CMS-10165 Description of Changes to Form_FINAL

Electronic Health Record Demonstration

Revised Physician Practice Application Form

The proposed physician practice application form necessary for participation in the Electronic Health Record (EHR) Demonstration includes the following modifications to the currently-approved form for the MCMP Demo (OMB NO.: 0938-0965). All of these modifications are a result of demonstration program policy, and are described below.

1. Introductory Narrative – The primary modification made was to delete references to the Medicare Care Management Performance (MCMP) demonstration and reflect the name of the new EHR demonstration initiative and the 5-year duration of this demonstration. Other modifications include:

• The first sentence of the opening paragraph was modified to clarify that the demonstration will target small and medium sized “primary care” physician practices.

• The first sentence of the opening paragraph was modified to indicate that the purpose of the demonstration is to promote the adoption and use of “certified EHRs” instead of “health information technology.”

• An additional statement was included to indicate that practices that incorporate health information technology will be eligible to earn additional incentives as part of the EHR demonstration initiative.

• The revised form indicates that each practice that applies to participate in the EHR initiative must have a designated staff person authorized to speak for the group and provide requested information. The reference to a “lead physician” for this purpose has been deleted from the revised form.

2. References to Quality Improvement Organizations (QIOs) and Doctor’s Office Quality (DOC-IT) practices have been deleted from the revised application form because neither is applicable to the EHR initiative.

3. Question No. 5 – Inserted new question 5 that requests the name and contact information for a “designated contact person.”

4. Formerly Question No. 8: This question, which requested information about numbers of Medicare beneficiaries served by the applicant practice who have specified chronic conditions, was deleted in the revised form.

5. Question 9 and 10: These questions were added to ascertain specific information about the practice’s EHR status and EHR product/vendor information.

6. Question 11: Since the EHR demonstration emphasizes the CCHIT-certified EHR component, this question was added to allow an assessment of the practice’s EHR capability and the degree to which the practice currently uses an EHR, if applicable.

7. “Physicians Participating in the EHR Demonstration” sheet:

• The reference to the MCMP demonstration was deleted and replaced with “EHR” demonstration.

• The group National Provider Identification number (if applicable) is now requested.

• The Practice Group UPIN number has been deleted, since UPINs are no longer being issued.

• Column five has been modified as follows: “Individual NPI - National Provider Identification number if applicable.”

• The footnotes originally included for the MCMP demonstration form have been deleted.

8. Consent to Share Data sheet:

   • The reference to the MCMP demonstration was deleted and replaced with “EHR” demonstration.

   • The request for the “Practice Group UPIN number (if applicable)” was deleted since this identification number is no longer issued.

   • Additional provider signature lines, including the applicable individual NPI, are included.

   • A new footnote was added that states: “This form must be signed by each participating physician in the practice. If additional signatures are necessary, please copy and submit additional signature sheets.”

   • The existing required footnote regarding the PRA requirements was modified to indicate that the time required to complete this information collection is 13 minutes per response (the response burden for the previously-approved form was 10 minutes).