Maria DeLeon, MD, (sitting) of Southwest Orlando Family Practice says she appreciated that the practice's information technology director, Jason Casorla, (standing) was in the office during its 2004 electronic health record system transition.primary care practices around the country began attesting to meaningful use of an electronic health record (EHR) system in hopes of earning $44,000 over five years from the Centers for Medicaid and Medicare Services (CMS).The attestation process—a series of questions answered on a Medicare Web site—is designed to show that the physician is using his or her certified EHR system to complete 15 core measures, his or her choice of 5 out of 10 possible menu items, and 6 out of 38 possible Clinical Quality Measures. Some measures are reported with a yes-or-no answer, and others are reported through numerator and denominator numbers.
For example, when attesting that you are tracking a patient's medication allergies through your EHR system, you would enter the number of unique patients seen during the reporting period (a minimum of 90 days this year) in the denominator box. In the numerator box, you would type how many of those patients have at least one entry (or an indication that the patient has no known medication allergies) recorded in their medication allergy list. CMS requires that 80% of those unique patients have a medication allergy status reported.
Sound simple? We spoke with three physicians confident that they will be among the first to achieve meaningful use this year. All faced different challenges in trying to meet the requirements, but they say the greatest challenge in their journey to meaningful use was the first part: adopting an EHR system. Once the doctors had the proper software in place, meaningful use was a natural extension.
IN-HOUSE IT STAFF ADDS CONVENIENCE/COSTS
Just a few miles away from the Universal Studios Resort in Orlando is Southwest Orlando Family Medicine (SOFM), a three-physician practice. Its doctors could earn a total of $132,000 ($44,000 each) over the next five years if they meet all three stages of meaningful use. Measures for stages 2 and 3 have not been finalized.
SOFM's secret weapon, however, is Jason Casorla, the practice's in-house full-time information technology (IT) director. Casorla will be paid much more than the meaningful use incentive, so it will not cover his salary, but his value to the practice isn't just for EHR system help.
"It was very important to us to have Jason there," says Maria DeLeon, MD. "One phone call and he's right there beside you. I could not imagine calling someone else not present at the office to help with the transition."
SOFM adopted its EHR system in 2004, the same year Casorla started, after serving as IT director for a manufacturing company. In February, Casorla had already registered the three physicians on the CMS Web site: http://cms.gov/ehrincentiveprograms. As of April 18, he was scheduled to receive the final software update from his vendor at the end of the month to deliver the data required for the attestation process. CMS permits a third-party to attest to meaningful use for a physician, but each physician must attest individually.
For DeLeon, the real challenge of meeting meaningful use didn't have anything to do with the Medicare requirements that were released last year. Her struggle came back in 2004 when she was the first doctor to go live on the practice's EHR.
"I am not really computer literate," says DeLeon, who had practiced since 1997 with paper records. "I had to start from scratch. It's not like our kids; now they know everything."
SOFM made an initial $200,000 investment in system software and licensing and has spent at least that much since three hardware upgrades and maintenance, says Liza Gonzales, RN, the practice manager and wife of practice founder, Patrick Gonzales, MD.
 Information technology director Jason Casorla of Southwest Orlando Family Medicine (standing) created customized electronic superbills for the practice's major payers to help Maria DeLeon, MD, and other physicians bill more accurately. |
"We've had a 50% revenue increase [since 2004], if not more," she says. SOFM has also grown in staff since its EHR adoption, from 21 clinical and nonclinical employees to 37 employees today.
Aside from the physicians, the practice has three full-time physician assistants and one nurse practitioner who sees 20 to 25 patients a day. Although helpful for generating revenue, the midlevel providers are not eligible for the Medicare meaningful use incentives.
Gonzales attributes much of the financial success to the EHR system, and more specifically, to Casorla, who created customized superbill templates for their major commercial payers and Medicare.
[The insurers] all have different things they pay for," she says. "We streamlined it so our providers don't have to think, 'Should I charge this or not?' It's right in front them."
The revenue growth allowed the practice to build a $9-million, 8,000-square-foot office in 2008 with 21 exam rooms, 4 nursing stations, and a bone-density scanning machine.
Only about 15% of SOFM's patients are insured by Medicare, but that population will grow as the practice recently contracted with a Medicare Advantage plan on the basis that its members would be eligible for meaningful use measures. To be eligible for the full first-year meaningful use incentive of $18,000, a physician must have at least $24,000 in charges for his or her Medicare patients.
DeLeon says she isn't concerned about meeting the meaningful use requirement because the EHR system is already ingrained in her practice.
"It was frustrating at the beginning, but it was all worth it," she says.
VISIT SUMMARY ALTERS WORKFLOW
 Hugh Taylor, MD |
One of the 15 core requirements of meaningful use is to provide a clinical summary of each visit to the patient after the visit. This step posed a workflow and prioritization challenge for Hugh Taylor, MD, a family physician with Family Medicine Associates (FMA), a 10-physician, three-office practice in Hamilton, Massachusetts, about 30 miles northeast of Boston.
Like SOFM, Taylor's practice adopted its EHR system years before the meaningful use incentive program had been created.
"We just felt paper records were problematic," he says. With three offices, charts were at times in another location, especially if one physician was covering for another doctor. "It was difficult to find the records and the information in the record."
In 2002, FMA chose a vendor that was sold to another company and hadn't been updated in years. So last fall, the practice switched to another vendor, one that guaranteed it would qualify for the meaningful use incentive, if the physicians met their requirements, too. As of April 20, Taylor had not yet attested to meaningful use, but was confident that he would meet the requirements soon.
