The government is investing 19 billion dollars into healthcare - for physicians and hospitals. The bulk of this investment is going to modernizing healthcare technology - particularly by use of electronic health records (EHR).

Electronic Health Records and Electronic Medical Records are terms that Microwize, and many others in the healthcare technology industry use interchangeably. EMR/EHRs are electronic versions of patient records. In the past, Electronic Health Records were distinguished as including the ability for reporting. However, with full suites of medical software that include Practice Management (PM) along with EMR, electronic medical records are capable of clinical reporting as well. Therefore, in terms of the stimulus package, they are essentially the same.

Qualified medical professionals for the Medicare HIT incentive include doctors of medicine, osteopathy, surgery, dental medicine, podiatric medicine, optometry and chiropractors. You must also not be hospital based, demonstrate meaningful use of a certified EHR and Submit Medicare Part B Claims.

The Medicaid incentive is extended to include certified nurse mid-wives, nurse practitioners and physicians assistants (under certain circumstances). You must also not be hospital based, demonstrate meaningful use of a certified EHR and at least 30% of your patients must receive Medicaid assistance (this is lowered to 20% for pediatricians).

Yes, absolutely. You may also qualify for the early adopter incentive. Anyone who qualifies before 2011 is eligible for the early adopter incentive of another $3,000 for the first year.

Funds for physicians will become available on January 1, 2011. The maximum amount if you qualify under Medicare is $44,000 over 5 years. This includes the early adopter incentive. In order to qualify for the early adopter bonus, you should start implementing and training now if you have not already. The payments are front loaded, with the bulk of the payments coming in the first 2 years. For Medicaid, the maximum amount is $64,000 over 6 years

If you do not demonstrate meaningful use of electronic medical records, by 2015, you will see a reduction in your Medicare payments. For 2015, you could lose 1% of your Medicare payments. This percentage will increase by 1% until 2017, at which point the secretary may increase the reduction up to 5%.

In order to qualify to receive the stimulus incentive under the Medicare portion, you must be a qualified professional who demonstrates meaningful use of an EMR and submit Medicare Part B claims. The EMR stimulus pays you the amount of 75% of your Medicare Part B claims, up to the maximum of $44,000 over 5 years, which the bulk of the payments in the first two years. In order to receive the maximum payment, you bill the following amounts in Medicare Part B claims:

• $24k for the first year
• $16k for the second year
• $10.7k for the third year
• $5.3k for the fourth year
• $2.7 for the fifth year

You must also qualify for the early adopter bonus of $3,000. In order to get the early adopter bonus, you must have an EMR implemented, be properly trained and use the EMR at point of care, which means you need to get started now in order to qualify.

The Medicaid Provision pays you 85% of the net allowable costs for your EMR. This includes implementation, training maintenance, etc. Therefore, the maximum really depends on the cost of your system. In order to receive a payment, you must first implement an EMR (which will qualify you for your "year 1" payment. By year 2, you must demonstrate "meaningful use." Again, the payments are front-loaded, and it is to your benefit to qualify sooner rather than later.

Payments start for physicians on January 1st, 2011 and penalties start for lack of EMR adoptoin in 2015

Early adopters qualify for a $3,000 bonus applied to the first year of payments. Therefore, early adopters increase their maximum payment for the first year from $15,000 to $18,000, and their overall payments from $41,000 to $44,000.

No, the stimulus bill specifically states that hospital-based physicians are not eligible.

An "eligible professional" who predominantly furnishes services in a geographic area that is designated by the HHS Secretary as a health professional shortage area may receive a 10% increase in their annual payment.

Payments have been proposed to be made in a single, consolidated annual payment. Annual Payments are proposed to be equal to 75% of the total Medicare allowed charges for covered services during that year. The Medicare allowed charge is the lesser amount of the actual charge or the Medicare physician fee schedule amount. Please note that these are the proposed methods of payment. The final rule on this is expected spring or early summer 2010.

