An op-ed piece by Scott Jens, OD, FAAO, CEO of RevolutionEHR
January 22, 2010
Introduction and Commentary
Ever since the American Recovery and Reinvestment Act (ARRA) was passed into law in February 2009, health care providers in the US have been intrigued by the $17 billion that has been promised as incentive funds available to them for adoption of electronic health records (EHR). Optometrists, like physicians, have not been quick to adopt EHR with under 20% currently using computerized recordkeeping in their exam rooms. The federal government’s effort to positively influence more widespread adoption of EHR will have its intended effect, but there are so many variables for doctors to consider that confusion abounds and EHR adoption plans are not easily made.
Consider the promises that are being made by software vendors. Some packages are being given away for “free”, although we all know nothing is really free. Vendors have made promises of future software certification before their system is actually presented for certification inspection. Software companies are also promising compliance with yet-to-be-determined guidelines, along with implications that the system will allow a doctor to collect the future Medicare incentive payments when the truth is that the doctor’s use pattern of the software is truly going to determine payment qualification.
In essence, doctors are being pressured by these companies to believe that they must quickly choose a system in order to receive the forthcoming incentive monies. Free offers, money back guarantees, doctors being advised that they buy ASAP or face the risk of not getting the bonus funds - these tactics represent hollow efforts by software companies to take advantage of the lack of knowledge of the facts by most practicing doctors.
There are few good sources of objective information about the federal stimulus funds, but through my effort to lead RevolutionEHR into the “meaningful EHR user era” I have attempted to be a sound, trustworthy source of information for optometrists. With a new federal rule published on December 30, 2009, the facts laid out in the summer of 2009 have been supplemented by new details that should be digested by every optometrist who expects to receive funds in the next five years as a reward for their adoption of EHR.
Payment Details
Most health care providers have seen the matrix that shows the maximum possible payments that doctors can receive by becoming meaningful EHR users between 2011 and 2016. For doctors who see substantive numbers of Medicare patients, the $44,000 total potential bonus payments will come in the form of five annual payments that are paid in decreasing amounts each year.
For the last six months, software companies have been suggesting that a doctor’s ability to collect all $44,000 is directly related to adopting EHR as quickly as possible. Of course, doctors are not fully prepared for a proper practice analysis, market review and product comparison, so they feel unnecessary pressure to jump at perceived deals in the market.
The FACT is that eligible providers, a term that references a health care provider who is a participating provider in the Medicare system, will be able to apply for incentive fund qualifications and initiate their EHR meaningful use review as late as October 1, 2012, and still be eligible for all $44,000 of federal funding. Doctors who feel pressure to purchase EHR today because of any software company’s misguided effort to push a doctor to a falsely urgent adoption deadline should be reassured that such pressure is somewhat artificial. While it is true that doctors should be in some state of progress to EHR implementation, and the earlier adoption of EHR will allow the doctor ample time to learn the proper and efficient use of EHR, the receipt of ARRA funding is not wholly contingent on EHR deployment in some immediate timeframe.
Meaningful EHR User Review Period
The original meaningful use definition stated that an eligible provider will need to use a certified EHR system, perform e-prescribing, share data with other providers and systems, and provide quality reporting from the software. The non-profit EHR certifying body, CCHIT, and the federal government worked through the latter part of 2009 to overlay the EHR certification standards to the first draft of meaningful use guidelines.
The new rule published in December identifies a new phrase, “meaningful EHR user”. The rule which is undergoing public comment through the first quarter of 2010 is 500 pages of detailed content that more specifically defines an eligible provider’s path to becoming a meaningful EHR user. Within the rule, the government clearly discusses the scenarios that they contemplated on their way to their draft plan for a meaningful EHR user review period.
The new rule states that in a provider’s first year of use of a certified EHR system, the doctor may apply for qualification for funds based upon their care of Medicare or Medicaid patients. Optometrists would need to have 30% of their patient population covered under Medicaid to apply for funds. The doctor’s EHR use will be scrutinized for a continuous 90 day period within the first payment year, judging the user against the meaningful EHR user criteria. If the doctor demonstrates meaningful use in that 90 day period, the first year’s EHR adoption bonus payments will be paid. In subsequent years, the doctor will be judged on the entire year’s ongoing EHR use.