Transitioning from paper to electronic back in 2002 was easier than switching vendors, Taylor says, because FMA's jump to electronic was gradual. Taylor would see two or three patients using the EHR system per day and then retire the paper record after transferring the historical information. FMA's system update was completed all at once, so after a weekend training session, the physicians went live on the new system.
"In retrospect, I think two or three training sessions would have been better," he says.
The new system cost the practice about $40,000 per doctor, so the meaningful use incentive will pay off that investment, assuming each doctor is successful for all three stages.
"Our reaction to meaningful use was, frankly, it was about time," Taylor says. "We certainly recognized the benefits of the electronic record: helped with cost control, coordination of care, and we felt that it was reasonable on a policy basis that Medicare should support this."
Like SOFM, Taylor's practice will delegate the meaningful use attestation to a part-time member of their administrative staff. FMA doesn't have in-house IT support.
Taylor says generating a visit summary—required for at least 50% of patients—has been one of the more challenging requirements of meaningful use because it requires him and the other doctors to finish their notation before the patient leaves the office. The visit summary must include diagnostic test results (if any), a problem list, medication list, and medication allergy list, according to the CMS final rule.
"It really requires you to stay on top of your note, so you have something to print out," he says. "If you're running behind, the temptation is to put off the notes, but you can't really do that anymore."
The meaningful use e-prescribing requirement (40% of permissible prescriptions must be sent electronically) was also a challenge because it was a new service for FMA and physicians. Although all the pharmacies around FMA's offices area accept e-prescriptions, physicians and clinical support staff needed to be reminded to send them electronically rather than printing them.
SOFTWARE UPDATE SLOWS RACE TO THE FINISH
 G. Ashley Register, MD, (center) says his EHR system made it easier to recruit young doctors to his small town. |
Think your practice is an early adopter of technology? G. Ashley Register, MD, a family physician in Cairo, Georgia, about 40 miles north of Tallahassee, Florida, is probably ahead. Register launched his formerly solo practice, Cairo Medical Care (CMC), with an EHR system in 1992. CMC now has three physicians.
Register's father owned a computer store and his wife was a computer science major in college, so he decided that using computers in his practice "was just the right thing to do," he says. Poor penmanship was also a motivating factor. He graduated from medical school without taking notes because he could never read what he wrote. "I knew from day one that I needed something other than a paper chart," he says. "I'm a role model for what this stuff was invented for."
He switched EHR system vendors in 2007 primarily because the tech support for his first system was on the West Coast and he wasn't able to get help when he needed it, Register says. He was also moved to upgrade his system because his practice was growing, despite being based in a town of only 10,000 residents.
"The only way we were going to be able to recruit new blood and young people was to go ahead and get the practice up to modern speed and ready," he says. "So we did that and then went out and recruited new doctors."
Although he had always had an electronic practice, Register calls the first six months with the new system "pure hell" because the practice maintained its old system at the same time and transferred patients as they came to the office from one system to the other. He called the following six months "warm water, and it's been good after that."
To complete the online attestation for meaningful use, Register's system needed a software update to help him and the other physicians fill in the required numerator and denominator boxes on the CMS Web site for the core measures and other requirements. As of April 18, he had received the update, but still hadn't had time to review the new features.
"The little issues are the ones holding us up for now," Register says. At presstime, he was planning to participate in a Web seminar to sort out what issues were attributable to the EHR system and which ones lay elsewhere.
One of the issues that Register, like Taylor in Massachusetts, has been challenged by is the patient visit summary. Register says he is happy to provide the summary for his patients, but he isn't sure how to integrate it into his workflow.
"It sounds easy and it sounds like something the patients would want," he says. "You're putting all your faith that the check-out person has got nothing else to do but go over the visit summary with the patient and that it's accurate." So far, Register has been satisfied having the check-out employee, usually a medical assistant, deliver the summary.
The workflow issue is especially important to Register's high-volume practice. He estimates he sees 40 patients a day with the new software but was able to see as many as 55 patients a day with his old system.
"Now I see a third less because of the time it takes to enter all the data, and it's so much more physician-driven," he says. "Everybody else's job is quicker and mine is slower."
Despite those complaints, Register says he is more satisfied with the new system because revenue hasn't suffered and he has more data at his fingertips.
"Even though we spent more and are frustrated more, in the end, my billers are able to collect more," he says. CMC's EHR system includes a billing module in its practice management system that links with his government and commercial payers to determine benefits eligibility in real time or by groups of patients, including co-pay and deductible information.
"Those things are cool," he says. "Pulling up a list of medication a patient has been on is cool, tapping into the pharmacy data and seeing what every doctor has given this patient is cool, being able to log in at the hospital is cool. There is not a sheet of paper on my desk. That is cool."
JUST THE BEGINNING
To qualify for stage 1 of meaningful use in 2011, physicians must use data from 90 consecutive days. For stages 2 and 3, physicians will have to report from a year's worth of data to complete the attestation, according to preliminary recommendations to CMS.
The next two stages may require new measures, such as requiring that at least 20% of patients access their record using a Web-based portal at least once. There also could be more demanding requirements, such as boosting the number of patients' demographics recorded as structured data become available for quality of care reports from 50% to 80% of patients.
Physicians who don't demonstrate EHR meaningful use starting in 2015 will see Medicare reimbursements cut by 1% each year until a maximum 5% penalty is assessed.
Some practices may decide to forgo the incentives and take the hit with the Medicare reimbursement penalties. Others, however, such as Southwest Orlando Family Practice, Family Medicine Associates, and Cairo Medical Care, can already see the finish line—and they are already starting to reap the benefits.
"From the beginning, we were not thinking about the financial aspect of it," says SOFP's DeLeon. "With or without the meaningful use, we're going to get our work done the right way."
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