As the time approaches when potential financial incentives for the widespread use of electronic medical records (EMR) finally kick in, there is increasing excitement and anxiety among medical practices. Unfortunately, there is also a lot of confusion.

What is the difference between the financial incentives from the Stimulus Bill and bonuses from ePrescribing or those from PQRI (Physicians Quality Reporting Initiative)?

And what do you need to do to qualify for and then claim these incentives and/or bonuses?

Meaningful Use Incentives. Healthcare providers are eligible for certain incentives if they can demonstrate “meaningful use” of EMR, which is based on a set of goals and objectives spelled out in a matrix that is being developed by the Department of Health and Human Services, with input from various government and industry work groups. At this time, some of these goals and objectives are more clearly defined than others. But the first of these will not go into effect until 2011.

Medical practices must demonstrate a certain level of adoption and proficiency within these categories of objectives in order to qualify for the federal incentives, which can range from about $2000 to $18,000 per provider within a given year (depending on the year of adoption). There is also a maximum of $44,000 per provider over about five years. Providers who do not adopt EMR within the specified time-line will not only fail to qualify for incentives but will also face eventual financial penalties in the form of reimbursement cuts.

ePrescribing. Also known as eRx, this is “the electronic generation, transmission, and filling of a medicinal prescription using either an EMR or practice management system or a web interface system”. This is facilitated by the Surescripts/RxHub electronic prescribing network, which links the prescriber to a most retail pharmacies. If a provider is using an EMR system, the process automatically checks for such things as drug allergies, drug-drug interactions, and formulary issues. Enhancements to the system will allow for two-way communication between provider and pharmacy so patients in your office can be told when their prescriptions will be ready for pick-up.

In 2008, eRx was actually part of the PQRI program (see below). In 2009, this was spun off from PQRI resulting in a separate bonus for eRx reporting. In 2010, providers who use eRx at least 25 times can earn a bonus worth 2% of their allowable professional Medicare charges – all providers within a practice must meet this threshold to qualify. In 2011, however, ePrescribing will be folded into the meaningful use standards and providers will need to eRx at least 80% of their patients to qualify for the bonus. Beginning in 2012, there will be increasing financial penalties for those providers who do not participate.

PQRI Incentives. The Physician Quality Reporting Initiative (PQRI) gave physicians their first exposure to what was informally called P4P or “pay-for-performance”. Specific objectives were listed for certain diagnosis codes and providers could initially earn a 1.5% bonus. This year it will increase to 2%, after which it will probably decrease and then, as with eRx, become part of the meaningful use criteria.

What all of this means is that this year practices can still earn a 4% bonus of allowable Medicare charges for professional services. And that is no small potatoes for any practice, regardless of its size. So, why are most practices still not participating? Many practices have complained about technical problems with the program as well as trouble getting information about whether or not they met the threshold for their bonus payment.

We have been using a program developed by Protodrone LLC called PQRI Toolset that audits practice billing before it is sent, in order to verify qualification for both PQRI and eRx incentives. For 2009, we hit a reporting threshold of 99.7% for PQRI, and our bonus was the highest of any other practice that reported PQRI measures for our specialty. For more information on the PQRI Toolset call Protodrone at 1-888-569-5593 or go to www.pqritoolset.com (ed. note: some of our partners have a financial interest in Protodrone LLC).

[This article first appeared in the March issue of Ophthalmology Management magazine]

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In an article on the Huffington Post, the FDA is quoted as saying that errors attributed to the use of electronic medical record systems were responsible for dozens of injuries and six patient deaths. This, say critics of EMR, flies in the face of the assumption that adoption of EMR/EHR will improve patient safety and save lives. Some university studies have looked specifically at hospital-based systems and found that some of them had actually caused more adverse drug events than would have been expected, especially since these systems are supposed to have fail-safe mechanisms against just such occurrences.

EMR critics say that because of financial incentives from the government, the widespread adoption of EMR is outpacing the ability to vet these systems, and that some hospitals and healthcare providers may be acquiring software that is faulty. Some sort of oversight is recommended in order to ensure patient safety. As Ross Koppel, a sociology professor at University of Pennsylvania puts it, “Faith-based EHRs won’t get us into heaven.”

However, the majority of adverse events occur in the universe of paper records. The main difference between paper and electronic charts is the facility with which the latter can be dissected and analyzed. Few doubt that, in general, electronic medical records systems will reduce medical error and improve the quality of care. But the onus is on the practitioner to practice due diligence when it comes to selection of the software that will have a major impact on the care of his or her patients.

