Pretzel Logic: Technology Decision-Making for Medical Practices 3/30/11

Meaningful Use, Chapters Two and Three

So now that you’ve got Meaningful Use Stage 1 out of the way, it’s time to start focusing on Stages 2 and 3.

OK, I’m kidding. But still, before you jump on the MU “escalator” (as the good folks at ONC like to call it), it may be worth taking a tiny peek at what Stages 2 and 3 might have in store. Not only for the morbid fascination of it, but also because it gives you some hints and clues about what might be waiting for you at the top of the “escalator.”

Where might we look for such clues? Why, the Meaningful Use Working Group (MUWG) of the Health Information Technology Policy Committee (HITPC), of course. This is a federal advisory group that provides advice to ONC on — you guessed it — Meaningful Use.

While the MUWG only makes recommendations and has no ability to create law or regulation, if history is any guide, their recommendations are likely to be the foundation for what eventually becomes regulation. [Full disclosure: I am not formally a member of the MUWG, but as a member of other WGs I do occasionally participate in their deliberations.]

On January 13, 2011, the first recommendations on Stage 2 and 3 were put out on the ONC website for public comment. The comment period is now closed. On April 5, the WG will have a public hearing to discuss the public comments that were received. You can see those recommendations here.

Just what was in those recommendations? You may recall that MU Stage 1 has 25 possible requirements for Eligible Professionals (i.e., ambulatory clinicians), of which you have to meet 20. Start with the 15 “core” set items that are required, and then choose five from among 10 in the “menu” set.

Note: I should point out that I’m going to focus only on physician requirements, not hospital. I’m less familiar with hospital requirements and, unlike hospitals, most physician offices don’t have staff who keep track of all of this mumbo jumbo.

For each requirement, there is an objective, which is what you have to do (“record demographics”), and a measure, which is how much of it you have to do (“for 50% of patients.”) The MUWG started with these 25 Stage 1 requirements and then built from there to get to Stages 2 and 3.

In some cases, they recommended that a Stage 1 requirement just continue into Stage 2, meaning that you just need to keep doing what you’re doing in order to keep getting your incentive payments. Some Stage 1 requirements that were optional “menu” items become “core” in Stage 2. In other cases, they raised the bar on an existing requirement by either increasing the measure (“go from 50% to 80%”) or increasing the scope (“go from CPOE for just medications to include radiology and labs”). And, of course, they also had some genuinely new recommendations.

A summary breakout of their recommendations is above, showing how requirements move from Stage 1 to Stage 2, and then from Stage 2 to Stage 3.

Going from Stage 1 to Stage 2, relatively few measures are left completely unchanged. Everything else is either made mandatory (which is unchanged if you chose any of those in Stage 1) or increased in some substantial way. And, there are six totally new requirements.

Going from Stage 2 to Stage 3, five measures are untouched from Stage 2, while a whopping 24 are increased in some way and six new ones are added to boot.

Bottom line is that, as promised by CMS and ONC, the requirements are increasing over time. Some are increasing in ways that are easy to predict, while others, like new measures, are much harder to anticipate.

Of course, the devil is in the details. The table above (click to enlarge) shows how each of the requirements fares over the movement from Stage 1 through the middle passage of Stage 2 to the distant horizon of Stage 3.

The full descriptions (such as they exist) are on the ONC website per the link provided earlier. You can get a good description of the original Stage 1 requirements here.

So, what you should take away from all of this? Remember, these are just recommendations from an advisory group, so there’s a lot of process between here and the actual requirements that you’ll be responsible for. That said, they are strong leading indicators and do suggest some general guidance.

First, this isn’t an “escalator” or a “fast-moving train” or any other non-weight-bearing analogy. This is a climb, pure and simple. Your committing to this climb is, unfortunately, without the benefit of knowing what mountains, cliffs, whitewater, and mountain lions lay over the first hill.

Second, you can run but you can’t hide. Almost all of what is optional in Stage 1 becomes mandatory in Stages 2 and beyond. Choose what’s easiest and manageable in Stage 1, but don’t be blind to what’s just over the hill.

Finally, beware of the “TBDs,” especially the quality measures. Many have found that the quality measures are their own set of MU requirements. There is a separate Quality Measures Working Group that is hard at work looking at new measures. There is no doubt that we can’t improve what we can’t measure, but it is all too easy for those who are not familiar with EHRs to assume that they yield quality measures easily and accurately. They do not.

