Can I use NCDR to participate in the federal Electronic Health Records (EHR) Incentive Program?

It depends. Use of ACC’s registries will not meet all of the requirements for the federal EHR Incentive Program for anyone. That said, physicians who meet the program’s definition of an “eligible professional” may be able to use the PINNACLE Registry® for certain requirements. They will not be able to use ACC’s other registries to meet the requirements of the program, nor will hospitals be able to use any of ACC’s registries to meet requirements for the EHR Incentive Program.

Which requirements of the federal EHR Incentive Program could potentially involve the use of ACC’s registries or registries generally?

For eligible professionals, there are two requirements that using the PINNACLE Registry could potentially fulfill. The first is the requirement to report clinical quality measures to the Centers for Medicare and Medicaid Services (CMS), a requirement that all successful participants must meet.

The second is in the menu set for Stage 2 of the program. Physicians must complete at least three out of the six possible objectives in the menu set. Specifically, this particular measure requires successful ongoing transmission of specific case report information to a specialized registry. While CMS declined to provide a definition of a specialized registry, it is clear that they intended national registries operated by medical specialty societies to meet the requirements. The key requirement here is that the information must be reported from the eligible professional’s certified EHR (not the hospital’s EHR) directly to the registry. The PINNACLE Registry gathers information directly from EHRs, thus enabling participating physicians to meet this requirement for eligible professionals. This objective is not available for Stage 1.

I am a physician in private practice/employed by a hospital who meets the definition of an “eligible professional.” Can I use the PINNACLE Registry to meet the federal EHR Incentive Program’s requirement to report clinical quality measures?

Reports from the PINNACLE Registry can be used to satisfy the EHR Incentive Program’s requirement to report clinical quality measures for 2013, assuming you are using a certified EHR to report your data to the PINNACLE Registry. At this time, the PINNACLE Registry will not be able to be used for this particular requirement of the EHR Incentive Program beginning in 2014 because CMS is changing requirements so that clinical quality measure reporting will only be allowed to occur from certified EHRs or certified EHR modules. The PINNACLE Registry is reviewing its options and the certification requirements. The ACC will provide additional information as decisions are made regarding certification for 2014.

Can any of the inpatient registries be used for clinical quality measure reporting for the EHR Incentive Program?

No, the only registry that can be used in 2013 and could possibly be used going forward is the PINNACLE Registry. CMS requires that all data used for clinical quality measure reporting for the EHR Incentive Program emanate from a certified EHR or certified EHR module and be transmitted from a certified EHR or EHR module to CMS. The other NCDR registries collect information through a variety of sources, including paper, and rely on certified vendors to transmit information from customers to NCDR.

Additionally, none of the other registries collect the requisite number of clinical quality measures from the enumerated list for the EHR Incentive Program.

Can the PINNACLE Registry be used to meet the specialized registry reporting requirement?

Yes, the ACC believes that participating in the PINNACLE Registry will enable eligible professionals to meet the menu set measure pertaining to successful ongoing transmission of specific case information to a specialized registry. The key requirements are that the information must be transmitted directly from the certified EHR to the registry and the certified EHR must be the eligible professional’s, as opposed to a hospital’s certified EHR.

Does the ability to use the PINNACLE Registry for the EHR Incentive Program requirements hinge on whether I am employed by a hospital or in private practice?

No, the ability to use the PINNACLE Registry for the EHR Incentive Program requirements has nothing to do with your employment status. Instead, it has to do with your ability to meet the definition of an eligible professional.

Do I have to use the PINNACLE Registry to meet any or all of the applicable EHR Incentive Program requirements if I want to participate in the registry?

No, using the PINNACLE Registry to meet federal program requirements is an optional service provided to registry participants. Specific release forms are required for the PINNACLE Registry to transmit your information to CMS for each of the programs. For more information, click here or contact the PINNACLE Registry at (800) 257-4737.

What is an eligible professional?

The term “eligible professional” is defined in the federal EHR Incentive Program regulations as a physician who performs less than 90 percent of his or her services in the emergency department or inpatient setting, as determined by CMS based on claims billed during the previous year. For more information on the definition of an eligible professional and the EHR Incentive Program, visit acc.org/healthit.

I would like to join the PINNACLE Registry. What do I need to do?

Click here for enrollment information or contact the NCDR at (800) 257-4737.