EMR – The Word on the Street – Part 3

In my previous post (EMR – The Word on the Street – Part 2),  I touched the topic of patient privacy and personal health information (PHI) security. Electronic medical records have changed the industry dynamics through information digitization. While one can debate on whether information technology makes information more vulnerable than before, it has certainly increased its usability. Although it is tough to explain data mining and the usage of big data in a short span of time, I managed to cough up some basic absorbable concepts for my patient group.

Most members of the group were surprised with the data crunching ability of contemporary EMRs. To most patients EMRs are quality control tools with simplistic features that help reduce chances of care discrepancies. Not a lot of people are familiar with an EMR’s data mining and reporting capabilities. Unfortunately that includes a number of physicians as well. EMR offers a cost effective alternative to traditional research methods. Dr. Ross Altman’s team was able to trace a drug to drug reaction that spiked glucose levels using electronic medical records from 3 different medical institutes. Dr. Altman accredited EMRs for enabling their research project, citing “EMRs were really critical in our study because they allowed us to validate our FDA-derived predictions at minimal cost.”

My reference had convinced most of the group members that data mining was in fact one of the main purposes of electronic medical records (learn more). Ironically I have similar sentiments, while I also believe in the coordinated care structure and how it could affect care along with better population health management. One of the most vital roles in coordinated care is the role of patients themselves. Patients have the most control over their own health and in order to truly improve care, it’s important for providers to involve patients in the entire process. Unfortunately, since my patient group was really small, I could not find a participant familiar with patient portals. I had to personally log in to my own web portal to give them a basic overview.

I talked about patient education material, online appointment scheduling, requests for prescription refills and referrals. The group seemed generally enthusiastic about the possibility of interacting with their provider online. Most of them appreciated the access to educational material, with one member explaining how it could help him remember the details shared in the exam room, “I almost forget most of the stuff my doctor tells me, so this is definitely good for me”. The newly released meaningful use requirements encourage patient engagement, and in fact it forms a part of its core objectives as the government looks to derive healthcare towards connectivity.


Popularity Contest – EMRs Vs Practice Management

The healthcare automation process is in full gear, with the EMR adoption rate close to 60%. With sights on affordable and accountable care, providers have become much receptive to change. Health IT offers improved efficiency at reduced costs through better information management. Electronic data interchange and practice availability online are necessities today as care move towards more accessibility. However, this change has not put an end to resistance. Some physicians still see EMR as a detractor and feel that they are better off with paper. Electronic medical records have been commonly branded immature and inefficient. Some providers feel that using an EMR sacrifices care quality and affects patient-doctor interaction. “I could write a note within a minute, while it takes me more time to complete the documentation on an EMR”, says one practitioner.

The shift to electronic medical records has been substantial and despite the increase in technological awareness, providers struggle to utilize EMRs in an optimal manner. Years and years of practice have made physicians more efficient with paper records, while electronic medical records are still comparatively new and alienating. “Let me clarify, providers are not adverse to technology. We had a wave of physicians adopting practice management systems to improve their scheduling, resource allocation and billing process. It was much simpler as providers knew what they were getting and how it would affect their practice. Whereas, with EMR everything is up in the air”, says one health IT consultant.

Practice Management Software and EMR

Practice management systems are popular with most practices within the US. As it focuses on the administrative tasks alone, providers do not have to worry about its effect on the care delivery process itself. Many physicians would also argue that the efficiency and productivity are administrative targets and care should not be measured in that way. “I don’t have an office manager at the moment, so I do my own scheduling and billing using the practice management software (read more). It is simple to get the hang of it unlike most EMRs that I have encountered”, says a single provider based in New Jersey.


Meaningful Use Stage 3 – Sneak Peek

With jury still out on the final rule for meaningful use (MU) stage 2, an advisory committee has already started planning for the next and the final stage of the federal incentive program. The committee co-chaired by Dr. Paul Tang from Palo Alto Medical Foundation and Dr. George Hripcsak from Columbia University will be working together to provide recommendations for the stage 3 rules. As before, the final stage is set to build on the requirements of the preceding stage. Several of the stage 2 menu objectives are expected to become the core objectives for MU stage 3.

However, the key focus of the final stage of MU will be on improved clinical decision support, machine readable data and medicine reconciliation. The last stage will also look to increase patient involvement through patient portals (read more) and EMRs. Industry experts believe that this will prompt widespread commercialization of health IT products. Tony Keller, a Meaningful Use consultant at CureMD, a leading EMR vendor adds, “The final stage for MU would be a fair reflection of the end goal, ‘the coordinated care structure’. Getting there requires significant changes, but meaningful use intelligently builds on its foundation, using a step by step approach. This has allowed the market to become more responsive, so when the time comes, I am sure that technology will support the transition.”