One concern that I have with all of this is with the timelines. The first cohort of MU over-achievers can start attesting to Medicare on April 18. They’re going to be required to start on Stage 2 on January 1, 2013. That’s not as far as away as it sounds if you think about the bureaucratic steps that need to be taken and the lead time needed for vendors to develop their products, get them certified, and train clinicians to use them.

I’m also concerned that many of the new requirements are trying to use MU as a lever to accomplish other objectives, such as public health goals and patient engagement aims.

The biggest concern for physicians is that many aspects of these new requirements are out of their control. Hopefully the public feedback to ONC that we’ll hear about on April 5 will quell the attempt by policy-makers to use physicians as the hammer to attack every nail, staple, rivet, and railroad spike.

Micky Tripathi is president and CEO of the Massachusetts eHealth Collaborative. The views expressed are his own.

News 3/29/11

Mark your calendars: attestation for the Medicare EHR program begins April 18th. If you are an eligible provider, you must have an active NPI and have a  National Plan and Enumeration System Web access user account. This CMS link includes step-by-step instructions, including screen shots. To date, CMS has paid out almost $37.6 million in EHR incentives and registered 25,217 eligible physicians and hospitals.

The average office-based physician supported $1.3 million in wages and benefits in 2009, according to an AMA report. Collectively, the nation’s 639,000 office-based physicians supported 4 million jobs and $1.4 trillion in economic activity. That’s about 6.2 jobs per physician.

Pulse Systems names family practice physician Tana Goering, MD as its chief medical officer. Pulse also announces that Loudoun Medical Group (VA) will implement Pulse Complete EHR for 170 of its physicians.

More than 40% of primary care physicians are considering leaving their field, though 60% said they enjoy better job satisfaction than they anticipated on their first day of medical school.

Patients taking advantage of $4 generic prescriptions unwittingly hurt the cause of e-prescribing and EMRs because of the way the transactions are processed and paid for. Patients typically pay cash for these discounted prescriptions, so transactions are not shared with pharmacy benefit managers. As a result, health systems are less likely to receive notification for inclusion in patients’ EMRs. The authors of a NEJM report suggest collecting data from pharmacy records in additional to those from PBMs.

The Wall Street Journal profiles  Atrius Health, a Newton, MA-based alliance of five medical groups representing over 800 physicians and about 700,000 patients. Their ACO-like setup has helped reduce costs to the tune of $62 million in 2010. Its collaborative efforts have also boosted quality measures, such as the number of patients receiving cholesterol screening. EMR has played a big role in measuring quality and identifying problems with patient care, as have the use of case managers to monitor chronic conditions and pharmacists to identify problematic drug interactions or cheaper medication alternatives. Still, University of VA professor Jeff Goldsmith notes that not all medical groups and small organizations will have the financial resources to invest in IT and other required improvements: "The idea that this could scale to the rest of the health system is seriously flawed.”

PCIS Gold to will integrate Alpha II’s ClaimStaker software into its medical practice management software.

I mentioned last week that Rhode Island lawmakers were considering a (silly) bill that would ban handwritten medical records. Rhode Island legislators are now considering  a seemingly simple proposal reminiscent of my Economics 101 class. The state is struggling to attract physicians, so lawmakers have suggested that commercial insurance carriers be required to pay a minimum of 125% of Medicare fees. In exchange, doctors must participate in the state’s Medicaid program and devote at least 5% of their work to free care. The state medical society opposes the law, fearing the floors may one day become the ceiling.

Meanwhile in Texas, a state representative proposes legislation allowing providers to opt out of a program that requires them to submit patient information to the state. The information collected by the Texas Health Care Information Collection is potentially sold to third parties for market research or health studies. Representative Susan King says the requirement places an unfunded burden on providers and that the state should not be in the business of collecting and selling information without patients’ knowledge.

EyePrescribe.com partners with DrFirst to offer e-prescribing services via the EyePrescribe.com web portal.

NoteSwift names Nuance reseller 1450, Inc. its exclusive distributor for EHR/EMR-related program. NoteSwift works with Dragon Medical to recognize meaningful data in dictations. NoteSwift then inserts the selected data into a provider’s EHR. NoteSwift only supports Allscripts Professional EHR versions 7, 8, and 9.0, though additional EHRs are in the works.