Who is eligible? Physicians, dentists, podiatrists, optometrists, and some chiropractors.
Meaningful use year: 1/1/2011. What does this mean to you? Implementation of a small practice should ideally start no later than early 2010 to ensure meaningful use can be demonstrated by 2011 - as it takes time to train, install, and begin to demonstrate and report on 'meaningful use'.
Payout Starts: Payments expected to begin May of 2011 according to final rules released July 13th, 2010.
Payment Details: Incentive payments equal 75% of allowed charges. $15,000 (1st year), $12,000 (2nd year), $8000 (3rd year), $4000 (4th year), $2000 (5th year), $0 for subsequent years. Note: early adopters (meaningful users in 2011, 2012) will be eligible for increased first year payment of $18,000. Example: Providers who bill $24,000 or greater annually will receive the maximum benefit ($18,000 - or 75% of allowable Medicare charges).
Penalties/Deductions. Beginning in 2015 and accelerating in subsequent years, non-adopters who are not meaningfully using a Certified EHR, fee schedules will be reduced as follows:

• 2015 - 1% Reduction
2016 - 2% Reduction 2017 - 3% Reduction
2018 - 4% (Secretary of HHS Option if fewer than 75% of eligible professionals are not meaningfully using a certified EHR) 2018 - 5% (Secretary of HHS Option if fewer than 75% of eligible professionals are not meaningfully using a certified EHR)

MEDICARE ELECTRONIC MEDICAL RECORDS STIMULUS ELECTRONIC HEALTH RECORDS SOFTWARE
	EHR Adoption 2011	EHR Adoption 2012	EHR Adoption 2013	EHR Adoption 2014	EHR Adoption 2015
2011 ($)	$18,000	0	0	0	0
2012 ($)	$12,000	$18,000	0	0	0
2013 ($)	$8,000	$12,000	$15,000	0	0
2014 ($)	$4,000	$8,000	$12,000	$12,000	0
2015 ($)	$2,000	$4,000	$8,000	$8,000	0
2016 ($)	0	$2,000	$4,000	$4,000	0
TOTAL	$44,000	$44,000	$39,000	$24,000	0

Who is eligible? Physicians, dentists, certified nurse mid-wife, nurse practitioners, and physician assistants practicing in a rural health clinic or Federally Qualified Health Clinic (FQHC). Eligible professionals cannot be hospital based, and patient volume must be comprised of at least 30% Medicaid patients. Pediatricians (again, non-hospital based) are eligible for Medicaid incentives with 20% Medicaid patient volume.
Meaningful use year: 1/1/2010. What does this mean to you? Implementation of an EHR for Medicaid providers should begin immediately to ensure to be eligible for the earliest payments - as it takes time to train, install, and begin to demonstrate and report on 'meaningful use'.
Payout Starts: Payments expected to begin mid-year 2011 according to final rules released July 13th, 2010. These are state-based payments, unlike the Medicare incentives that are paid at the federal level.
Payment Details: Incentive payments equal 85% of net allowable charges, and based upon EHR expenditures. $15,000 (1st year), $12,000 (2nd year), $8000 (3rd year), $4000 (4th year), $2000 (5th year), $0 for subsequent years. Note: early adopters (meaningful users in 2011, 2012) will be eligible for increased first year payment of $18,000.

MEDICAID ELECTRONIC MEDICAL RECORDS STIMULUS ELECTRONIC HEALTH RECORDS SOFTWARE
	EHR Adoption 2011	EHR Adoption 2012	EHR Adoption 2013	EHR Adoption 2014	EHR Adoption 2015	EHR Adoption 2016
2011 ($)	$21,250	0	0	0	0	0
2012 ($)	$8,500	$21,250	0	0	0	0
2013 ($)	$8,500	$8,500	$21,250	0	0	0
2014 ($)	$8,500	$8,500	$8,500	$21,250	0	0
2015 ($)	$8,500	$8,500	$8,500	$8,500	$21,250	0
2016 ($)	$8,500	$8,500	$8,500	$8,500	$8,500	$21,250
2017 ($)	0	$8,500	$8,500	$8,500	$8,500	$8,500
2018 ($)	0	0	$8,500	$8,500	$8,500	$8,500
2019 ($)	0	0	0	$8,500	$8,500	$8,500
2020 ($)	0	0	0	0	$8,500	$8,500
2021 ($)	0	0	0	0	0	$8,500
TOTAL	$44,000	$44,000	$39,000	$24,000	0	0