Among the newly added requirements, physicians would be required to enable nearly 10% of their patients to receive health readings, submit their medical history and modify or update their health information in the electronic medical records.

Working the spirit of coordinated care, physicians would be required to provide electronic care plans to referred providers and care sites in case the patient is moved. Whereas, referred providers would be responsible for updating the original patient care site with a percentile of the patient health information.

Shifting back to clinical decision support (CDS), the preliminary plan for stage 3 is calling for a minimum of 15 CDS rules. That is 3 times the amount set for stage 2. Tony Keller believes that this shows the intent of the government, “Patient safety and quality of care are the two most important factors deriving the technological change in healthcare. The end goal is better health and a happier life for every American.”

The advisory panel also recommended an increase in minimum requirement for electronic hospital medication discharge orders to insurance drug formulates, from 10% in the proposed Stage 2 rules to 30%. Providers are also expected to be required to record additional demographic information while some prior requirements such as smoking status may be eliminated, having met the state requirements.

Stage 3 would also require physicians to contribute towards population health using electronic medical records to generate lists of patients with specific conditions while maintaining a real time view using KPI dashboards to ensure improvement in quality of care, clinical research, practice outreach and reduction in care disparity.

According to the advisory board’s agenda, they would be able to release the final recommendation for meaningful use stage 3 to the HHS by May 2013. With the final rule for stage 2 expected to be released any day now, 2013 should effectively complete the picture for the healthcare reform.


Where are we With the Healthcare Reform?

I recently had a chance to connect with a former colleague and Health IT expert, Keith Smith. Keith is an independent Health IT consultant working closely with hospitals and private practices. He helps them manage the logistics for implementation as per their operational and technological needs. Given the recent surge in innovative Health IT solutions, I invited Keith to share some of his experiences and perspective on EMRs.

What is your opinion about the adoption numbers by CDC?

Well if you look at it from the perspective of ONC and the government, things are moving along at a decent pace. With adoption tipping over 55%, you can clearly sense a shift in tides. Moreover, according to the report, half of the physician populous that had not yet implemented an EMR solution was planning to do so within the next year.

How far do you think we have come in terms of the healthcare reform?

That’s a subjective question and I am sure there would be plenty of other opinions as well. I think the right way to look at it is to trace back from the end goals of improved health, longer life span, patient convenience, etc. Accountable Care Organizations in principle sum up what healthcare should be like. Right now we are in a transitional phase and most of the innovative solutions coming out are experimental at best. However, this year will be monumental for Health Information Exchanges and EHRs as we move towards connected care. Earlier this year, HIMSS Analytics released a 7 stage US Ambulatory EMR Adoption Model (UAEAM) that gauges the capabilities of health organizations to improve care quality through electronic medical records. According to this report, almost 11% of healthcare providers are at the third stage, having replaced the paper charts with EMRs backed up clinical decision support systems and capable of electronic messaging.

What do you think about the meaningful use measures?

I think the purpose of meaningful use (MU) was to educate the healthcare community on effective use of electronic medical records. While it does serve that purpose, MU’s objective based incentives can distract physicians from care quality to the fulfillment of these measures. Care is a service and I do not believe in standardization of care processes. It affects the individuality of the practice and often causes an ethical dilemma for providers. However, MU is voluntary and it has been effective for a number healthcare practitioners. The stimulus has helped many practices expand and improve their care delivery processes. Hence, I believe that this program can benefit the community at large, though it may be early to start measuring its success.

Read more: Healthcare & the race between vendors to develop the best software


What Does Meaningful Use Pay for?

Who would have thought for the CMS meaningful use incentive program to become one of the most polarizing topics in healthcare industry? Today, physicians stand divided. While some seek to benefit from the direction of use it provides, others blame meaningful use for stifling innovation in EMRs and health IT. Many medical professionals argue that use of medical technology should not be capped by regulations, “It is like a limiter. I should be able to decide how an EHR benefits my patient. Care should not be standardized. We deal with individuals as individuals. Not machines.”, says an annoyed physician.

However, the issue with meaningful use is not limited to standardization. Physicians attesting have to deal with several unique issues while reporting for meaningful use. The most significant concern has been the loss of productivity and the increase in overtime. When shifting from a paper based system, physicians want more control over documentation procedures and while few electronic medical records fulfill that need through customization, the meaningful use criteria still dictates clinical documentation for most physicians.

Some providers feel that restriction and control over their work causes an unnecessary delay that leads to loss of business and frustration among staff members. “The meaningful use incentive program is strategically designed to push physicians into adoption. Nobody incorporates overtime fees that one has to pay or the visitation slots that get freed up for meaningful documentation to be complete, particularly during the implementation and early adoption phase.”, says one provider.