I usually defer to Mr. H when it comes to harsh criticism. However, after reading this article, I decided I can no longer remain Ms. NiceGirl. A local paper details the struggles of physicians adopting EMRs, yet the journalist clearly doesn’t have a handle on the industry. For example, the article says that EMR software “can range from free to over $800,000.” I’m not sure why $800,000 is the magic number since the price tag can definitely go higher for larger groups. eClinicalWorks software is labeled as “chronic disease management-focused” and “super-specialized,” as opposed to NextGen, which can “cater to almost any need.” Huh? And, I have no idea what this is suppose to  mean: “The (Epic) software speaks multiple languages to enable global healthcare providers to work as a team.” Plenty more examples to convince me never to write an article on geophysics, nuclear fission, or sewing.

E-mail Inga.

News 3/24/11

CDPHP, a New York IPA/HMO, says its patient-centered medical home pilot resulted in a 9% decrease in the rate of medical cost increases at its three participating practices. Hospital admissions were 24% lower than expected and advanced imaging utilization and ER visits declined. The practices also demonstrated improvements in quality measures, including the proper use of antibiotics and diabetic eye exams.

Dr. Edward Rippel is profiled in the Hartford paper as the first solo practitioner in Connecticut to earn NCAQ recognition as a patient-centered medical home. Rippel claims his $50,000 investment in eClinicalWorks EMR five years ago proved to be the game changer in terms of providing coordinated patient care with better outcomes. Since starting EMR, 20% more of his diabetic patients have hemoglobin A1C levels at treatment goal and none of his 200 diabetic patients are on dialysis. Streamlined workflows, increased productivity, and savings from moving his billing in-house helped Rippel recoup his EMR investment within two years and earned him additional revenues from P4P programs.

Urgent care software provider Practice Velocity partners with Healthagen to give consumers mobile access to Practice Velocity’s ZipPass functions. Patients using the Healthagen’s iTriage product will be able to schedule appointments and pre-register directly into the ZipPass application.

Five Rhode Island senators are sponsoring legislation that would require all physician notes and records to be typed, rather than handwritten. Of course the Rhode Island Medical Society opposes the bill. Of course it won’t pass.

Coinstar announces plans to invest in SoloHealth, a developer of health screening and information kiosks. SoloHealth is introducing SoloHealth Station, which will screen vision, blood pressure, weight, and BMI. The technology will support personalized advertising messages and kiosks will be placed in high-traffic retail areas. The service will be free to consumers. Coinstar, by the way, is the same company that provides self-service kiosks for DVD rentals in grocery stores. The company is betting that consumers will embrace the idea of one-stop shopping for a gallon of milk, the latest DVD, and a blood pressure check.

Sermo partners with Janssen Global Services to develop mobile and web services to facilitate physician referrals and ensure continuity of care. The first set of services for physicians will be rolled out this spring.

Lake Regional Health System’s (MO) first primary care clinic will go live on eClinicalWorks EMR March 28. Six more clinics and an urgent care facility will go live in April and May.

MedLink is selected as a preferred vendor to participate in Baptist Health South Florida’s EHR donation program. Baptist will subsidize up to 85% of the cost of the iSuite EHR for its affiliated physicians.

The 17-provider Orthopaedics East & Sports Medicine Center (NC) selects SRS e-prescribing application as a first step towards full EHR adoption.

Six oncology treatment centers are adding IntelliDose software to their Allscripts EHR to handle oncology-specific functions. Allscripts and Intellidose signed a partnership agreement last year.

MD-IT, a provider of medication documentation and software for physician offices, acquires Word for Word Transcription.

Quest Diagnostics launches a 12-week, 10-city Care360 EHR Road Test bus tour to provide live demonstrations of the Care360 EHR software.

E-mail Inga.

News 3/22/11

The once anti-certification SRSsoft earns ONC-ATCB modular certification for its EHR technology. Not long after the interim Meaningful Use and certification requirements were announced, SRS CEO Evan Steele told HIStalk Practice that “SRS will not seek to become a certified product because it would be such a disservice to our clients and future clients.” His concern was that Meaningful Use requirements (at least as originally proposed) would hinder provider productivity. Steele now says that “SRS has cracked the code on productivity-focused meaningful use” and that providers using SRS will be able to satisfy Meaningful Use measures while simultaneously increasing productivity. In a recent Readers’ Write piece on HIStalk, Steele shared additional insights on how Meaningful Use can be achieved without negatively impacting physician productivity (it’s a great read).

MD-IT adds e-prescribing to its medical documentation platform, based on Surescripts technology.

