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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One of the goals of meaningful use and all the related federal spending of health IT is for EMRs to improve care coordination. But the current reimbursement system that’s heavy on fee-for-service encourages software developers and users alike to focus on documentation of billable events rather than coordination of care, a new study finds.

Read more on EMRs and care coordination

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As we get closer to 2011, the health IT initiatives are heating up. Here’s a timely article on this subject:

Last week, one day shy of its Dec. 31 2009 deadline, the Dept. of Health and Human Services issued its long-awaited near-final rules defining the “meaningful use” requirements doctors and hospitals must meet to cash in on the government’s $20 billion-plus health IT incentive programs starting 2011.

Read more on Meaningful Use by Marianne Kolbasuk McGee

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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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Previously, I described some of the benefits gained from having an office computer network, even if you haven’t yet implemented an electronic medical records system. At our practice, even as we prepared for EMR, we began to see unexpected benefits. At that time, the thought that a computer network could help improve overall efficiency in the practice was met with skepticism from staff, especially some of the doctors. Over a year later, I was pleasantly surprised at the variety of ways that the office network makes our practice work smarter.

Emailing Documents Instead of Printing

Any forms that have to be distributed throughout the practice are ‘printed’ as PDF files and emailed, instead of printing memos and physically handing them out. This also allows the sender to keep a record of what has been sent. I have also used this to scan and email important documents to myself, which can then be shredded, so I don’t have to drag paperwork home from the office.

Document Repository

The redundancy and security of our servers makes them ideal to store private (for an individual’s use only) and public (for use by all staff members) documents. Some of the doctors use these to backup important personal or financial information. Large documents that are frequently updated, like employee manuals, can be accessed electronically without the need for wasting massive amounts of paper at the slightest change. It can also be used for important timely documents such as a practice-wide Influenza Pandemic plan.

‘All Hands’ Alerts

Previously, someone would have to call the satellite offices to try to locate a missing chart or document. Now an alert is sent to everyone in the practice via the network. This has significantly cut down on hours spent on this process.

Security Issues

Prior to setting up our practice-wide network, we had a rag-tag collection of PCs which were unsupervised. Any employee could send email or access the Internet with impunity. Now that the amount of bandwidth needed for our EPM and EMR is critical, unauthorized use of this resource is a problem. Our administrator can access email or Internet usage and determine its appropriateness. It is important to note that employees should be instructed that use of practice computers is not considered personal and is subject to scrutiny.

Batch Scanning of Paper Documents

Temporary workers help handle the load of documents which need to be scanned into the EMR system – these include laboratory data, personal documents, or medical records from other physicians. The batches are then processed by clinical techs, from whatever location they may be at, and placed in the appropriate patient files.

Public Outlook Folders

Our executive secretary posts the doctors’ social schedule, meeting schedule, and on-call schedules. The clinical supervisor posts announcements, memos, and meeting minutes. The doctors have also posted any articles of interest to others for viewing. Our marketing director posts ad tracking data, as well as advertising proofs for review. Our EMR committee has a shared task-list folder for sharing progress on template changes or other projects.

Confidential Documents

Our bookkeeper and business office personnel can send certain critical documents electronically with password-protection.

Computerized HVAC Control

We installed this system at our ambulatory surgery center. It tracks temperature and humidity throughout the building and plots these on a graph. Our nurse administrator can optimize the system depending on the use of the facility, and can even remotely monitor the system from home if there is a problem at night or over the weekend. We have been able to run the building much more efficiently, recouping half of the system cost already from energy savings.

Networked Devices

Expensive peripheral devices such as color laser printers can be shared among employees, making them more cost-effective. Newer diagnostic equipment is frequently network-ready, so reports can be accessed from anywhere in the practice without having to print and fax, saving paper costs on both ends. Cameras are also networked so images can also be seen electronically instead of using expensive photo paper.

Employee Intranet Portal

This is basically an internal website for staff members only. What started out as a simple way of communicating within the practice has grown into a myriad of tools, from critical ones to fun ones:

• Practice Wiki – from the Hawaiian word wiki meaning ‘fast’, a wiki is a simple website that can be easily edited by many different users. We use this to post manuals and how-to’s for every kind of task or project.
• Employee blog – this is a website managed by our marketing director and keeps the staff up to date on practice news. Employees can also post news of interest to their colleagues which makes it a great morale booster.
• Security cameras – these networked cameras can be accessed by physicians and supervisors. Buildings can be checked on remotely during off-hours or during periods of bad weather. They can also be used for theft deterrence.
• Doctor scheduler tool – supervisors can check all the doctors’ schedules at a glance to determine optimal staff scheduling.
• Work order system – our staff utilizes an online work order system for department-specific issues. Examples include printer cartridges needed at a particular location, a leaky faucet at a satellite office, or a new employee who needs orientation, security codes, or time card access. These ‘orders’ would then be distributed to the appropriate department (physical plant, clinical supervisor, IT staff, HR staff, etc.). In the past, this required phone calls or paper messages which would invariably get lost.
• EMR Bug Tracker – this is a tool used to post problems or ‘bugs’ with the EMR system. These can range from misspelled words to a template that crashes to a wish list item. Our IT department can prioritize these on the fly.
• Various auditor tools – these are used by different supervisors to monitor things such as schedule changes, use of the EMR medication module, coding audits, or triage workflow, to name a few.

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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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