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For those of you who are at the stage of EMR implementation where it is time to decide on the EMR software system, we have a new resource which I think you will find very useful.

Medical Practice Trends has partnered with the folks at SoftwareAdvice.com to give you an EMR Software Checklist. They have a huge database of information from many EMR software vendors and have used this to create a checklist of selection criteria to help medical practices with their EMR system decision-making. Then, one of their consultants will call and walk you through the checklist and explain the best practices for researching EMR software. Software Advice will even provide a “short list” of EMR systems for you to consider based on your unique requirements. Last year, they helped over 10,000 organizations find the right software.

What’s the catch? There isn’t one really. It’s a totally free service for you. SoftwareAdvice receives a “finder’s fee” if they successfully match you with an EMR software company. As an affiliate, Medical Practice Trends gets a cut of that. Hey, we have to pay our electric bills, too.

So, here’s what to do:

First, if you haven’t already started your EMR project, get our free report (located in the right-hand sidebar) “Getting Through the EMR Maze”. This will give you an overview of EMR implementation and help you avoid making costly mistakes.

Next, CLICK HERE to go to the EMR Checklist page. Fill out the information and then you can download a PDF of the checklist so you can get started doing your research right away. Good luck!

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With just over 100 responses to our EMR survey (and counting), I decided to go ahead and post the results thus far. Reader responses are listed in decreasing order, from most votes to least.

Question #1 – Our practice is currently using:

1. EMR on a limited basis – 30%
2. EMR to a significant degree – 26%
3. ePrescribing only – 25%
4. No EMR, just practice management – 17%

Question #2 – My role in the practice is:

1. Administration – 32%
2. IT (information technology) – 28%
3. Clinical/Medical Tech – 22%
4. Physician/Partner – 18%

Question #3 – We anticipate the costs of EMR to our practice will be:

1. More than $10K per provider – 46%
2. Not sure, we have not made the transition yet – 24%
3. Between $5K and $10K per provider – 20%
4. Less than $5K per provider – 8%

Question #4 – Our biggest obstacle to EMR implementation is/was:

1. Physician resistance – 32%
2. Lack of useful information/not knowing where to start – 26%
3. Uncertainty about which system to get – 26%
4. Cost – 15%

Question #5 – Our practice size/situation is:

1. Solo practitioner – 50%
2. Small group, 2-5 physicians – 31%
3. Mid-size group, 6-12 physicians – 12%
4. Large group, less than 40 physicians – 3%
5. Mega-group or clinic, more than 40 physicians – 3%

The most interesting answers I think were to questions 3 and 4. A majority of respondents feel that the cost of EMR implementation will be at least $10K per provider and that physician resistance is the most common obstacle. I am actually not surprised about that last one as that was a major issue in our practice.

Questions or comments? Post them here….

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EMR Update 6 – eRx and PQRI: Are Your Leaving Money on the Table?

This Issue:

• How can your practice qualify for ‘Stimulus Bill’ financial incentives?
• ePrescribing(eRx) & PQRI – what bonuses can you expect for each?
• How do you make a claim?
• Find out about PQRI Toolset, a tool that can help you claim bonus payments

(Note: MPT has a financial interest in Protodrone LLC, creator of PQRI Toolset)

Podcast: Download (Duration: 10:42 — 4.3MB)

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The Centers for Medicare and Medicaid Services (CMS) announced today a proposed outline for Meaningful Use criteria, in accordance with EMR implementation provisions under the Health Information Technology for Clinical and Economic Health (HITECH) Act, part of the American Recovery and Reinvestment Act (ARRA) of 2009. These specify some of the guidelines by which physicians can receive incentives of up to $44,000 per provider, over 5 years, beginning as early as 2011.

Stage 1 criteria (the first of 3 total) would cover 25 meaningful use objectives (and 23 for hospitals). These are listed under modules known as Health Outcomes Policy Priorities such as Improving quality and patient safety (use of drug-allergy interaction checks, use of ePrescribing, maintaining active medication list, etc.), Engaging patients and their families in their health care (e.g., provide patients with a copy of their health information), Improving care coordination (e.g., exchanging key clinical information among authorized entities), Improving population and public health (e.g., capability to submit data to immunization registries), and Ensuring adequate privacy and security for personal health information (through the use of appropriate EMR technology).

