Bowtie Confidential 11/10/12

Accountable Care Act and its Effects on the Board of Directors

Most boards have for some time received updates on the Accountable Care Act (ACA) and other significant changes to the healthcare environment. However, there has been an understandable unwillingness to step forward into the ACA realm despite the fact that the organization’s future may hang in the balance.

In June of this year, it became time to take that step and up the education and awareness process to the board concerning ACA and the eventual system transformation. Leadership and the board should know how to react to these new requirements. They should also know the impact on their organization (and the industry). If ACA board education and awareness has not taken place in your healthcare organization, then you’re behind!

The Supreme Court’s decision in June 2012 to support the Accountable Care Act (ACA) further enabled the use of Accountable Care Organizations (ACO) as one of the principal tools for addressing healthcare costs and improving care.

Many hospitals and health systems have begun planning efforts that include communication regarding ACA. This process provides updated briefings for the board on the decisions regarding primary implications and imperatives of the ruling. The briefings are consistent with the board’s responsibilities related to their fiduciary and legal obligations. Executive leadership, general counsel and external strategic advisors are well suited to provide these briefings and information sharing sessions.

Board members do not need to fully understand the legal statutory fundamentals for the decision and/or read the ACA in its entirety. However, they should be familiar with key themes. Although board members will not be required to be subject matter experts in the law of reform — they will need to look to the advice of leadership, executive management, and external consultants. The bottom line is that the board will be expected to have sufficient understanding of ACA that will allow each member to ask the appropriate questions and evaluate the advice of advisors and consultants.

The board should assess the need for focus on the following:

• Information technology. Technology will become an ever-increasing component as the reliance on EMR, data gathering and analysis become key to operations. The ability of the organization’s technology architecture to address new relationships between data and payment will be essential for survival.
• Finance. Understand the impact of the changes brought about by ACA reform. The organization’s responses will affect its financial standing and survival.
• Strategic planning. Both internal and external. Review and assess potential options for relationships and alignment with other organizations and services provided.
• Compliance. Government enforcement of the ACA’s new anti-fraud provisions and its supplemental requirements for maintaining tax-exempt status.
• Human resources. How will the organization address and incorporate ACA’s implications on the organization as a major employer?
• Delivery network. Are all of the necessary provider groups appropriately aligned? This includes hospitals (including referral centers), physicians (primary and specialists), post-acute care providers, etc. In addition, what is the strategy for patient medical home models?

In summary, the ACA ruling establishes a singularly important teaching moment. Attentive management will take the initiative to educate the board frequently and thoroughly on the ACA ruling, its importance to the national and local healthcare environment, and its financial implications to a specific hospital or health system. The awareness and understanding will position the board to respond to the expected and unexpected impacts, the rate of change and the availability of strategic opportunities.

These sessions also provide leadership with the opportunity to remind the board of the organization’s strategic plan and the necessary elements to address these challenges. In this way, your organization can have a board that is more informed and effective in their fiduciary responsibilities.

Rob Drewniak is vice president, strategic and advisory services, for Hayes Management Consulting.

News 11/8/12

Healthcare software and services company iMedX acquires Greenlight Transcription.

In its 2013 physician fee schedule published last week, Medicare adds two additional categories of hardship exemptions for the e-prescribing rule. Doctors and practices who achieve MU  by June 30, 2013 and those who demonstrate intent to use EHRs can apply for an exemption to the reimbursement cuts slated to start next year.

Eye Health Services (MA) selects SRS EHR for its 21 providers and 11 locations.

The Medicare Payment Advisory Commission estimates facility fees tacked on to routine office visits will add $2 billion a year to Medicare spending by 2020. As more hospitals acquire physician practices, look for increased pushback from insurance companies and employers.

Through the end of September over 300,000 EPs have signed up to participate in the EHR incentive program. Since the program’s inception, Medicare has paid 82,535 EPs over $1.4 billion in incentives while Medicaid has issued more than $1.2 billion to over 60,000 EPs.

SRS reportsthat power has been restored in its Montvale, NJ headquarters and staff will be back in the office Thursday. The company’s Sandy Relief Drive, by the way, generated almost $5,000 in employee donations, which the company matched in purchasing supplies  for affected Staten Island residents and schools.  The balance of the money will be donated to the Red Cross and Governor Christie’s Relief Fund.

eClinicalWorks receives full NCQA certification as a CAHPS PCMH survey vendor to conduct NCQA HEDIS surveys.

