The patient-centered house that technology built

Michael McBride

So you want to be a Patient-Centered Medical Home (PCMH). You're not alone. Many primary care physicians (PCPs) have embarked on the same journey and for good reason. It's been shown that PCMHs can lower the cost of healthcare, increase revenue for both providers and payers, and improve patient outcomes. In addition, the technology requirements to be recognized as a PCMH now closely mirror those needed to prove "meaningful use" of health information technology (HIT) under the new healthcare legislation.

 

Accomplishing meaningful use means securing up to $44,000 in incentive funds from the federal government. It also means aligning your practice with the parameters needed to become recognized as a medical home.

The organizations that created the standards and methods for recognizing PCMHs recently worked with the federal government to align the two agendas. Thus, the technology needed to accomplish meaningful use (e.g., e-prescribing, electronic medical records [EMRs], patient registry, evidence-based diagnostic tools, electronic claims processing) is, for the most part, the same technology needed to become a PCMH. This way, PCPs can simultaneously accomplish both goals without breaking the bank. This makes 2011 the best year to go electronic!

 

Steven Waldren, MD

"The PCMH model aligns PCPs with what they do best. It's the potential future of healthcare," says Steven Waldren, MD, director of the American Academy of Family Physicians' (AAFP's) Center for Health IT. "Dr. Barbara Starfield's pioneering research on cost and quality relative to the penetration of primary care physicians versus the penetration of subspecialists noted that the more primary care physicians you had in a community, the lower the cost and the higher the quality. So, coordination of care—having someone who really understands primary care in a specialty like family medicine—that's a highly skilled position. I think there are opportunities to get the entire team—physicians, mid-levels, nurses, everybody—working in concert. We have a huge workforce shortage in primary care and we need to work together as a team to fill that gap.

"Physicians need to think of it as a journey they're likely already on," Waldren says. "There are many aspects of the medical home that they're doing just by being a good primary care practice. So, it's not 'we have to start all over and dump everything.' It's really—how do you continue to improve and move forward from where you're at today."

RADICAL CHANGES

As a conscientious physician, you've educated yourself on the PCMH initiative. You may have visited the Web sites of the AAFP, the American College of Physicians (ACP), the American Academy of Pediatrics (AAP), and the American Osteopathic Association (AOA). You may have read "Joint Principles of the Patient-Centered Medical Home," the basic tenants of becoming a PCMH, written in 2007 by the four primary care organizations just mentioned. You probably know that PCMHs strive to be:

• service oriented for patients;


• more efficient for better profit;


• more effective for better patient outcomes;


• more fun to work in for staff and physicians.

You have some understanding of the scrutiny your practice will be under during your journey to becoming a PCMH. However, you might not be fully aware of the radical changes that will take place in your practice, nor the extent to which technology will play a role in your becoming a recognized PCMH.

THE TECHNOLOGY OF THE PCMH

HIT plays a major role in the formation and ongoing support of the PCMH. As of 2011, PCPs that wish to be recognized as medical homes must demonstrate the ability to:

• disseminate critical patient data to the entire care team;


• engage patients in their own healthcare by enabling them to communicate directly with care providers through email, and through a Web portal, where patients can schedule appointments with their care team, and securely access, review, and track their medical records over the Internet;


• electronically prescribe medication (e-prescribe); and


• provide electronic support for quality measurement and performance improvement programs to operate.

 

But what does all that mean? And what technology is needed to accomplish it?

 

"You can’t reasonably accomplish Level 3 medical home without having an electronic medical record in place," says John Sawyer, MD.

"Technology is just a tool to be able to implement the transformation that primary care practices have to go through," Waldren says. "There's a set of capabilities that are needed in a practice, and for each one of those capabilities, there are tools—technologies—in place.

"The path for each practice will be a little different depending on where the practice is," Waldren says. "Some practices start with some of the technologies around open-access scheduling and work from there. Some will work on the quality side installing patient registries, and doing the quality improvement. Others start with implementing an electronic medical record. So, it really depends on where you are in your practice.

"But, of the things doctors should think about—having e-prescribing, a patient portal, an electronic medical record system, and a registry type of functionality—these are probably the most important."

Most primary care practices have some combination of these in operation. However, they might not have the full capabilities required by PCMHs.

 

Bruce Bagley, MD

"PCMH is no more profound than 'Extreme Makeover' for primary care, so that the office works more efficiently, so that there's better service for patients, so that there's a better bottom line for physicians, and so that it's a more fun place to work," says Bruce Bagley, MD, the AAFP's Medical Director for Quality Improvement. "It's that simple—improving the organization, function and efficiency of the medical practice."

Bagley admits that PCPs today who are considering become a PCMH might find the process somewhat daunting, due to competing messages, programs, and incentives coming out of the healthcare reform initiatives. However, he says, it's all really "the same work."

"They're all saying that we should have better information technology support for the clinical side of our work," Bagley says. "Registries, EMRs, email with patients, patient portals—they're all whistling the same tune."

PATIENT REGISTRIES FOR CHRONIC ILLNESS CARE

"We really need a team approach to care, where the physician isn't the only one doing all the care," Bagley says. "We need registries for chronic illness care, like diabetes, hypertension, heart disease, chronic obstructive pulmonary disease (COPD), and asthma. There should be registries for each of those in a practice, to ensure that patients get evidence-based guideline treatment on a timely basis."

Bagley believes that PCMHs will be a central piece of the accountable care organization (ACO) model. The legislation, he notes, requires that there be "adequate primary care services" within the ACO. "I like to view the PCMH as one of the components of an ACO," he says. "Like the other components—specialty care, hospital care, imaging, lab, management, and IT—they each must contribute to the overall efficiency of the enterprise in order for it to be successful."

For example, many EMRs currently operating in primary care practices enable physicians to complete the documentation necessary for a PCMH. However, they might not have the patient registry capability to enable the population-management functionality that a PCMH requires.

Primary care practices with EMRs in place that lack patient registries have few options. They can wait until their vendor creates a registry that will install into their EMR, they can use off-the-shelf software that culls patient data from the EMR to create a database from which a registry application would extrapolate the data, or they can install a new electronic health record (EHR) system that has built-in patient registry functionality.

"That's one of the biggest gaps in current EMR technology. So many practices are trying to find ways around that, either by creating advanced spreadsheet applications, or implementing a stand-alone registry application to augment their current EMR," Waldren says.

E-PRESCRIBING

A fair amount of practices are doing some sort of e-prescribing; however, in many instances, the orders are not going electronically to the pharmacy. Instead, the order is processed electronically within the EHR, but then printed out and faxed to the pharmacy. This by itself does not disqualify a practice from being recognized as a medical home. However, going from electronic to paper and then back to electronic—when the pharmacy tech has to enter the order into the pharmacy's information system—increases the possibility for error and decreases the "convenience factor" for the patient.

"In our [AAFP] membership, about 70% of physicians have an electronic health record application in their practice," Waldren says. "But when we looked at the functionality they were using, it's a smaller percentage of those that are doing e-prescribing. It's starting to take off, though.

"The big things that aren't out there relative to the medical home have to do with registry type functionality for population-based management, and patient portal-type functionality to do patient engagement," he says.