The implementation of Stage 1 meaningful use standards would begin in 2011. Stage 2 (which would essentially expand upon certain aspects of Stage 1) and Stage 3 (which would deal with achieving improvements in conditions of a national high-priority nature and population health outcomes) would follow later.

While this certainly doesn’t clear things up completely for the individual physician, every piece of information that trickles down from Washington is eventually analyzed and translated for all parties which have a vested interest in the process. Hopefully, resources such as this can help doctors stay informed and as up-to-date as possible.

If you have any comments or questions, please post them here. If we don’t know the answer we’ll certainly try to find someone who does.

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EMR Implementation – How do you stack up against your colleagues?
We’ll post the results in a week or so.
Click the Next button after you answer each question

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One of my partners asked if our practice could use free GMail instead of replacing our old and failing mail server (not free) and having to purchase the licensing for the Microsoft software (definitely not free). When I looked into it, it turned out to be a bit more complicated than just deciding between a free mail service or one that has recurring expenses.

You see, with the advent of recent privacy regulations, there are increasing responsibilities being placed on the shoulders of medical practitioners to insure the protection of patient medical information. Before we get down to the details, let’s discuss some terminology:

Privacy vs. confidentiality. According to Gary Kurtz, in an article in the Journal of Healthcare Information Management, privacy is the right of an individual to control disclosure of his or her medical information. Confidentiality is the understanding that the information will only be disclosed to authorized personnel. This is what is known as a “need to know” basis.

Information Security. Since patient information will be increasingly common in a digital-only format, loss of electronic medical records could have an adverse impact on patient care. So it is up to the guardian of that information, typically the physician, to ensure that there are proper procedures for protecting both the safety and the integrity of that data.

The data safety relates to such issues as access to the information with minimal downtime, proper backup of the data with redundancy, and a disaster recovery plan which is regularly tested.

Integrity refers to processes which insure a true, uncorrupted and legal record. Most EMR systems maintain what is known as an audit trail, which tracks every change made to a record, when and by whom. Without an audit trail, it would be nearly impossible to tell if a patient’s record had been altered. Imagine a physical chart written on a dry-erase whiteboard – changes could be made at any time without discovery.

That said, the two main issues of information security relate to Who is controlling the information and Who has access to the information.

Who controls the information. Previously we discussed the two main types of EMR systems available: server-based and web-based. In server-based systems, the patient data is typically located on a computer or server in the doctor’s office. The upside: the doctor has ultimate control over the information. The downside: the practice is responsible for maintaining the security of the patient records, something which most medical practices have little experience with.

In a web-based system, the doctor accesses the EMR system via the internet, and the data is located off-site, usually on the server of the EMR vendor or a third party. The upside: these entities usually have a lot of experience with information technology security processes as well as the resources to implement them. The downside: the information may be stored on the same server as information from other medical practices; there is the potential for the information to be accessed by someone other than an authorized party. In addition, loss of the internet connection means loss of access to your patient files.

Who has access to the information. As stated above, access to patient information should be on a “need to know“ basis. There may also need to be additional provisions for restricted types of visits such as patients with HIV, mental health issues, or those undergoing drug treatment.

HIPAA (the Health Information Portability and Accountability Act) determines how patient health information may be shared electronically. So a medical practice would need, according to HIPAA language, to insure the confidentiality of the patient information not only within its domain, but would also need to take any steps necessary to make sure that third parties who have access to the same information (outside vendors, laboratories, consultants, etc.) maintain confidentiality as well. This could even be carried, in the extreme perhaps, to anyone who potentially has access to patient records, such as cleaning service companies or maintenance contractors. A practice would be well-advised to sign Business/Vendor Associate Agreements for HIPAA compliance with these companies. You can find many examples of these online that you can use.

Other potential gaps in information access include:

• computer monitors within sight of other patients (these should be locked if an employee leaves her station)
• printers or faxes located in ‘public’ locations
• lost or misplaced laptops or thumbdrives with critical information and without password protection
• passwords taped on monitors (you should have a strict password policy including passwords which expire periodically)
• doctor or staff smart-phones or PDAs which are not password-protected
• a wireless network in the office with inadequate security encryption
• unattended EMR workstations (these should automatically lock after a short period of inactivity)
• unauthorized software downloads which could allow breach of the network

So, going back to our story about GMail…for a medical practice to use GMail for its email service, it would need to enter into a Vendor Associate agreement with Google Inc. and require Google to adhere to the practice’s procedures and policies for privacy of patient information (and every medical practice that used GMail would have to do the same). Needless to say, Google is highly unlikely to agree to signing these types of agreements with possibly thousands of doctors, and be potentially exposed to significant liability.