The owner of a  medical clinic agrees to provide free medical services to the owner of storage units in exchange for free storage for old paper medical records and computer hard drives. The agreement was never put in writing, the new storage company owner is demanding back rent, and the clinic can’t get to its records since it hasn’t paid. The only winners in this mess, of course, are the attorneys fighting things out.

meridianEMR introduces a Meaningful User Tracking Board, designed to give practices insight into whether or not providers are meeting Meaning Use requirements in their EHR use.

Kaiser Permanente Hawaii says more and more patients are embracing online tools to schedule appointments, refill prescriptions, and communicate with doctors. Patients and physicians exchanged 21% more emails last year than the year before and online prescriptions jumped over 11%. Patients viewed 433,000 lab test results online, an 8.4% increase.

North Bridge Imaging Group (MA) signs a long-term agreement with Affiliated Professional Services for medical billing and PM services.

CMS has an FAQ section for the EHR incentive program, which I try to read every week or so. A couple of recent inquiries worth noting:

Can eligible professionals participate in the 2011 PQRS, 2011 eRx Incentive Program, and the EHR Incentive Program at the same time and earn incentives for each? To summarize the CMS answer:

• PQRS incentives can be received regardless of an EP’s participation in other programs.
• If participating in the Medicaid EHR incentive program, EPs are eligible for the eRx incentive.
• If participating in the Medicare EHR incentive program, EPs must report the eRx measure to avoid penalty, but are eligible to receive only one incentive payment. If the EP is participating in the Medicare EHR incentive program, the EP will receive the Medicare incentive payment and not the eRX Incentive.

For large practices, will there be a method to register all of the Eligible Professionals (EPs) at one time for the Medicare or Medicaid Electronic Health Record (EHR) Incentive Programs? Can EPs allow another person to register or attest for them? Again to summarize, CMS says that currently there is no method for a third party to register multiple EPs, so each EP must register him/herself. EPs are not permitted to allow a practice manager or anyone else to register in their place. However, CMS plans to implement functionality in May that will allow an EP to designate a third party to register and attest on his/her behalf.

E-mail Inga.

News 3/17/11

Main Line Health (PA) is implementing eClinicalWorks for its affiliated physicians.

WebPT EMR announces a certified billing partner program that includes integration with Kareo’s medical billing software, as well as with BMS.

National Billing partners with Practice Fusion to offer an EHR solution for its physician billing clients. National Billing uses Kareo’s practice management system.

RCM consulting services company TrustHCS partners with RemitDATA. TrustHCS will utilize RemitDATA’s business analytics and post-adjudication claims tools in its physician services practice.

Document management solution provider Accentus expands it ambulatory care service offerings through the acquisition of Mrecord, a speech recognition and medical transcription services company.

Doximity raises $10.8 million Series A venture capital to accelerate development of Doximity’s free communication platform for healthcare providers. Doximity, which is led by Epocrates co-founder Jeff Tangney, allows physicians to use their iPhone, iPad, Android device, or computer to connect with other providers to collaborate on patient treatment.

A big thank you to Dr. Jayne for pitch hitting on HIStalk Practice earlier this week while I was taking a few days off. I’m hoping to convince her to drop in more regularly and share more of her wisdom on ambulatory EHR and related topics. Meanwhile, I am guessing I am was not the only one Spring Breaking this week, given the slow trickle of news in the HIT world.

Academic faculty physicians in primary and specialty care reported slight increases in compensation from 2009 to 2010. Median compensation for primary care faculty physicians was $163,704 (up 3%) and specialists was $241,969 (up 2.7%.)

MED3OOO CEO Patrick Hampson will serve as a 2011 Ernest & Young Entrepreneur of the Year judge for Western Pennsylvania/West Virginia.

Allscripts opens two offshore development centers in Pune and Bangalore, India that will provide customer support and other services.

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A private investigator who specializes in preventing and detecting fraud against dentists shares a scary story of how a practice manager stole over half a million dollars from her employer. Most of the theft involved cash and over the years the practice manager developed a “duffle bag full of tricks,” including:

• Non-legitimate write-offs
• Not entering cash receipts into the computer
• Excess overtime pay, since the practice manager also handled payroll
• Tampering with check ledgers for cash disbursements

Since  the practice manager was a 20-year, trusted employee, her employers ignored plenty of warning signs, that included refusing to take vacation and often working in the office alone at odd hours. Plenty of good lessons here for any medical practice.

E-mail Inga.