It's possible for a PCP to become recognized as PCMH using work-arounds to accomplish the required functionality during level one and level two of the PCMH review process. However, level three is a different matter altogether.

"NCQA recognition doesn't require you to have the technology—it requires you to perform the functions," Waldren says. "You can accomplish level one and level two PCMH, but in level three it becomes exceeding difficult to do without a fully functioning EMR. And to get to a full vision of a PCMH, it's very hard without robust HIT.

"The capabilities [PCPs] should address are 1) patient registries, 2) the ability to do quality measurement and tracking, and 3) e-prescribing and patient engagement," Waldren says. "Those are the big components needed to support meaningful use, which are also key components of the medical home. You can do that inside of a full EMR, or you can do it with lighter-weight technology coming out that's focused on those different types of functionalities. But, those are the key capabilities to think about first.

"This allows the practice to focus on capturing good clinical data that's codified and structured," Waldren says. "That way you can leverage the decision-support tools that are out there, and when you go to do the documentation part of it with the full EMR, you already have a 'problem list' ready to go. You don't have to then go through the process of documenting that stuff. It's already been documented and it just needs to be pushed into the system."

SPEAKING FROM EXPERIENCE

In April of this year, the NCQA recognized Hudson Headwater's Health Network (HHHN) as a Level 3 PCMH—the highest level that can be achieved. The multi-hospital healthcare organization applied and was awarded Level 3 recognition in just one step.

"You can't reasonably accomplish Level 3 medical home with out having an electronic medical record (EMR) in place," says John Sawyer, an MD of Internal Medicine and Medical Director at HHHN. in Queensbury, New York. "So, the implementation of the EMR was a 2-year process that took place prior to our application to become a medical home." HHHN next focused on e-prescribing.

"We realized that electronic prescribing was the minimum we'd need, along with allergy and formulary checking," Sawyer says. "Best practice meant installing computers and Internet access at the point of patient contact in the exam rooms using tablet PCs or other mobile Internet devices. Desktop computers were less desirable, but preferable to putting a computer outside the exam room for the staff to use.

"Carrying computers around instead of paper charts—logging in and out of computers instead of writing everything down—this was a huge adjustment for our staff," he says. "Being able to care for panels of patients or patient populations was also a major change in orientation. You need to orient your practice around patient access for visits, phone calls, and patient portals. Focus on the patient's needs as opposed to the provider's needs. And having an organized lead person in the practice who's not necessarily one of the providers will help get you through the hurdles," Sawyer says.

REVENUE OF THE MEDICAL HOME

 

Martin Serota, MD

"In my opinion, there are two basic reasons why practices have chosen to become a PCMH. One, it's the right thing to do, and two, the potential for payment reform," says Martin Serota, MD, vice president and chief medical officer at AltaMed Health Services in Los Angles, California. AltaMed expects to be accredited by The Joint Commission as a PCMH in July 2011.

According to Serota, The Joint Commission's "approach is more oriented toward large-scale enterprises like AltaMed, than the National Committee for Quality Assurance (NCQA) model, which focuses more on individual physician practices." AltaMed is a large Federally Qualified Health Center (FQHC) operating 40 healthcare sites, with more than 100 physicians, delivering more than 500,000 physician visits per year.

 

Sawyer says that you need to orient your practice around patient access for visits, phone calls, and patient portals. "Focus on the patient’s needs as opposed to the provider’s...."

"Most practices have always wanted to do the right thing, and long ago adopted many of the principles we now bundle under the term PCMH," Serota says. "Unfortunately, our current reimbursement system does not reward, and in fact penalizes, many of these patient-centered behaviors. The PCMH movement is as much a way to collectively negotiate for payment reform as it is a way to drive process improvement."

Nowhere in healthcare is the need for payment reform more keenly felt than in primary care. That's because the current fee-for-service payment environment is making it increasingly more challenging to remain profitable and open for business.

 

Figure 1: Medical Home Recognition Standards

"In a fee-for-service-world, primary care physicians get paid for office visits," Bagley says. "The problem is that most payment plans don't take into account the different business models for a primary care practice versus, say, a neurosurgeon. Unlike the latter, PCPs make all their money in the office. Since [payers] have traditionally treated payments the same to control costs, primary care has gotten strangled to death over the last 10 years, because there's no margin in it." Patient self-management is a big component of the PCMH model. Through the practice's Web portal, patients can interact directly with their care team. This "non-visit"-based care (e.g., motivation interviewing, shared goal setting, home monitoring, and contact between visits) is not reimbursable under the current fee-for-service payment system.

In response, health plans are developing new methods to reimburse PCMH physicians for services rendered, as well as for gathering and reporting data on performance improvement measures. Such healthcare activities would be paid for by a "care management fee." This is a fee that health plans pay to PCMHs on a "per patient per month" basis. It could be as little as a few dollars per patient per month, but cumulatively, for a practice with hundreds or thousands of patients, it would be significant. Potentially, a PCP's revenue could increase dramatically, while the quality of their care improves as well.

"If a practice got three, four, or five dollars per month for every single patient in the practice, then that ends up being a lot of money," Bagley says. "Depending on the market conditions, there should be some enhanced reimbursement that can come in a number of different forms. It can be 'enhanced fee for service,' it can be a 'care management fee,' or it could be 'performance bonus incentives for quality measures.' We think there has to be a blended payment model where [the revenue] comes from all of these."

"The people that are going to be successful, whether they're primary care or hospital folks, or specialty care or imaging doctors, are the ones that are going to be the most adaptable as the system changes," Bagley says. "They're going to have to be able to respond to the changing payment incentives. So, if it means extra money for reporting quality measures, you better have a system in place to help you collect those efficiently and send them in, which is one of the meaningful use criteria."

PREPARING FOR PCMH-DRIVEN HEALTHCARE

Fortunately, the federal government and state governments now agree that medical homes can dramatically improve our healthcare system. Forty states have passed more than 330 laws in support of PCMHs, and the federal government now provides incentive funds to offset the cost of implementing the technology necessary to become a PCMH. At last count, 2,314 practices are recognized by the NCQA as PCMHs. Along with the move toward ACOs, PCMHs bring primary care back to the center of healthcare.

"In 30 years of watching this, I've never seen so many people talking about the central importance of primary care to a viable healthcare system, not only for accessibility, but for overall cost savings," Bagley says. "So, when you hear the politicians, the health plans, and physicians of all stripes all acknowledging that primary care has to be the central focus of the healthcare system, it's very different from what we've heard in the past."

"All these practice changes can't be done overnight. It takes time," he says. "Especially when you're trying to keep everything pumping the way it is now in the current payment environment. There's not a lot of time and energy to make all these changes, so you have to do it a little more slowly."

Nevertheless, Bagley encourages PCPs to make the changes sooner rather than later. "If somebody clicks a switch a year from now and virtually all payments rely on having these capabilities—and you haven't done anything—you're going to be scrambling," Bagley says. "In level one, it's possible for a practice to do a fair amount without advanced technology," Waldren says. "So, the first step is to ask if there's the possibility for a 'differential payment' in your area for the medical home, and if so, what's required. I would focus there first. Then, you'll know if there are things you can do that will increase your revenue for just being a medical home.