The minimum standards to demonstrate 'meaningful use' of an EMR will get increasingly tighter, and eligible professionals will be tied to the meaningful use requirements for the year that they file. For example, in 2011 - Providers will be able to choose from 5/10 items from a menu set of objectives, in addition to core meaningful use requirements - giving providers some flexibility with the EMR/EHR features they use to achieve meaningful use. Proposed Stage 2 and Stage 3 requirements will require increasingly tougher standards. The earliest adopters who adopt EHR software today and demonstrate 'meaningful use' of the EMR software by 2011 will realize the highest possible EMR software payments through the stimulus package electronic medical records software payments. Eligible providers that elect not to utilize an EHR system by 2015 will see Medicare/Medicaid reimbursement penalties. The meaningful use final ruling outlines a graduated approach - meaningful use requirements will be increasingly stringent in the years following 2012 (Stage 2 and 3).

The following Q&A is MDS's interpretation of the final rules of the Centers for Medicare and Medicaid Programs (CMS); Electronic Health Record Incentive Program as outlined by the Department of Health and Human Services in this document.

The final rules for stage 1 meaningful use (qualifying year 2010 or 2011) contain 15 "core" objectives that eligible providers must meet.

CPOE (computerized physician order entry) for medication orders. Specifically, more than 30% of unique patients with at least one medication in their medication list seen by the eligible provider must have at least one medication order entered using CPOE.

• Implement drug to drug and drug allergy interaction checks.
• Maintain up to date problem list of current and active diagnoses for 80% of patients.
• More than 40% of permissible prescriptions written are generated and transmitted electronically using certified EHR technology.
• Maintain active medication list for 80% of patients.
• Maintain active drug allergy list for 80% of patients.
• Record demographic info, such as gender and race, for 50% of patients seen by eligible providers.
• Record and chart changes in vital signs, such as height, weight, BMI, blood pressure, for more than 50% of patients over age 2.
• Record smoking status for more than 50% of patients over age 13.
• Provide clinical summaries.
• Report clinical quality measures to the Centers for Medicare and Medicaid Services.
• Provide more than 50% of patients with electronic copy of health information upon request within 3 business days.
• Protect electronic health information created or maintained by certified EHR.
• Implement one clinical decision support rule for EP's specialty or hospital's high priority condition and track compliance with that rule.
• Perform at least one test of certified e-health record's capability to electronically exchange key clinical information (interoperability), such as problem list or medication list, among providers of care or patient-authorized entities.

For a complete look at the final rules for meaningful use, please review the document in its entirety: http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf

The final rules for stage 1 meaningful use (qualifying year 2010 or 2011) contain 10 "menu set" objectives - where eligible providers need to achieve 5 out of 10. Providers choose which menu set rules to select and defer. *Must choose one of these two.

• Drug formulary access
• Import/store 40% of lab results
• Patient lists by condition
• Provide patient-specific educational materials (>10%)
• Medication reconciliation between care settings (>50% in transitions of care)
• Care summaries to referred/transitioned patients (>50%)
• Submit immunization data to registries (at least one test/follow-up)
• Submit syndromic surveillance data to public health agencies (at least one test/follow-up)
• Patient reminders (>20% patients age 65+ or <5) # Eligible Providers Only
• Provide patients with health record (>10% within 4 days of updating)

You must be able to report starting no later than 90 days prior than December 31, 2010 (i.e. October 3rd 2010) . The EHR reporting period may be any continuous 90-day period within the first payment year and the entire payment year for all subsequent payment years. Qualifying providers who adopt and are "meaningfully using" a certified EHR system by 2011 and 2012 will realize the highest incentive of $44,000. Providers who adopt in 2011 will receive the first payment of $18,000 beginning in 2011. CMS expects the first payments to begin in March of 2011.

The final rules for stage 1 meaningful use (qualifying year 2010 or 2011) contain 15 "core" objectives that eligible providers must meet. CPOE (computerized physician order entry) for medication orders. Specifically, more than 30% of unique patients with at least one medication in their medication list seen by the eligible provider must have at least one medication order entered using CPOE.