Thus, it is stated in the new rule that a user could apply for and begin their evaluation period for meaningful use on October 1, 2011, demonstrate such use, and be eligible for the bonus payment for the use through December 31, 2011. Since the bonus matrix provides for the same $44,000 total whether a provider demonstrates first meaningful EHR use in 2011 or 2012, doctors truly have until October 1, 2012, as the last possible date to begin demonstration of meaningful use or risk not receiving some of the $44,000 total bonus pool.
Quality Reporting Details
The current Medicare PQRI process allows Medicare to better understand the details of the care delivered to patients with particular chronic, and costly, diagnoses. Optometrists have been reporting on macular degeneration, diabetic retinopathy, and e-prescribing for over two years now with minor Medicare bonus dollars available for good PQRI code submission.
Until the new rule was delivered on December 30, there were no specialty-specific criteria for the quality reporting component of meaningful EHR use. Details within the rule now are available for optometrists to generally understand the expected reporting that will need to come from their certified EHR systems.
The software will be configured to report particular codes about general and ophthalmic details of patient care services rendered by eligible providers. Medicare will evaluate the proportion of services that include these details relative to the total number of Medicare patients seen in a time period.
- General details for to be reported are:
1. Preventive Care and Screening: Inquiry Regarding Tobacco Use
2. Blood Pressure Measurement
3. Drugs to be avoided in the elderly — patients who receive at least one drug to be avoided; patients who receive at least two different drugs to be avoided.
For all three of these cases, this is the extent of the known detail of what is expected to be reported by a meaningful EHR user.
- Ophthalmic details to be reported are:
1. POAG Optic Nerve Evaluation — assessing the percentage of patients 18 years and older with a diagnosis of POAG who have had an optic nerve head evaluation during one or more office visits within 12 months
2. Diabetic Retinopathy Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy — assessing the percentage of patients 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months
3. Diabetic Retinopathy Communication with the Physician Managing On-going Diabetes Care — assessing the percentage of patients 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
These are similar to some of the current PQRI reporting elements and have yet to be explained in further detail to equate their reporting by a meaningful EHR user.
Conclusion
Through the early part of 2010, there will continue to be very little clarity to the issue of meaningful use as the government wades through the 60 day comment period on the proposed rule for the EHR incentive program. According to my contacts at CCHIT, they are in the process of performing a gap analysis to look for the differences between their current Preliminary ARRA 2011 Certification standards and the details within the newly proposed rule. Software vendors that have already started the certification process of their optometry EHR system will need to undergo will need to have their system re-inspected. Others will simply wait until the final certification details are defined.
This leaves providers on the outside of the process, looking in and wondering “how do I get my funding?” The uncertainty that the doctors feel is related to the acceleration of EHR certification that has resulted from the ARRA’s $17 billion EHR adoption program. To say it another way, the only reason that EHR adoption has become a hot button topic is the 2008 collapse of the American economy. Had it not been for that disaster, EHR adoption by all health care providers would have progressed at a controlled pace. There would have been ample time for certifying bodies like CCHIT to take the necessary time to convene workgroups for each health care specialty leading to Comprehensive certification standards for each specialty. But with the ARRA, the vendors are left to scramble toward the fastest path to certification possible or face the possible rejection by doctors who will only buy systems that are seemingly on the cusp of certification.
It should be somewhat startling to optometrists that there has been no entity that has provided a real-time, “expert” analysis of the current state of the ARRA stimulus program. This update is part of an ongoing effort by RevolutionEHR to help optometrists have a better grasp of the progress of the process. ODs should monitor trusted resources for the latest information and are urged to ask detailed questions of their EHR vendor or prospective vendors. One thing is true - there are no definitive answers today and anyone who poses with all of the answers should be challenged. Many have claimed that early adoption is the key to meaningful use and stimulus funds, but more important than early adoption is thoughtful adoption. There is time for thoughtful adoption.
Look for additional information in the future as RevolutionEHR will continue to provide briefings and commentary. Like every other upstanding EHR vendor in optometry, it is our absolute intention to achieve the proper EHR certification standards to allow our users to become meaningful EHR users. Optometrists need to know that software certification is just the first part of the process to receiving ARRA funds, and that demonstrating meaningful use is what is ultimately required. And that is something no software vendor can promise.