"After that, I would think about the needs of your practice and your patients relative to the different pieces of the medical home, to decide how to focus your efforts for the next step," he says. "Doing 'meaningful use' makes a lot of sense because you get $44,000 [in Medicare incentives]," Waldren says, "and you're required to do e-prescribing, quality measurements, and some of the patient portal stuff, so you're already on your way toward achieving the medical home by getting those functionalities into your practice."

A BRIEF HISTORY OF THE PATIENT-CENTERED MEDICAL HOME

The medical home model first got its start in pediatrics in the late 1960s. The ability to track the healthcare of special needs children became an important aspect of those practices, and the government provided pediatricians with federal funding to assist in the implementation of the technology they needed.

For decades, those medical home capabilities (e.g., care coordination, extra help for the families, etc.) stayed within pediatrics. Then, in this decade, four large primary care organizations—the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the American Academy of Pediatrics (AAP), and the American Osteopathic Association (AOA)— along with the National Committee for Quality Assurance (NCQA) recognized that medical home type functionality enables primary care physicians (PCPs) to once again take the lead in healthcare, and fulfills the federal government's drive to lower costs and improve care for patients. They developed the Physician Practice Connections® – Patient-Centered Medical Home™ (PPC-PCMH) standards, through which primary care practices can become recognized as medical homes.

 

THE IMPORTANCE OF A PATIENT REGISTRY


A patient registry, also known as a practice-based registry, is an information management tool that enables physicians to manage a population of patients who share specific chronic diseases. The registry underlies the evidence-based functionality of an electronic medical record (EMR).

The patient registry "guides" physicians to gather the data they need on each patient, performs analytics on that data, suggests courses of evidence-based treatment, monitors the outcome of lab tests, and reports any missing test results, all of which enables physicians to better track and manage the care of chronically ill patients.

For example, a diabetes registry enables physicians to identify and list those patients in the practice who have diabetes, the type and the severity. It would stipulate that annual foot and eye exams are required, as well as hemoglobin A_1c (HbA_1c) tests every 6 months, and that current blood pressure reading is needed if one is not already in the database.

It then can suggest proactive ways to reach out to these patients. Not only can it point out which patients have been prescribed an exam by the doctor, but also whose results are not present in the registry, indicating patients might not have followed through with their exam, or for whom the laboratory performed a test other than that which the doctor ordered. This is population-based management.

Patient registries operate best when part of an electronic health record (EHR) system. However, practices with EMRs that lack patient registries can implement population-based management using off-the-shelf spreadsheet and database programs (e.g., Microsoft Excel and Microsoft Access). This solution is not ideal, and could hinder a practice's ability to prove meaningful use. However, it can fulfill the "functionally" requirement for being recognized as a medical home.

GAINING NCQA MEDICAL HOME RECOGNITION

"I think it really is a set of steps because it's a journey," says Steven Waldren, MD, director of the American Academy of Family Physicians (AAFP) Center for Health IT. "It's not a big-bang. You don't close your practice on Friday, do the transformation, and on Monday you're a medical home. It's really a set of milestones, as you implement the different functionalities sets of the medical home."

NINE SPECIFIC FUNCTIONALITIES

There are nine specific "functionalities" a practice must demonstrate in order to become recognized by the National Committee for Quality Assurance (NCQA) as a Patient-Centered Medical Home, much of which is provided through electronic health record (EHR) functionality (list taken from the NCQA Web site):

1. access and communication;

2. patient tracking and registry functions;

3. care management;

4. patient self-management and support;

5. electronic prescribing;

6. test tracking;

7. referral tracking;

8. performance reporting and improvement;

9. advanced electronic communication.

 

ADDITIONAL INFORMATION ON THE WEB

These sites provide the details and steps primary care physicians need to take to become Patient-Centered Medical Homes (PCMHs):

http://www.ncqa.org National Committee for Quality Assurance

http://www.pcpcc.net/ Patient-Centered Primary Care Collaborative

http://www.aafp.org/pcmh American Academy of Family Physicians

http://www.transformed.com/ TransforMed, a subsidiary of the AAFP

To learn more about state and federal government support for and regulations of PCMHs:

http://www.pcpcc.net/federal-and-state-government

http://www.pcmh.ahrq.gov U.S. Department of Health and Human Services PCMH Resource Center

http://www.jointcommission.org/accreditation/pchi.aspx The Joint Commission

This article was originally posted at http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=731288&sk=&date=&pageID=5

 

 

 

 

 

What you can learn from three practices poised to achieve meaningful use

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."

Send your feedback to medec@advanstar.com

This article was originally posted at http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=722647&sk=&date=&pageID=4

 

 

Despite incentives, cost is a barrier to small provider EHR use

The cost, physician practice size, and lack of technical resources still present barriers for small healthcare providers in adopting electronic health records and participating in the meaningful use incentive program.

Solo practitioners and small practices find it difficult to locate a lender willing to offer them an unsecured loan, said Dr. Sasha Kramer, a solo practitioner dermatologist in Olympia, Wash. Others who try to finance their electronic health record (EHR) system with the vendor have no leverage in negotiating terms because of their limited market share.

Kramer was among public and private health IT experts and physicians who spoke at a June 2 hearing of the House Small Business Committee’s health care and technology subcommittee.

Two years ago, Kramer purchased and deployed an EHR system that cost more than $41,000. It took four weeks to learn and integrate. Although quick by many standards, it reduced the number of patients she saw by 75 percent, from 4 per hour to 1 per hour, and slashed her revenues, she explained.

[Editor's Desk: This Week in Government Health IT.]

Two years later, she has to replace that EHR because her vendor was acquired and no longer supports her system. “I have to invest $30,000 in a new system and take time again from my patients to learn it,” she said.

“Despite these factors, I fully support the infusion of health IT into physician practices. It is a critical component in improving the healthcare delivery system and, more importantly, providing optimal patient safety and care,” Kramer said.

For instance, she has each patient’s chart and information for each visit and can track drug interactions and medication refills and past medical history. “It is much easier to communicate with other providers, and I am able to operate more efficiently with less employee time spent pulling and organizing charts,” she said.

Dr. Farzad Mostashari, national coordinator for health IT, is familiar with the difficulties of solo physicians and small practices acquiring and deploying health IT. Before coming to the Office of the National Coordinator for Health IT (ONC) in 2009, he led the New York Primary Care Information Project where in three of the city’s most underserved communities in one year’s time more than 1,000 providers went live with EHR systems.

ONC has funded 62 regional health IT extension centers nationwide that are now assisting more than 70,000 mostly primary physicians with EHR purchase, implementation, project management and other technical challenges of establishing and becoming meaningful users of certified EHRs. ONC also lists more than 700 certified EHR products on its website.

“I make no bones about the transformation of workflows and processes and the difficulties that many practices, especially smaller practices, will face as they make this difficult transition. But it is a rewarding process and ultimately will not only lead to improved patient care and coordinated care but will help those practices succeed financially over the long run,” Mostashari said.