Almost half of primary care physicians expect to participate in an ACO model within the next year.

The Washington Post profiles physicians who aren’t necessarily enamored with EHRs and would prefer to hang on to their paper charts. Naysayers include physicians who say EHRs haven’t “lived up to the hype”  and worry about gaps in technology. On balance, one cardiologist notes:

“When you first go to EHR, it’s really a nightmare for the first three months in terms of trying to get comfortable with the system. But now, it helps our work flow, and we have fingertip access to information.”

CMS posts a couple new FAQs, including a question on how to handle transitions of care summary of care records for Stage 2 MU. For the Stage 2 transition of care and referrals objective, CMS provides details on  different ways providers can meet the measure that more than 10% of summary of care records for transitions and referrals be transmitted electronically. One approach is to use certified EHR technology to electronically transmit summary care records for transitions of care and referrals. Alternatively providers can use their EHRs to create a summary care record and use an eHealth Exchange to facilitate electronic transmission.

E-mail Inga.

News 11/6/12

The number of US physicians in independent practices is expected to drop to 36 percent by 2013; a third of those providers are predicted to offer subscription-based services such as telemedicine or online consults. The vast majority (87 percent) of doctors cite financial concerns as a chief reason for leaving private practice and 53 percent point to EMR requirements as the top reason for joining health systems.

CMS announces a seven percent increase in Medicare payments for family physicians in 2013 and a three to five percent increase for other primary care providers.

First Choice Health Centers (CT) chooses eClinicalWorks EHR for its six-location community health center organization.

A shout-out to occasional HIStalk Practice contributor Lyle Berkowitz, MD who earned a spot on the list of Top 25 Clinical Informaticists.

Diagnostic Radiology (OH) contracts with Comprehensive Medical Practice Management for billing and PM services.

athenahealth ranks number 24 in the large company category for the 2012 Top Places to Work in Massachusetts.

The Raleigh, NC newspaper covers local EHR efforts, beginning with a local physician’s displeasure at the recent Allscripts announcement to discontinue the MyWay product. Almost three-fourths of the state’s physicians use EHRs; 50 percent of those say EHRs have not improved the quality of treatment, or have decreased quality, or are not worth the expense.

An analysis of CMS data reveals the most commonly deferred Stage 1 menu objectives: providing a summary of care to patients at transitions to other physicians or hospitals (84 percent), using the EHR to send reminders (80 percent), and sending information to public health agencies (68 percent). The least deferred tasks were checking drug formularies and generating patient lists. In general, all the Stage 1 menu items will be required core measures for Stage 2.

AMA News takes a look at how some physicians are using smartphone apps to increase patient compliance and education. Advocates point to the convenience of online tools since most patients already have their smartphones close at hand.

The 27-clinic Hometown Urgent Care (OH) selects DocuTAP for EMR and practice management.

A Rand Corporation study finds that physicians with fewer than 10 years of experience account for 13.2 percent higher overall costs than physicians with forty or more years of experience.

The American Academy of Pediatrics issues a policy statement calling for additional privacy protection in EHRs for adolescent patients. Key recommendations include developing criteria for who has access and control of the medical record; allowing adolescents to record consent for care; building options to shield the release of certain diagnoses, tests, and prescriptions; developing billing systems to suppress protected information.

Physician offices added 11,200 of healthcare’s 30,500 new jobs in October.

In case you didn’t get your fill of MGMA commentary a couple weeks ago, check out Dodge Communication’s summary of the best and not-so-best of the trade show floor. Their write-up is fun and they even posted a picture of a pair of the cool green Converse tennis shoes adorn by the Pulse crowd. By the way, I am still hoping someone at Pulse to send me a pair.

E-mail Inga

HIStalk Practice Interviews David Whitlinger, Executive Director, NYeC

David Whitlinger is executive director of New York eHealth Collaborative.

Give me an overview of NYeC and its various initiatives.

The New York eHealth Collaborative is the state-designated entity for the State of New York. It is responsible for establishing healthcare IT across the state. It has a couple of key programs. One of them, of course, is adoption of electronic health records in general, and we do that as one of the two regional extension centers for the state. The other is the New York City Regional Extension Center. We work tightly together.

