In order to participate in the EHR incentive program, you must first be using a certified EHR. As mentioned earlier, the standards and criteria for certification are spelled out in a separate regulation and are administered by ONC. This rule details the particular certain functionalities and vocabularies be included in EHR systems; it is left to the EHR incentive program rule and others to determine which of those functionalities and vocabularies must be enabled. When considering participation in the federal EHR Incentive Program, you must ensure that you have an EHR that is certified based on the relevant edition of the EHR standards, implementation specifications and certification criteria. For reporting periods before 2014, those were published in July and October 2010. Beginning with reporting periods in 2014, the new rule will apply.


There are two components to qualified EHRs – using the appropriate standards and containing certain functionalities. A standard is formally defined as “a technical, functional, or performance-based rule, condition, requirement, or specification that stipulates instructions, fields, codes, data, materials, characteristics, or actions.” As an example, Current Procedural Terminology is the standard for coding of procedures and services. Setting standards is a necessary component of developing a full-fledged health IT network and is integral for interoperability.

There are many organizations that work to develop standards. At times, competing standards may be developed and we are dependent upon industry to come together and agree to it. Generally, the government does not develop or set the standards; instead, it adopts and incorporates what industry deems best.

The specific standards will change over time to meet the changing needs of the industry. EHRs will need to do the same in order to remain certified, a requirement for physicians to qualify for the EHR incentive payment.

Certification criteria

One of the major changes to the criteria for a certified EHR is that it must be able to calculate the measures described in the EHR incentive program. This change was made in response to concerns raised by the ACC and others that the measures as proposed would require a separate set of record-keeping to determine if a participant met the thresholds and the exact numbers to be reported for numerators and denominators. Now, the EHR will need to make those calculations, and participants should be able to more easily report that information to CMS as required for the EHR incentive program. Another example of a required functionality is that the EHR must record when electronic health information is created, modified, accessed or deleted, as well as an indication as to what occurred and who performed the action.


The ONC rule sets a rather low bar for certification – it does not require usability testing, nor does it include the full array of functionalities that may be necessary in your practice. Additionally, it does not include any specialty-specific testing requirements or components. As a result, the ACC recommends that cardiovascular practices research the organization certifying the EHR they are considering purchasing. Some organizations will likely test and certify for the bare minimum required under the EHR incentive program, while others will test and certify for usability and innovative functionalities - far beyond what is required by law.

The ONC has announced the organizations below have been accredited to certify EHRs:

Complete EHRs versus EHR modules

There are two types of certifications that EHR systems can receive under the ONC rule: Complete EHR certification and EHR Module certification. A Complete EHR meets all of the criteria for the relevant certification year and is certified as such. EHR Modules provide one or more capabilities required by the EHR certification criteria for a Complete EHR. The modules must be separately tested and certified for the certification criteria and labeled as such. With a modular approach, a physician practice could essentially build its own Complete EHR by selecting modules from a number of vendors.

The 2014 Edition of the EHR standards, implementation specifications and certification criteria adds another term to the mix: Base EHR. The Base EHR must include fundamental capabilities all practitioners would need to have. To put it into context, the Base EHR is one component of a Complete EHR and could be developed as a Module to be combined with others to meet the requirements for a Complete EHR. This new term allows for more flexibility for physicians and hospitals. The idea is that physicians and hospitals will only need to buy EHRs with as much functionality as they need to participate successfully in the EHR Incentive Program, rather than all of the bells and whistles. Instead, they can purchase a Base EHR and then only enough Modules, interfaces, add-ons, etc. as is necessary to collect information and report data on applicable criteria. For instance, a Base EHR need only be certified to collect and report data on one CQM. An EHR Module might be purchased that is certified to report other CQMs as selected by the physician or hospital.

Developing a Complete EHR by using a modular approach is more challenging for physician practices, especially small cardiovascular practices that generally do not have staff with the necessary skill sets to ensure that all of the requirements are met and technological challenges are minimized or eliminated. For instance, there is no requirement that the EHR modules be tested and certified for their ability to interface with other EHR modules. So it would be left to the cardiovascular practice to ensure that two modules could “talk” to each other. Practices could decide to have the systems they develop from modules certified as Complete EHRs, but this is likely to be an expensive and time-consuming process. There may be EHR selection consultants capable of providing this service, but it may again be costly and time-consuming. Therefore, the ACC anticipates that most cardiovascular practices, especially small to medium ones, will purchase Complete EHRs, rather than developing their own from EHR modules.

If you decide to create your own Complete EHR from certified EHR modules, you will need to send the product certification numbers to the ONC who will verify those modules, when put together, constitute a complete EHR. They will send you a new certification number to provide to CMS when you attest to using a qualified EHR. You should also be aware that the 2014 Edition requires certification for individual CQMs; thus, an EHR may be certified to report on certain CQMs and not others, or it may be certified to report all. This becomes important when determining which CQMs you will report to CMS.

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