Kramer urged Congress to provide sufficient financial resources so solo physicians can establish health IT and to consider delaying the penalties that take effect in several years for those who do not become meaningful users until such time that a functional integrated EHR system is widely available. She also said that some physicians should be exempted from financial penalties so that they are not pushed into early retirement, which could further exacerbate the physician shortage.

[Interview: CMS' Jessica Kahn on early EHR, HIE lessons learned.]

Andrew Slavitt, CEO of OptumInsight, a health IT services company, said that the temporary financial incentives will not be enough to compensate for provider productivity losses. Meaningful use is just a starting point for private sector innovation revving up.

Capabilities that enhance provider productivity are not driving the purchase and design of EHR technology.
“New product development is focused on satisfying the regulatory hurdles of the payer, CMS, rather than simple innovations that improve productivity,” Slavitt said.

Slavitt suggested that federal policymakers align the requirements that physicians are subject to among multiple programs. He also urged continued federal investment in health information exchanges and the extension centers, which have proven to be a strong tool to provide expertise for small practices. The Small Business Administration should also supply business loans to small providers.

This article was originally posted at http://ping.fm/Vbxw8

 

Mobile health apps momentum begets momentum

Smartphone health applications made great strides this week. The highest-profile of those, perhaps, is the contest-winning multi-lingual EMR app from Polyglot – but that’s not the only one of note.

Take the Withings blood pressure cuff for the iPhone, for instance. This nifty device even garnered FDA approval just this week. The cuff plugs into an iPhone, in which an application measures and records blood pressure, then sends that data to either directly to a doctor or to a program such as Google Health or Microsoft HealthVault.

[Q&A: ONC's Mostashari on the innovation electronic data will spark.]

While the FDA has hinted it will be approving more mobile applications, particularly those of a clinical nature, mobile health apps continue to emerge at a feverish pace. Also in the spotlight this week: Ginger.io, an Android app that taps mobile phone data – including location, who a user calls, and when – to predict common colds, depression, even the flu.

As for Polyglot’s Meducation app, which won the ONC-funded SMART (Substitutable Medical Applications, Reusable Technologies) Platform Apps Challenge, the software provides medication instructions in more than a dozen languages.

Developer challenges and contests for health apps are becoming more common. ONC earlier this month funded another developer challenge, the Investing in Innovations (i2) Initaitive, to catalyze health IT innovation.

Federal agencies, such as the DoD’s T2 program, are also releasing mobile health apps, most recently software to help veterans manage PTSD, or post-traumatic stress disorder.

Cool factor aside, mobile health apps hold the potential to put health data into patients' hands in a way never before seen and, in so doing, ultimately bolster population health.

But there's a hitch: People still have to use them and adjust behavior accordingly.

This article was originally posted at http://ping.fm/U0VCo

Thomson Reuters names top 10 U.S. health systems

Ten U.S. health systems have been identified by Thomson Reuters as performing at the top when it comes to quality of care, efficiency and patient satisfaction - metrics that are boosted with the use of information technology.

Thomson Reuters released its third annual study Wednesday identifying the 10 top:

1. Advocate Health Care*  ― Oak Brook, IL


2. Cape Cod Healthcare ― Hyannis, MA


3. CareGroup Healthcare System ― Boston, MA


4. Kettering Health Network* ― Dayton, OH


5. Maury Regional Healthcare System ― Columbia, TN


6. Mayo Foundation**  ― Rochester, MN


7. NorthShore University HealthSystem ― Evanston, IL


8. OhioHealth* ― Columbus, OH


9. Partners Healthcare ― Boston, MA


10. Spectrum Health** ― Grand Rapids, MI

*Denotes three-time winner
 **Denotes two-time winner

Compared with their peers, the Thomson Reuters 10 Top Health Systems saved more lives, caused fewer medical complications, made fewer medical errors, followed recommended standards of care more closely, released patients half a day sooner on average, and scored better on patient satisfaction surveys.

"This year, the 10 Top Health Systems set a new standard for high quality of care across all of the communities they serve," said Jean Chenoweth, senior vice president for performance improvement and 100 Top Hospitals programs at Thomson Reuters.

"To produce consistent, strong performance across multiple hospitals, health system leaders must be providing crystal clear goals and communication as well as the means for staff to execute effectively," Chenoweth said. "These systems are positioned to continue performing well as we move further into the era of healthcare reform."

These 10 health systems rose to the top when researchers from the Thomson Reuters 100 Top Hospitals program analyzed the performance of 285 health systems based on eight metrics:

• In-hospital mortality


• Medical complications


• Patient safety


• Average length of stay


• 30-day mortality rate (post-discharge)


• 30-day readmission rate (post discharge)


• Adherence to clinical standards of care (evidence-based core measures published by the Centers for Medicare and Medicaid Services


• Hospital Consumer Assessment of Healthcare Providers and Systems patient survey score (part of a national initiative sponsored by the U.S. Department of Health and Human Services to measure the quality of care in hospitals).

The study evaluated U.S. health systems with two or more short-term, acute care, non-federal hospitals that treat a broad spectrum of patients. Researchers used public data from the Medicare Provider Analysis and Review (MedPAR) dataset and the CMS Hospital Compare datasets.

The Thomson Reuters 100 Top Hospitals program has analyzed and reported on the performance of hospitals since 1993. For more information, visit www.100tophospitals.com.

 

 

No New Health-Law Waivers to Be Given

The Obama administration on Friday said it would stop granting new waivers to the health-care overhaul in September following sharp opposition from Republicans who cited the waivers in their bid to undermine the law.

As of the end of May, the administration had granted 1,433 waivers to a part of the 2010 law that prevents employers and other health-plan providers from capping annual benefit payouts below $750,000 a year. Those entities, and any others that secure a waiver by Sept. 22, will be able to keep their one-year waivers, and apply for extensions through 2013.

But the Department of Health and Human Services said it would stop accepting new applications for the program after Sept. 22. The waivers largely went to low-wage employers who offer "mini-med" plans with limited benefits, including McDonald's Corp. and the Foot Locker Inc. athletic chain.

By cutting off applications, the administration will avoid the bursts of attention each time it granted a new batch. Opponents of the law contended that the administration had shown favoritism in granting the waivers, prompting federal health officials to disclose the names of recipients and the application process for granting them.

Steve Larsen, a Health and Human Services official responsible for insurance oversight, said the department is cutting off new applications because "the vast majority of plans that would need a waiver…are the ones that would have applied and did apply this year." He said waivers were granted to plans covering about 2% of privately insured Americans.

Critics of the health-care overhaul seized on the administration's move as a sign that the law is flawed. "They are shutting it down because it's become clear that the only way to keep what you have and like is to be exempted from the very law they said would lower costs," Sen. Orrin Hatch (R., Utah) and House Ways and Means Committee Chairman Dave Camp (R., Mich.) said in a joint statement.



A Government Accountability Office report this past week found that the administration mostly granted waivers for those who said they would have to raise premiums by more than 10% and cut benefits if they didn't get a waiver. It largely denied applications that projected a premium increase of 6% or less.

The Obama administration described the waivers as a bridge until 2014, when new health-insurance exchanges are expected to largely eliminate such limited-benefit plans and give consumers a chance to shop for better coverage. In the meantime, health plans with waivers must tell consumers their coverage is subject to an annual dollar limit lower than usually allowed under the law, according to new disclosure requirements the administration released Friday.