• Implement drug to drug and drug allergy interaction checks.
• Maintain up to date problem list of current and active diagnoses for 80% of patients.
• More than 40% of permissible prescriptions written are generated and transmitted electronically using certified EHR technology.
• Maintain active medication list for 80% of patients.
• Maintain active drug allergy list for 80% of patients.
• Record demographic info, such as gender and race, for 50% of patients seen by eligible providers.
• Record and chart changes in vital signs, such as height, weight, BMI, blood pressure, for more than 50% of patients over age 2.
• Record smoking status for more than 50% of patients over age 13.
• Provide clinical summaries.
• Report clinical quality measures to the Centers for Medicare and Medicaid Services.
• Provide more than 50% of patients with electronic copy of health information upon request within 3 business days.
• Protect electronic health information created or maintained by certified EHR.
• Implement one clinical decision support rule for EP's specialty or hospital's high priority condition and track compliance with that rule.
• Perform at least one test of certified e-health record's capability to electronically exchange key clinical information (interoperability), such as problem list or medication list, among providers of care or patient-authorized entities.

For a complete look at the final rules for meaningful use, please review the document in its entirety: http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf

The final rules for stage 1 meaningful use (qualifying year 2010 or 2011) contain 10 "menu set" objectives - where eligible providers need to achieve 5 out of 10. Providers choose which menu set rules to select and defer. *Must choose one of these two.

• Drug formulary access
• Import/store 40% of lab results
• Patient lists by condition
• Provide patient-specific educational materials (>10%)
• Medication reconciliation between care settings (>50% in transitions of care)
• Care summaries to referred/transitioned patients (>50%)
• Submit immunization data to registries (at least one test/follow-up)
• Submit syndromic surveillance data to public health agencies (at least one test/follow-up)
• Patient reminders (>20% patients age 65+ or <5) # Eligible Providers Only
• Provide patients with health record (>10% within 4 days of updating)

Objective: Use CPOE
Measure: CPOE is used for at least 80 percent of all orders

Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP has enabled this functionality

Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.

Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of "none" if the patient is not currently prescribed any medication) recorded as structured data.

Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of "none" if the patient has no medication allergies) recorded as structured data.

Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP "smoking status" recorded

Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.

Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over

Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.

Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP

Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP.

Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information
Objective: Provide clinical summaries to patients for each office visit.
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits.

Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.

Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries.

Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).

Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.

Objective: Use of CPOE for orders (any type) directly entered by authorizing provider (for example, MD, DO, RN, PA, NP)
Measure:CPOE is used for at least 10 percent of all orders

Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure:The eligible hospital has enabled this functionality

Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT
Measure:At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry or an indication of none recorded as structured data. Hospital

Objective: Maintain active medication list.
Measure:At least 80 percent of all unique patients admitted by the eligible hospital have at least one entry (or an indication of "none" if the patient is not currently prescribed any medication) recorded as structured data.

Objective: Maintain active medication allergy list.
Measure:At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry (or an indication of "none" if the patient has no medication allergies) recorded as structured data.

Objective: Record demographics.
Measure:At least 80 percent of all unique patients admitted to the eligible hospital have demographics recorded as structured data

Objective: Record and chart changes in vital signs.
Measure:For at least 80 percent of all unique patients age 2 and over admitted to the eligible hospital, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

Objective: Record smoking status for patients 13 years old or older
Measure:At least 80 percent of all unique patients 13 years old or older admitted to the eligible hospital have "smoking status" recorded

Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure:At least 50 percent of all clinical lab tests results ordered by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach
Measure:Generate at least one report listing patients of the eligible hospital with a specific condition.

Objective: Report hospital quality measures to CMS or the States.
Measure:For 2011, an eligible hospital would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an eligible hospital would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure:Implement five clinical decision support rules relevant to the clinical quality metrics the Eligible Hospital is responsible for as described further in section II.A.3.

Objective: Check insurance eligibility electronically from public and private payers
Measure:Insurance eligibility checked electronically for at least 80 percent of all unique patients admitted to an eligible hospital

Objective: Submit claims electronically to public and private payers.
Measure:At least 80 percent of all claims filed electronically by the EP or the eligible hospital.

Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies, discharge summary, and procedures), upon request.
Measure:At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

Objective: Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request.
Measure:At least 80 percent of all patients who are discharged from an eligible hospital and who request an electronic copy of their discharge instructions and procedures are provided it.

Objective: Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically.
Measure:Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure:Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

Objective: Provide summary care record for each transition of care and referral.
Measure:Provide summary of care record for at least 80 percent of transitions of care and referrals.

Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure:Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries.