NYeC is also building a statewide network in conjunction with the Department of Health and various RHIOs from around the state. The first two predominant capabilities that the statewide network will support are patient record lookup – the ability to query for a patient record across the network — as well as Direct, the ability to use a single hit in the SHIN-NY network to support point-to-point communication between two provider organizations.

In support of that, we have a couple of other initiatives we kicked off in order to further substantiate the markets towards usage of the SHIN-NY, including interoperability workgroups. We — with several other states and a collection of HIE vendors and EHR vendors — came together to form an organization that will work on tight plug-and-play interoperability technical specifications for patient record lookup and Direct.

That work now is coming into culmination. The test specs are done and we’re in the final throes of working with an ONC-certified test house to be the test body for products that meet those requirements. For New York, we expect that’s going to be a mandatory requirement for EHR vendors such that their products are SHIN-NY-ready and they’re ready to be on the state network plug and play.

The other program that we anticipate starting to bear fruit next year is an accelerator program. Those companies are accelerating products on top of the SHIN-NY network, using the SHIN-NY services for products geared towards team-based or collaborative care.

One of the biggest struggles for HIEs financial viability. What is SHIN-NY’s financial model and how is it faring?

Let me talk about it from several different aspects. The way our model is constructed today is as a retail model. In other words, those that use the network pay for the usage of the network – both payers and providers. That’s the model that we put together.

That being said, we have done a couple of things in putting this cost structure together and two things of note. New York City and the surrounding area is one of the densest healthcare delivery geographies in the country. By loading up the volume of usage of the network and driving the cost of delivery of that network down to a very low level, we are able to provide the per-unit cost to those that are paying for it at a public utility or commoditized level. We went into this as to substantiate the services with an expectation that we were going for volume and that the per-unit cost was going to be at a public utility or commoditized rate.

And so where are you today financially or is it still too early to tell?

It’s too early to give you some numbers or to quote figures but we are on target for the volumes or the adoption rate that’s necessary to succeed with our financial model. Where we need to be in a year from now is a full commercial model as that’s roughly when grants resolve. We’re on track for that.

What were you look for in companies to be part of your accelerator program?

I’ll try to give you four areas that were identified by our provider community as focus areas or capabilities that are necessary to support team-based or collaborative care.

One is care plan management. That’s the idea of having a single care plan for a patient with multiple providers that are using that care plan and contributing to it and looking at it with each other or prescribing for the patient simultaneously. There’s an ability of coordination between the provider community and all are working on the same patient at the same time. A lot of the products that we’ve seen and that are being accelerated for our program have to do with community communication: how do you notify and allow the different providers to know what each other are doing?

The second focus area is around analytics and being able to manage patients at the provider level in a panel. If a provider is seeking to be proactive and address their high-utilization patients, what are the reports that you can run and know what the other providers in that community are also doing with these patients? If you’re proactive, the reports that you use help dictate the work that you do with those patients.

The third area has to do with alerting. We received a lot of feedback, and a lot of interesting companies have come in to the accelerator with ideas around this. In the alerting ideas, you might have patients that end up in the wrong place for receiving care and there are care managers who are looking out for those patients. If they knew that the patient was in a high-cost location for care, they could intercede before the patient gets overworked and the financial mechanism gets overdrawn. A classic example is a patient showing up at an ER and the ER doesn’t know anything about the patient, so they don’t have any choice but to do a full workup, run all the tests, and do all the necessary treatments. If the care manager has a good depth of knowledge of that individual, they could be alerted and contact the ER. After the patient is stable, they could spend more time getting the patient transitioned to a better form of care, and not just ER services.

The last category, which is the Holy Grail, is patient engagement. We’re looking for and have found some companies that are really seeking to get patients engaged more in their own care, be more proactive in their care plan, and be more proactive in their engagement with their providers.

Were your applicant companies New York-based or are they from all over?

About half of the companies that applied are New York-based. The rest are outside of New York or outside of US altogether and across the world.

A recent CMS report indicates that only about 12 percent of physicians who signed up with an REC have attested to Meaningful Use. How does your REC’s record compare?

