop a high level HIT strategic plan.Set goals and develop a high level HIT strategic plan.

• Identify regional collaborative opportunities.Identify regional collaborative opportunities.

• Begin assessing workflow and change goals at the Begin assessing workflow and change goals at the department level.department level.

• Begin vendor evaluation and/or selection process.Begin vendor evaluation and/or selection process.

• Be ready to sign contracts and begin implementations Be ready to sign contracts and begin implementations soon after final definitions are released.soon after final definitions are released.


Online Tool KitsOnline Tool Kits

• Stratis Health (Minnesota QIO) Toolkit for CAHs Stratis Health (Minnesota QIO) Toolkit for CAHs

http://www.stratishealth.org/expertise/healthit/hospitals/http://www.stratishealth.org/expertise/healthit/hospitals/index.htmlindex.html

• Agency for Healthcare Research and Quality HIT Agency for Healthcare Research and Quality HIT Evaluation and Adoption ToolboxEvaluation and Adoption Toolbox

http://healthit.ahrq.gov/http://healthit.ahrq.gov/

arra & hit in rural america

Documents

arra medicare share

medicare reimbursement

medicare incentivescahs

use medicare

arra hit

meaningful users

meaningful ehr users

maximum year