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It doesn’t matter if your practice is just a single doctor at one location, or numerous physicians across multiple satellite offices. Either way, even before you can implement an EMR system, you’ll need to start by developing your system infrastructure. Although typically a contractor will take care of the network wiring for your office network, it is still a good idea to be familiar with some issues related to network wiring as well as terminology so you don’t get taken advantage of. Consider using a contractor who has been certified by the Building Industry Consulting Service International (BICSI), as this certification is the standard for contractors who deal with complex data and voice cable installations.

Some of the specific issues with which you should be familiar include:

Wiring: Typical Cat5e network wires have either a T568A or T568B standard. Select either, and be sure everything is wired to the same standard. The Cat6 wire standard is newer and more expensive, possibly a bit much for most medical practices. Copper wires between telephone communications closets shouldn’t contain segments over one hundred meters. Consider using fiberoptic cable for wiring over longer distances, as these cables can move more information and aren’t as vulnerable to interference and lightning. Fiberoptic, however, is more expensive.

Wireless: Are you considering wireless networking, also known as WiFi? If so, you will have to select a standard: either 802.11a, 802.11b, 802.11g, or 802.11h. Some newer standards provide higher data transfer speeds, but cost significantly more. The wireless standard that you choose should depend on whether you’re running a thin or fat client ( see Designing the Office Network for more about thin vs fat clients. Also, beware of interference from such common devices as cordless phones and microwave ovens.

Overwire: Most existing buildings are wired above the ceiling. Wiring is then dropped down the walls. When wiring, I would recommend ‘double drops,’ as the largest cost of wire installation is the labor. You will thank yourself later when you want to add more network devices (scanners, printers, diagnostic equipment, etc.), as these additional network connections will already be there.

Cooling: Network and server equipment create heat, and tend to shut down when over-heated. Plan for this by being sure that you have adequate cooling – you may want to consider installing a small, dedicated air-conditioning unit.

Electrical connections: It’s a  standard IT practice to have a certified electrician install isolated circuits for your network and servers – usually the outlets are orange so you can tell them apart.

Security: Don’t forget about security! Make the wiring closet secure, and remember that anyone with access to this closet can dismantle your network at any time.

Multiple locations: You’ll have to create a WAN, or wide-area network, to make a connection between remote office locations, so do your research and check out all your options. Larger metropolitan areas will generally have more options available for wide-area networks.

Fiber Backbones: Local utilities commonly maintain a fiber backbone which they allow businesses to access. These fiber backbones allow for high bandwidth rates between office locations (10-100Mbps) at a reasonable cost.

Local Phone Service: Meet with your local telephone sales people and service technicians. They understand the offerings in your geographic area. Some of the key points to discuss are:

• T1 lines: would a Metropolitan Area Network (MAN) or a Point to Point (PTP) be better?
• Inquire about both burst and committed information rates. A fast T1 connection may not cut it if the maximum isn’t available when you need it most.
• Will the phone company supply you with and maintain your router hardware, or will you need to take on this task yourself?

The costs of network infrastructure are much lower in new buildings. Apart from easier (and less costly) installation, the ability to oversee the network wiring in a building under construction is an advantage for clear design. Unfortunately, the majority of practices are located within existing buildings, so sound design and forethought in planning will help save your practice excessive costs and headaches later.

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If you talk to anyone who is involved in the electronic medical records (EMR) industry, one of the biggest points of discussion is what is known as “Meaningful Use of EMR.” What started as a well-intentioned (by some) effort to establish standards for EMR software systems has morphed into political jockeying by corporations, consumer watchdogs, and others.

The US Dept of Health and Human Services (HHS) outlined these criteria for Meaningful Use of EMR:
1)    Improve quality, safety, efficiency, and reduce health disparities
2)    Engage patients and families
3)    Improve care coordination
4)    Improve population and public health
5)    Ensure adequate privacy and security protections for personal health information

And although each of these has defined goals followed by specific objectives and measures for the years 2011, 2013, and 2015, these still sound a bit ambiguous. Many industry experts, however, expect these to be more fine-tuned as the dates approach, but medical practices will have to stay informed to keep ahead of the curve.