Beginning in September, that allowable annual limit increases to $1.25 million. For plan years beginning September 2012, it rises to $2 million.

This article was originally posted at http://online.wsj.com/article/SB10001424052702303635604576392200148966610.html

5 Strategies to Combat Health Reform Pressures

Health plan executives say their three major challenges are figuring out how to deal with healthcare reform, the health insurance industry's systemic shift from wholesale to retail business and bending the cost curve.

Resolving the challenges will require health plans to shift their focus from group to individual sales, identify and test new behavior predictors and shorten the timeline of product development.

The findings were part of a session about predicting and managing change presented at the annual conference for America's Health Insurance Plans. The session was based on a study developed from interviews with 40 senior healthcare executives by SAS, a Cary, N.C.-based business analytics firm, and Chicago-based Stonegate Advisors, a healthcare research and analytics company.

"Health plans are facing a fundamental change in how they do business," explained Sarah Rittman, a senior industry consultant for SAS. "Accurately predicting market shifts will be imperative for developing go-to-market strategies."

The study, Tackling U.S. Health Plan Challenges with Advanced Analytics, presents these strategies for health plans:

1. Predict market changes in new and creative ways

Today's healthcare market depends on traditional actuarial and underwriting principles to predict risk. But the post-reform market will require health plans to combine third party data – like credit information, social media and purchase data ? with claims data to help understand potential market shifts.

2. Get to know your customers as unique individuals

Reform is expected to bring a flood of individuals into the health insurance market. Member-centric product and service strategies haven't been a focus but now "health plans will need to understand what individuals like and what they want," says Rittman. That includes learning their price and product sensitivity and how they like to communicate and how often. "It will take years for the healthcare industry to figure out how to influence consumers.

3. Do retail like pros

Healthcare needs to learn from other industries – like banking, telecommunications and airlines – that have been through a similar process. "These industries re-invented themselves," explains Marc Pierce, president and founder of Stonegate Advisors. He said that to succeed health plans will need to shorten their product development cycle, add service and loyalty programs, and develop sophisticated pricing strategies.

4. Manage the cost of care

In post healthcare reform managing expenses at a plan member level will be critical to keeping premiums affordable and maintaining the required MLR of 80% to 85%. Plans will need to develop analytics to monitor services, treatment patterns and cost trends to identify medical expense concerns. "Health plans will need to know what customers they can impact and how. They'll need a way to identify those members who are on the edge in terms of willingness to change a behavior and then develop a program that will influence them," says Pierce.

5. Collaborate more effectively with providers

Controlling healthcare will require that health plans work with their providers to develop payer/provider models to see what works based on financial viability and sustainability, including pay for performance, patient centered medical home, an integrated care system and an accountable care organization. Collaboration should include the ability to share clinical, claims and pharmaceutical data to track and analyze outcomes. "This is very valuable information for both the payer and the provider," says Rittman.

This article was originally posted at http://www.healthleadersmedia.com/page-2/TEC-267558/5-Strategies-to-Combat-Health-Reform-Pressures

 

 

A necessary dose of e-prescribing flexibility

Physicians understand the potential of health information technology to help improve patient care, and doctors are willing to work with the federal government through incentive programs designed to encourage more practices to go paperless. But the government went too far when designing the punitive side of some of these incentives, tying penalties to burdensome, unfair and even unrealistic mandates on many of the practices that are trying to work toward the same goals.

That's why the Centers for Medicare & Medicaid Services made the right move in adjusting its Medicare electronic prescribing incentive program to correct several key shortfalls in the original plan. The program offers a 1% bonus next year to eligible practices that e-prescribe a minimum number of times in 2011, but it also will impose a 1% penalty on those that don't. Under a new proposed rule released in late May, CMS outlined a number of revisions to the details of this plan that members of organized medicine, including the American Medical Association, had insisted were sorely needed.

The changes, which are set to be finalized this summer, provide a measure of relief to physician practices that were worried about being subject to Medicare e-prescribing penalties even though they are actually early technology adopters.

Because CMS did not align the requirements for its e-prescribing program with those for its separate electronic medical records meaningful use program, some practices had to contemplate installing a stand-alone paperless drug order system -- on top of the EMR they already had -- just to be compliant. Some practices took this duplicative step earlier in the year just to be sure.

With its latest changes, the Medicare agency has confirmed that practices that already have certified EMRs can use those systems to meet the e-prescribing mandate as well. CMS recognized that in most cases, approved EMRs have the same level of functionality when it comes to sending paperless drug orders as the systems called for by the e-prescribing program.

In future reporting years, physicians who use certified EMRs will know for sure that their systems will be acceptable to the government when it comes to e-prescribing.

Better aligning the requirements of the e-prescribing and EMR programs was only one of the revisions that CMS needed to make. Many other physicians were facing Medicare penalties for practice circumstances that truly were out of their hands.

CMS initially only proposed exemptions to the e-prescribing requirements for rural physicians with limited Internet access and those living in areas where pharmacies don't accept paperless medication orders. That left too many other physicians who still would have faced a 1% penalty in 2012 simply because they had limited opportunities to prescribe electronically. Now CMS also will offer exemptions to doctors who don't prescribe enough drugs in the first place, who are barred by law from issuing enough electronic drug orders (such as under prohibitions on e-prescribing of controlled substances), or who prescribe drugs only during patient encounters that don't count under the program (such as many surgeons). Practices also will be able to avoid the penalty if they did not e-prescribe by the June deadline because they were planning instead to adopt and use EMRs in 2011 to qualify for meaningful use bonuses.

When the proposed changes are finalized, physicians not meeting the e-prescribing requirements will have until Oct. 1 to apply for one of these waivers. The agency predicts that more than 200,000 doctors and health professionals might be eligible to claim a hardship. By expanding the exemption list and the deadline to file, CMS is acknowledging that many practices will not meet the minimum this year not because they don't want to, but because they can't.

When it comes to providing needed regulatory relief to doctors, the Obama administration shouldn't stop with the changes it already has proposed. Medicare and Medicaid have a whole host of burdensome, redundant or unnecessary rules for physicians, including certain regulations pertaining to translators, claims audits, documentation and enrollment.

Now that CMS has shown it can be flexible on the e-prescribing requirements, it needs to devote its attention to these rules.

This article was originally posted at http://www.ama-assn.org/amednews/2011/06/13/edsa0613.htm

 

 

CMS to align e-Rx incentive with EHR program

The Centers for Medicare and Medicaid Services (CMS) plans to modify its electronic prescribing incentives schedule to better align with its electronic health record incentive program so physicians can both avoid e-prescribing penalties and also participate in CMS’ EHR Incentive Program.

E-prescribing is  a requirement for meaningful use of electronic health records (EHRs) to qualify for incentives.

CMS released the proposed rule on May 27 and it will be published in the June 1 Federal Register. The public will be able to comment for 60 days.

In 2009, CMS started the E-prescribing (eRx) Incentive Program. To qualify for eRx incentives this year, providers must e-prescribe 10 orders between Jan. 1 and June 30, 2011.