I hate to brag, but I will. We’re oversubscribed for our REC services. We are signed up for about 5,107. That was our contract number, and we now have around 5,500. We’re about 10 percent overprescribed for services.

We are now somewhere around 1,200 that have achieved Meaningful Use. If you understand some of the Meaningful Use program, you know we’re in a lull right now as to when people can attest and how they can attest and report. We’re expecting – and we’re very much on top of this with our provider community – a big wave at the end of the year here.

By the time all of the accounting mechanisms get caught up, we expect our Meaningful Use number to be around 3,000 or 3,100 in the January-February timeframe, so we’re doing well. We’re on track. The provider community is doing their part. The vendor community is doing their part. Our REC agents going in and working with the practices are doing a tremendous job.

What do you find to be the biggest challenges for physicians in terms EHR adoption?

You know, I think there’s a little bit of EHR fatigue. There’s a lot of work that’s going on in bringing themselves up to speed. There’s a lot to digest and understand. There’s a lot of work going into practices and helping them understand what’s important when doing an EHR implementation and focus on those things, and then grow the usage using the Meaningful Use measures as guide after they get there. It’s overwhelming at first blush. We spend a lot time getting them to understand it all in digestible chunks.

Would you like to add any additional comments?

The state of New York, because of the tremendous investment that it has had for the last couple of years, is working to provide a very robust HIE network as a public utility. We are doing something that the public should look at as for the public good and as a public utility that is available to all of them. It’s in the community, owned by the community, governed by the community. That’s really what we’re about here at NYeC.

To that end, we are looking at putting a consumer- or patient-facing portal up in the early part of next year that really is going to benefit the general public. That will be also coinciding with Meaningful Use Stage 2 requirements of patient access to their record. We’re looking forward to the healthcare providers in the state of New York really being able to leverage that, not only for the Meaningful Use Stage 2 requirement, but because it’s the right thing to do for their patients. It brings patients access to all of their records and not just the records of any one provider.

News 11/1/12

From Evan Steele: “Re: SRS and Sandy. A tree fell and took down a telephone pole right by our office, so we are without power. Our phone system is in the cloud, so any employee with power and Internet is working from home (they just plug their office phone into their cable modem and their extension works). Employees without power and Internet are working out of a conference room in a hotel. We haven’t missed a beat and are fully servicing our clients – AMAZING!” It is truly amazing, given the reports that more than eight million people from North Caroline to Maine lost power at some point during the storm. SRS, which is based in Montvale, NJ,  may be headquartered in a hotel conference room for a few more days — the local utility provider says it will take 10 days to restore power to the remaining 225,000 affected people.

Pulse Systems co-founders and brothers Basil Hourani and Alif Hourani resign from their posts as CEO (Basil) and CTO (Alif) and CFO Jeff Burton takes over as president and CEO. The French technology company Cegedim purchased the company two years ago for $61 million.

An AHIMA-published article explores what physicians want in ambulatory EHRs and why, until recently, HIT vendors have ignored their needs. A Mayo Clinic study previously concluded that vendors need to include several specific features and functionality in order to increase EHR adoption in practices, including:

• a flexible, customizable, virtual workspace
• workflows that mimic paper-based processes
• intuitive and easy-to-use interfaces
• the ability to work on multiple platforms, including mobile devices
• integrated clinical guidance

The evolution of cloud-based computing and smart mobile platforms are now making EHRs more affordable and attractive to physicians and spurring EHR use in practices. I’d add the obvious observation that MU and similar financial incentives are also impacting adoption.

October has been a record month at HIStalk Practice in terms of readership, which of course makes me happy. Site traffic spiked during MGMA and will help push us over 12,000 visits and 22,000 views for the month. Our wonderfully supportive sponsors also appreciate readers stopping by, especially those that take a moment to click on their ads and check out their offerings. If you find the reading worthwhile, the biggest compliment you can pay us is to tell a couple of colleagues about our sites and advise them that reading all things HIStalk will make them smarter, hipper, and better looking (the latter only applies to readers willing to adhere to my occasional fashion tips.) Thanks for reading.

East Bay Eye Specialists (CA) selects SRS EHR for its four-physician practice.

CMS releases its list of 24 EHR Direct vendors that have qualified to submit quality data to CMS by EPs for the  2013 PQRS program year.

E-mail Inga.