Financial Incentives

As part of the ARRA (American Recovery and Reinvestment Act of 2009), financial incentives will be given to those physicians whose practices demonstrate “meaningful use” beginning January, 2011.

The incentive payment, according to CMS, is equal to 75% of Medicare-allowable charges for covered services in a given year, and maxes out as follows:

• Year 1 – $15,000
• Year 2 – $12,000
• Year 3 – $8,000
• Year 4 – $4,000
• Year 5 – $2,000

For those practices who are early adopters of the technology and hit the threshold for meaningful use in 2011 or 2012, the first year payment would be $18,000. Note that this only applies to Medicare; there are additional incentives for healthcare providers who have a certain threshold of Medicaid patients and/or who practice in a rural area. The threshold for office-based pediatricians is lower, and so they would be more likely to qualify for those additional funds.

[table courtesy of SoftwareAdvice.com]

Even considering the fact that EMR implementation may cost anywhere from $10,000 to $50,000 per provider, these incentives would certainly make that investment more palatable.

Those practices that procrastinate, however, will be penalized with cuts in Medicare and Medicaid payments:

• 2015 – 1%
• 2016 – 2%
• 2017 – 3%
• 2020 – 5% (maximum reduction)

So, how do you know if you qualify? According to the health IT blog NetDoc, to be a “meaningful EHR user”, a physician must satisfy three criteria:

1. Must use “certified EHR [EMR] technology”
2. Must demonstrate that the certified EHR technology is connected in such a way that it provides for the electronic exchange of health  information to improve the quality of health care, such as promoting the coordination of care (using HL7 or XML standards)
3. Must submit information on clinical quality measures specified by HHS (such as PQRI)

Some physicians have told me that because there isn’t a final definition of what is considered “certified EHR technology” they are just going to wait. Big mistake. Most health care IT experts working on and advising on this issue feel fairly strongly that the Office of the National Coordinator for Health Information Technology (ONCHIT) will set CCHIT (Certification Commission for Health Information Technology) criteria as the standard for EMR certification.

CCHIT is a non-profit organization funded by various corporations and groups such as the American College of Physicians and the American Academy of Family Physicians, and was recognized by the US Dept of Health and Human Services (HHS) as a certifying body in 2006.

Some critics, however, charge that CCHIT is a shill for the Healthcare Information and Management Systems Society (HIMSS), the healthcare industry’s membership organization focused on healthcare IT. Although made up of both corporate and individual members, these critics feel that their goal is to corner the market for certain major EMR players. Nevertheless, unless or until there is an alternative, most EMR vendors are using CCHIT certification as the benchmark.

In addition to the EMR certification criteria, the ONCHIT is expected to adopt an initial set of standards and implementation specifications by the end of the year 2009.

Timeline

So, is too late to implement EMR in your practice and still qualify for the financial incentives? Well, that depends on the size of your practice, type of specialty, and how motivated your doctors and staff are to go paperless. Just don’t expect to run down to Office Depot, buy an EMR program and launch it the next day (although there is talk about WalMart getting into the EMR business, but we’ll leave that story for another day…)

According to MBA HealthGroup, these are some reasonable time frames to expect for EMR Implementation:

• Stage 1 – up to 6 months – researching vendors, getting buy-in, setting up an EMR committee, checking out demos, and making a final decision on the EMR system
• Stage 2 – up to 5 months –  time it will take to actually ‘go live’. In the meantime, adapting workflow to EMR system you chose, ordering hardware, and standardizing processes
• Stage 3 – between 6 and 12 months – amount of time it will likely take to achieve “meaningful use”, which includes ePrescribing, documenting electronically, and ability to report certain items (which are still being determined)

[timeline courtesy of MBA HealthBlog]

Smaller groups and solo doctors may be able to purchase a more basic, “out-of-the-box” EMR system and more quickly adapt their workflow to the system, rather than vice versa in the case of larger medical practices. But, the one thing you can count on with EMR implementation is that you can’t count on anything – that is why some sort of timeline is important [see EMR Implementation Rollout].

What this boils down to is that those practices that have already started implementing EMR will have a good shot at getting those higher financial incentives. On the other hand, physicians who have been wishing that the whole idea of EMR was just a fleeting fad may not only miss out on these incentives but may also face cuts in their reimbursement.

Questions? Comments? Post them below

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