Objective: Capability to provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received.
Measure:Performed at least one test of certified EHR technology capacity to provide electronic submission of reportable lab results to public health agencies (unless none of the public health agencies to which eligible hospital submits such information have the capacity to receive the information electronically).

Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure:Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an eligible hospital submits such information have the capacity to receive the information electronically).

Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure:Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.

Interoperability is defined as the ability of a system or a product to work with other systems or products without special effort on the part of the system owner. Interoperability is a fundamental requirement for widespread EMR adoption. For patients, increased interoperability means increased provider choice, greater transparency, lower costs, and better clinical outcomes. The future of interoperability is the sharing of patient information at the point of care, giving all providers within a patient's care contiuum access to a longitudinal medical record (EHR). The new "standard" of service for providers and care facilities will be defined by their ability to provide optimum care for all individuals, regardless of provider, payor, or point of care.

But with the technological ability to "transform care" through interoperability comes additional risk. The "seamless flow" of information from one IT system to another requires added security measures, ones that support identification and authentication, audit measures, encryption, and residual protection. The process of identifying vulnerabilities should include an analysis of the IT system security features, and the security controls (technical and procedural) used to protect the system.

While interoperability is the new buzz word in EMR adoption and integration, it will require a substantial investment by the end user in terms of regulatory compliance and establishment of policies and procedures for each user. Establishing the role of Compliance Officer is critical to maintain security and report any threats or breeches as they occur. Contaminated or corrupted data will result in inaccuracy, fraud, and erroneous clinical decisions.

EMR Cost Estimator Solo Practice - Local (Client Server) Installation - Five or Fewer Total Users
EXPENSE ITEM	2011	2012	2013	2014	2015
EMR/PM Software License	7,500	0	0	0	0
Annual Subscription Fees	0	0	0	0	0
eRX License	250	250	250	250	250
Formulary License	250	250	250	250	250
Annual Software Maintenance	1,640	1,640	1,640	1,640	1,640
Application Server	5,200	0	0	0	0
Work Station PCs (5)	5,000	0	0	0	0
Tablet PCs (3)	5,400	0	0	0	0
Broadband Internet Connection	0	0	0	0	0
Wireless Network Hardware	1,200	0	0	0	0
Hardware Maintenance	600	600	600	600	600
EXPENSE SUBTOTAL	27,040	2,740	2,740	2,740	2,740
TAX DEDUCTION*
Software	8,000	500	500	500	500
Hardware	16,800	0	0	0	0
Service (Maintenance)	2,240	2,240	2,240	2,240	2,240
TAX DEDUCTION SUBTOTAL**	27,040	2,740	2,740	2,740	2,740
EFFECTIVE TOTAL COST (After Tax)	17,846	1,808	1,808	1,808	1,808
ARRA INCENTIVES***	18,000	12,000	8,000	4,000	2,000
NET COST**** () = Cash to You	(154)	(10,192)	(6,192)	(2,192	(192

EMR Cost Estimator ASP (Hosted) System - Five or Fewer Total Users
EXPENSE ITEM	2011	2012	2013	2014	2015
EMR/PM Software License	0	0	0	0	0
Annual Subscription Fees	4,800	4,800	4,800	4,800	4,800
eRX License	0	0	0	0	0
Formulary License	0	0	0	0	0
Annual Software Maintenance	0	0	0	0	0
Application Server	0	0	0	0	0
Work Station PCs (5)	5,000	0	0	0	0
Tablet PCs (3)	5,400	0	0	0	0
Broadband Internet Connection	1,440	1,440	1,440	1,440	1,440
Wireless Network Hardware	1,200	0	0	0	0
Hardware Maintenance	600	600	600	600	600
EXPENSE SUBTOTAL	17,000	6,840	6,840	6,840	6,840
TAX DEDUCTION*
Software	0	0	0	0	0
Hardware	11,600	0	0	0	0
Service (Maintenance)	6,840	6,840	6,840	6,840	6,840
TAX DEDUCTION SUBTOTAL**	18,440	5,400	5,400	5,400	5,400
EFFECTIVE TOTAL COST (After Tax)	12,170	4,514	4,514	4,514	4,514
ARRA INCENTIVES***	18,000	12,000	8,000	4,000	2,000
NET COST**** () = Cash to You	(5,830)	(7,486)	(3,486)	514	1,564