Medicare providers cannot earn an incentive under both incentive programs for the same year. However, providers will be subject to an e-prescribing payment adjustment if they do not meet the requirements under the eRx Incentive Program, regardless of whether the eligible provider participates in and earns an incentive under EHR incentive program.

[Q&A: PwC's Bruce Henderson on why the proposed ACO regs are so "onerous and grinding."]

“Stakeholders claim that the requirements under both programs are administratively confusing, cumbersome, and unnecessarily duplicative,” the proposed rule said.

The proposed rule will expand the exemptions and the time to report them so providers can avoid the payment penalties. Exemptions will include putting off deploying an e-prescribing system because they are participating in the EHR incentive program. The rule would also revise the description of qualified e-prescribing systems to include certified EHR technology under meaningful use.

Among the requirements, e-prescribing systems must be able to generate and transmit prescriptions and active medication list; check for drug-drug interactions; and check whether drugs are in a health plan’s formulary or preferred drug list.

The American Medical Association welcomed the flexibility of the proposed rule and the elimination of unreasonable penalties. “Physicians who are working to adopt e-prescribing and other health IT should not be unfairly penalized for practice patterns that do not fit neatly within the current, limited exemption process,” said Dr. Cecil Wilson, AMA president, in a statement..

In February, the Government Accountability Office had said that CMS should reconcile the inconsistencies between the two programs.

The EHR program provides incentives from 2011 to 2016 and introduces penalties beginning in 2015, while the e-prescribing program provides incentives from 2009 to 2013 and provides for penalties from 2012 to 2014, when the program ends. Both programs require providers to adopt and use technology that can perform similar electronic prescribing-related activities.

[Related: VA, DOD test joint EHR interface in Hawaii. See also: HHS proposed rule on disclosure highlights access reports.]

The EHR program requires providers to adopt and use EHR systems that are certified to meet criteria which include electronic prescribing-related capabilities, while the e-prescribing program does not have a certification requirement.]

According to the e-prescribing program, a physician or group practice in 2011 can qualify for an incentive equal to 1 percent of its total estimated Medicare Part B physician fee schedule allowed charges for covered professional services.

In 2012, a payment adjustment will begin for those who do not e-prescribe and increase each year through 2014. Specifically, those physicians will receive 99 percent of the fee in 2012, 98.5 percent in 2013 and 98 percent in 2014.

This article was originally posted at http://ping.fm/kzxqb

 

Medicare to offer more waivers from e-prescribing penalty

[caption id="" align="alignnone" width="468" caption="New revisions to Medicare e-prescribing incentives are part of a larger administration effort to identify burdensome federal regulations. A review by the White House Office of Management and Budget, led by Director Jack Lew, has uncovered some rules that appear redundant. [Photo by AP / Wide World Photos"]"][/caption]

Physicians who see Medicare patients would have more opportunities to avoid being penalized for failing to prescribe medications electronically by a June 30 deadline under a proposed rule from the Centers for Medicare & Medicaid Services.

The proposed revisions would provide relief to eligible physicians who do not expect to report at least 10 paperless drug orders to CMS by June 30. Medicare will penalize doctors for failing to meet 2011 e-prescribing requirements by reducing payments by 1% in 2012. On May 26, the Medicare agency said it would give doctors a second chance to avoid the penalty after the deadline. It would allow physicians who did not meet the minimum reporting requirements to claim one of several hardship exemptions through a special website by Oct. 1.

The proposed rule also would apply to physician practices that already have adopted certified electronic medical record systems in an effort to earn Medicare or Medicaid meaningful use bonuses. Those practices could use those systems to satisfy the e-prescribing requirements as well. Under the current program, practices that use certified EMRs to send paperless drug orders will satisfy the e-prescribing requirement as long as the system meets four specific functionalities. If the proposed rule is finalized later this year, certified EMRs will be acceptable for e-prescribing in future reporting years even if they don't technically meet the four specific functionalities.

In addition to the expanded hardship exemptions, the revised language on the certified EMRs was a change requested by members of organized medicine, including the American Medical Association. Physicians complained that because the requirements for the e-prescribing incentive program and the EMR meaningful use incentive program were different, some paperless practices were concerned that they would need to buy and use a stand-alone e-prescribing system to avoid the 1% reduction in 2012.

"Eliminating unreasonable penalties and burdensome requirements, and providing physicians with more flexibility through an exemption process, will help ensure more physicians are able to successfully participate in the e-prescribing incentive program," said AMA President Cecil B. Wilson, MD. "The AMA has continually stressed to CMS that these changes were essential and is pleased to see them become a reality in a rule that will be finalized later this summer."

The Medical Group Management Assn. also was pleased with the proposed rule. However, some practices already had taken special steps earlier this year just to avoid the penalty -- actions that now have become unnecessary, said Anders Gilberg, MGMA's vice president of public and private economic affairs.

Some groups used temporary e-prescribing software, independent of their EMRs, and discarded the systems after reporting the minimum 10 e-prescribing encounters per physician. Others, such as some surgery practices, struggled to find ways to prescribe medications during office visits just so they would not be penalized in 2012.

"It's unfortunate it took until almost June for the proposed rule to come out," Gilberg said.

Expanded hardship exemptions

Approximately 109,000 to 209,000 physicians and other health care professionals could be eligible to file for hardship exemptions to the e-prescribing penalty by Oct. 1, CMS said in the proposed rule. The Medicare agency has proposed developing a special website for doctors and others to claim one of several hardships. CMS would approve the claims on a case-by-case basis, said Michael Rapp, MD, director of the CMS Quality Measurement and Health Assessment Group.

The initial rules had provided only two hardship exemption categories -- for physicians who practiced in rural areas with limited high-speed Internet access or for those who worked in areas with a limited number of pharmacies that accept electronic drug orders. CMS had required one of these exemptions to be reported before June 30.

The proposed rule would allow doctors to choose from these two hardships as well as four new exemptions on the website by the October deadline. The site would go live sometime after the rule is finalized in August, Dr. Rapp said.

The expanded list of hardship exemptions would include:

• Physicians who register to participate in the Medicare or Medicaid EMR incentive program, and adopt and use certified EMR technology by the 2011 deadline.


• Physicians who cannot prescribe enough drug orders electronically due to local, state or federal laws, such as those prohibiting paperless orders for narcotics.


• Physicians with limited prescribing activity.


• Physicians with insufficient opportunities to report the e-prescribing measures because the types of patient visits they claim are not eligible under the program.

"There will be an opportunity for physicians to indicate that they feel that they fit, and are requesting to be classified, in one of these hardship categories," Dr. Rapp said. "Then those individuals would be taken off the list to be 'subject to the negative payment adjustment.' "

Those who report that they e-prescribed 10 times before June 30 automatically would not be subject to the 2012 penalty, Dr. Rapp added. Of that subset, those physicians who report 25 e-prescribing encounters by Dec. 31 would receive a 1% bonus in 2012, assuming they do not opt instead for a Medicare bonus for meaningful EMR use in 2011.

More regulatory relief on the way?

The softening of the e-prescribing requirements is part of the Obama administration's initiative to provide regulatory relief across the federal government. Dept. of Health and Human Services officials are considering revising several of its regulations over the next two years. CMS also will identify and address conflicting requirements between the Medicare and Medicaid programs.

An initial review of the rules has determined that some regulations appear to be redundant and unhelpful, said Jack Lew, director of the White House Office of Management and Budget.

"It will be asked if some of these actually benefit patients or are they a matter of bureaucratic, anachronistic rules," Lew said.

The Medicare agency already has gathered input on revising potentially burdensome rules identified by the AMA and other members of organized medicine. They include:

• Requirements to provide translators for Medicare and Medicaid patients with hearing impairments or limited English proficiency.


• Misaligned incentive programs, such as EMR meaningful use and the physician quality reporting system.


• Overlapping claims reviews by auditors, such as Medicare administrative contractors and recovery audit contractors.


• Various Medicare documentation requirements.


• The prohibition on the use of Medicare consultation codes.


• Burdensome Medicare enrollment requirements.

This article was originally posted at http://www.ama-assn.org/amednews/2011/06/06/gvl10606.htm

 

HHS Releases NPRM Altering HIPAA Accounting Rule

the Department of Health and Human Services (HHS) released for public review a Notice of Proposed Rulemaking (NPRM) about the accounting provisions of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.  An advance copy of this NPRM is here.  The Federal Register publication of the rule is available here. There will be a 60-day comment period from the time of publication.

This proposed rule implements a statutory provision from the Health Information Technology for Economic and Clinical Health (HITECH) law.  It dramatically alters the current HIPAA accounting rule, with substantially increased burdens for covered entities and business associates.  For example, it requires a much broader set of disclosures to be tracked by covered entities and business associates.  More significantly, it also creates-based on HHS' general authority under HIPAA rather than the HITECH law-a new obligation for covered entities and business associates to track internal "access" to protected health information in a designated record set.

Over the next few weeks, companies in the health care industry-including all covered entities and their business associates-should evaluate these proposals carefully and should determine promptly whether they wish to comment on this proposed rule.

This article was originally posted at http://ping.fm/IybCT

 

Mass. extension center enrolls 2,500 providers to deploy EHRs

The Massachusetts Regional Extension Center has signed up more than 2,500 primary care providers to assist them in becoming meaningful users of health IT, making it the leader of the nation’s 62 centers in meeting its recruitment goal one year into the program.

After enrolling physicians, the next milestone will be for the extension centers to help physicians go live with certified electronic health records (EHRs) with electronic prescribing and quality reporting capabilities, according to a May 25 announcement from the Office of the National Coordinator for Health IT.

The health IT experience and skills of the extension center staff were crucial to reaching its goal so quickly, said Bethany Gilboard, director of health technologies for the Massachusetts eHealth Institute, which become the extension center in April 2010.

“We have three clinical relationship managers who are exceptional in working with the small physician practice,” she said.

The extension center program established by ONC is charged with helping 100,000 providers to overcome the hurdles of deploying certified EHRs and becoming meaningful users by 2012 to 2014.

Each extension center sets its own goal based on the number of providers that fit the description of a priority primary care provider. The Massachusetts center members include 45 percent of providers in small practices, 29 percent from community health centers, 16 percent from small practice consortia, and 10 percent from public hospitals.

The center has organized a roadmap that lays out the steps and expectations of physicians, consultants, and vendors to achieve meaningful use. If followed, the center guarantees that providers will qualify as meaningful users to be eligible for Medicare and Medicaid incentive payments from the Centers for Medicare and Medicaid Services, Gilboard said.

“We take a lot of the guesswork out for the small provider who has no one to turn to,” she said.
Provider members also have access to a special member portal of the extension center website where physicians can ask questions of their colleagues and learn from each other.

The Massachusetts center also systematically canvassed the state with emphasis on community hospitals with less capital resources to support their physicians in the transition to EHRs.

Staff contacted CIOs at all 72 hospitals in the state and found out if they had a strategy for establishing EHRs. They asked about the number of employed and independent primary care providers associated with the hospital. For those hospitals with a physician hospital organization or an independent practice association, the center offered a wholesale approach to membership for all primary care physicians. Alternatively, they supplied a draft letter that explained the benefits of the extension center and encouraged individual physicians to join.

Center staff also met with providers around the state at hospitals or medical society meetings through 25 educational summits and presentations. Once physicians enroll in the center, they’re invited to local meetings to share stories and hear about the experiences of local physicians who have already migrated to EHRs, known as meaningful use vanguards or MUVers.

This article was originally posted at http://ping.fm/45FMd

 

 

Patients more comfortable with doctors who use EHRs

Good news if you use an electronic health record (EHR) system—and a tip on how best to use it, courtesy of the Sage Healthcare Insights survey: Patients feel more comfortable with physicians who use an EHR system, and they believe that the information contained in the medical record is more accurate when they physically see the information being entered electronically.

The Sage Healthcare Division of software firm Sage North America conducted the survey among patients and physicians to determine attitudes regarding EHR adoption. “What we learned is patients like to see their verbatim information entered into the record as they said it, not as the doctor interpreted it,” says Betty Otter-Nickerson, president of the Sage Healthcare Division.

Other findings:

• About 42% physicians use an EHR system to document patient care, and about one-third use an EHR during patient encounters.


• 62% of physicians and 81% of patients have positive perceptions of documenting patient care electronically.


• 45% of patients had a “very positive” perception of their physicians or clinicians documenting patient care with a computer or other electronic device.


• More than 60% of physicians believe that the best benefit to using EHR is the access they have to patient records in real time.


• Physicians also believe that the ability to seamlessly share information with other doctors, pharmacies, and payers are among the most important benefits.


• The majority of survey respondents agreed with the statement that EHR systems will help improve the quality of healthcare (78% of patients, 62% of physicians).


• Although both physicians and patients believe that EHRs will help improve the quality of healthcare, both groups have concerns about privacy and the security of EHRs (81% of patients, 62% of physicians).


• Given their use of and exposure to the security measures used to keep electronic medical records secure, physicians using EHRs have fewer concerns about the security of records.


• 47% of patients recall seeing their physicians or their nurse/assistants taking notes in a computer or other electronic device, whereas only 39% of patients recall seeing their physicians or their nurse/assistants taking notes directly into computers during treatment.


• Physicians and patients agreed on the benefits of using electronic devices to document patient care during an encounter.


• The most important benefits of EHR systems agreed on by the two groups: 1) Provides real-time doctor access to patient medical records and histories; 2) When appropriate, helps physicians securely and seamlessly share information with other doctors, pharmacies, and payers; 3) Helps doctors make good decisions about patient care, ultimately driving the quality of patient care.

Overall, most physicians and patients agreed that medical records stored electronically will help improve patient care. Also, physicians and other clinicians who participated in the study said that EHRs are tool to help them perform their work more efficiently.

According to the survey, patients, on the other hand, increasingly expect their doctors to offer them access to EHRs and patient e-tools, and as a result, are encouraging their physicians to adopt more connected technologies, Otter-Nickerson says.

“Patients who participated in the survey said they had greater confidence in providers who use electronic records,” she says. “This suggests that there’s an opportunity for doctors to learn directly from their patients how to improve their practices and their patient relationships.”

The Sage Healthcare Insights study was conducted online in December 2010. The survey was sent to 7,738 physicians or other clinical users of a Sage product or service. The patient survey was sent to 18,000 healthcare consumers. Statistically, the sample size is large enough that the findings are applicable to the population.

This article was originally posted at http://www.modernmedicine.com/modernmedicine/InfoTech+Bulletin/Patients-more-comfortable-with-doctors-who-use-EHR/ArticleStandard/Article/detail/724096?contextCategoryId=44687

 

Study: EMRs speed genetic health studies

Recruiting thousands of patients to collect health data for genetic clues to disease is expensive and time consuming. But that arduous process of collecting data for genetic studies could be faster and cheaper by instead mining patient data that already exists in electronic medical records, according to new Northwestern Medicine research.

In the study, researchers were able to cull patient information in electronic medical records from routine doctors' visits at five national sites that all used different brands of medical record software. The information allowed researchers to accurately identify patients with five kinds of diseases or health conditions – type 2 diabetes, dementia, peripheral arterial disease, cataracts and cardiac conduction.

"The hard part of doing genetic studies has been identifying enough people to get meaningful results," said lead investigator Abel Kho, MD, an assistant professor of medicine at Northwestern University Feinberg School of Medicine and a physician at Northwestern Memorial Hospital. "Now we've shown you can do it using data that's already been collected in electronic medical records and can rapidly generate large groups of patients."

The paper is published in Science Translational Medicine.

To identify the diseases, Kho and colleagues searched the records using a series of criteria such as medications, diagnoses and laboratory tests. They then tested their results against the gold standard – review by physicians. The physicians confirmed the results, Kho said. The electronic health records allowed researchers to identify patients' diseases with 73 to 98 percent accuracy.

The researchers also were able to reproduce previous genetic findings from prospective studies using the electronic medical records. The five institutions that participated in the study collected genetic samples for research. Patients agreed to the use of their records for studies.

Sequencing individuals' genomes is becoming faster and cheaper. It soon may be possible to include patients' genomes in their medical records, Kho noted. This would create a bountiful resource for genetic research.

"With permission from patients, you could search electronic health records at not just five sites but 25 or 100 different sites and identify 10,000 or 100,000 patients with diabetes, for example," Kho said.

The larger the group of patients for genetic studies, the better the ability to detect rarer affects of the genes and the more detailed genetic sequences that cause a person to develop a disease.

The study also showed across-the-board weaknesses in institutions' electronic medical records. The institutions didn't do a good job of capturing race and ethnicity, smoking status and family history, all which are important areas of study, Kho said. "It shows we need to focus our efforts to use electronic medical records more meaningfully," he added.

This article was originally posted at http://ping.fm/rcnib

CMS explains how to get paid EHR incentives

The Centers for Medicare and Medicaid Services will pay physicians four to eight weeks after they verify that they have satisfied conditions for meaningful use of electronic health records. That means that the soonest that CMS will issue incentives is in May.

Providers will not receive the incentive payments within that time frame, however, if they have not yet met the threshold of $24,000 for allowed charges in claims for covered services to Medicare beneficiaries during 2011, CMS said in an announcement April 28.

[Related: HHS calls value-based pricing program 'historic change' in which Medicare pays for quality, not quantity of care.]

CMS launched meaningful use attestation on April 18. Once met, a qualifying physician will receive $18,000 in incentives for fulfilling the first stage of meaningful use.

The payments to physicians for the Medicare EHR Incentive Program are based on 75 percent of the estimated allowed charges for their covered during the entire payment year.

If a physician does not reach the threshold by the end of 2011, CMS said it expects to pay the incentive to the provider in March 2012, after allowing 60 days beyond the end of the 2011 calendar year for all pending claims to be processed.

CMS will use a payment file contractor to generate electronic payment of the inventives through the same bank account that providers receive payment for their Medicare claims, according to the announcement

[Editor's Desk: This Week in Government Health IT.]

To receive the maximum amount of $44,000 in incentives over the five years of the program, physicians must begin participating in 2011 or 2012. Providers who supply services in a "health professional shortage area" may receive additional incentives, CMS said.The bonus will be separate lump-sum payments within 120 days after the end of the year.

EHR incentives for hospitals and cirtical access hospitals start with a $2 million base payment. They will receive initial and final payments.

States manage the Medicaid EHR Incentive Program, in which physicians can receive up to $63,750 over six years. Medicaid hospitals also begin with a $2 million base payment. Timing of the states’ payment of incentives varies according to their program, CMS said.

This article was originally posted at http://ping.fm/Dj8kR

GAO says VA not transparent enough

The Veterans Administration’s new resource allocation process uses a standardized electronic model, but the transparency of networks' decisions for allocating resources to medical centers is limited, a new GAO report concludes.

[Editor's Desk: This Week in Government Health IT.]

In its April 29 report, GAO recommends that the VA require networks to provide rationales for all adjustments made to allocations proposed by VA's resource allocation model, and that it develop written policies to document practices for monitoring resources. The VA concurred with these recommendations.

The new process involves three steps:

• First, VA headquarters proposes medical center allocation amounts to networks using a standardized resource allocation model. The model includes a standardized measure of workload that recognizes the varying costs and levels of resource intensity associated with providing care for each patient at each medical center.


• Second, network officials review the proposed amounts and have the flexibility to adjust them if they believe that certain medical centers' resource needs are not appropriately accounted for in the model.


• Third, networks report final medical center allocation amounts to VA headquarters and any adjustments made to the allocation amounts proposed by the model.

VA headquarters did not ask networks to report reasons for each adjustment made to allocation amounts; networks reported reasons for some adjustments, but not for others.


VA officials said that the new network resource allocation process was not intended to be used to question networks' decision making, but to increase the transparency of networks' allocation decisions to VA headquarters while maintaining network flexibility.

However, absent rationales from networks on all adjustments made to medical center allocation amounts, transparency for decisions made through the allocation process is limited. Furthermore, understanding why networks make adjustments is key in determining if any modifications to the model are needed for subsequent years.

VA officials told GAO that they intend to conduct annual assessments of the new resource allocation process, including a review of adjustments to the model, to identify areas for improvement.

[See also: VA, DOD to incorporate open source in EHR.]

VA centrally monitors the resources networks have allocated to medical centers to ensure spending does not exceed allocations, but does not have written policies documenting these practices for monitoring resources. VA monitors resources through two primary practices – automated controls in its financial management system and regular reviews of network spending.

Specifically, VA's financial management system electronically tracks the amount of resources that networks and medical centers have available--the resources allocated, less the resources already spent--and prevents medical centers from spending more than what they have available by rejecting spending requests in excess of available resources.

In addition, each month VA headquarters officials compare each network's spending with what the network planned to spend and determine whether spending is on target, and whether any differences from the plan are significant.

However, VA headquarters does not have written policies documenting the agency's practices for monitoring resources, which is not consistent with federal internal control standards. These standards state that internal controls should be documented, and all documentation should be properly managed, maintained, and readily available for examination.

Without written policies, there is an increased risk of inconsistent monitoring of VA network and medical center resources.

This article was originally posted at http://ping.fm/UT5ro