On the other hand, there are a number of physicians that advocate for the CMS program. Some medical professionals believe that the meaningful use program is actually transforming healthcare, using a step by step approach. “We know that EMRs have been around for a while and some hospitals have been using these systems for nearly a decade. However, when you talk about solo practitioners without IT personnel, you can’t just expect them to start utilizing these systems in an efficient way. They would need a plan or a beginner’s guide to introduce them to the potential benefits of their EMRs.”, says Keith Smith, a health IT consultant.

Apart from the incentives, the improvement in care quality is what should ideally be the strongest proponent of Meaningful Use. It may add to the responsibility of providers to collect, analyze and share medical information, but it is through these changes that the healthcare system can truly transform. Farzad Mostashari the National Coordinator for Health Information Technology explains, “MU is a step by step road map of how our healthcare system can transform itself to provide higher quality of care, safer patients and patient coordinated care,” adding, “That means not only MU is the blue print of how to deliver better care, it is also the blue print of how healthcare providers can thrive in the healthcare markets.”

Read more: Everything You Need to Know about Meaningful Use Hardship Exemptions in 2016

Meaningful Use Audits

It shouldn’t come as a surprise to most healthcare professionals that CMS plans on auditing practices for meaningful use. The introduction of this audit is an effort to curtail the possibility of fraud or abuse within the healthcare system. The Office of National Coordination for Health IT (ONC) had asked the Office of Inspector General (OIG) to conduct the investigation on whether EMRs are being used intentionally or otherwise to commit billing frauds through up-coding etc. against Medicare and Medicaid programs.

Although it remains unclear as to how CMS plans on managing such an expansive audit, most professionals are dreading uninformed random visits by the feds that can potentially disrupt practice operations. General speculation suggests CMS to scrutinize physicians opting out of the meaningful use program having completed the stage 1. However, that does not mean the rest would go unnoticed.

A compliance officer believes that most physicians are used to external audits and will adapt accordingly, “We haven’t had a meaningful use audit before but that does not mean we are not familiar with the procedure. It’s the word ‘Audit’ that has a negative connotation.”

A number of physicians were taken aback when CMS unveiled the proposed requirements for meaningful use stage 2. Many complained that their EMRs lacked the required technology, while others bemoaned the inclusion of measures such as the requirement for patients to use online portals. Physicians overwhelmed by these requirements simply may not wish to comply with stage 2 and a looming audit is likely to act as more of a deterrent then anything. Many Health IT experts are questioning the intent of CMS as such steps may directly affect the rate of EMR adoption.

However, one Health IT expert points that this would help prevent providers planning on gaming the system without actually implementing the EMR, “The Medicaid stimulus is payable to physicians acquiring EMR technology. They just have to present a signed document indicating the adoption.”, adding “This has allowed some to take advantage of the stipulation, setting a poor example for the rest of the care community.”

The audit will evaluate if the physician has effectively performed an operation as reported. “It is common for providers to check options such as risk assessment without actually performing or documenting it. Most providers don’t even know what the task even entails!”, says a Meaningful Use consultant. If a provider is unable to produce the relevant documentation, it would constitute as a fraud and incentives will be recouped accordingly. RECs along with vendors are actively trying to educate physicians in this regard as the plan begins to materialize.


The Meaningful Use Stage 2 – What’s next?

The “proposed rule” of meaningful use – stage 2 raised a lot of eyebrows. The daunting 455 page proposal perplexed healthcare professionals across the nation. This set the stage for an extensive feedback session as many reputable practitioners and large hospital networks joined forces to voice their concerns. Apart from the EMR interoperability requirements, providers felt that some objectives were not entirely within their control and had to be reconsidered. These included objectives such as ensuring that a significant portion of patients utilize web portals to interact with the practice and  physicians felt that this did not take a lot of variable factors into consideration. American Hospital Association believes that requiring patients to electronically view, transmit and share health information is not feasible and may raise significant security concerns. AHA also suggests that discharge information should be made available within 30 days instead of 36 hours and the reporting period should be toned down to 90 days instead of 12 months.

A health IT expert commented that most requirements did resonate with the medical community. However, the approach itself may be incorrect, “We understand the importance of care quality, which is why we develop the tools for it. But it is not like we can flip a switch and be done with it. The process needs to be incremental and the objectives need to be realistic.” He added, “The government needs to consider the impact on physicians hoping to qualify this year and those who have already attested and completed the process.”

EMR adoption continues to improve over time and according to the numbers released by CMS almost 62000 providers have attested and received their incentives since May 2011. Industry experts and vendors believe that the meaningful use penalties will help improve EMR adoption rates. “We can already witness the change as more and more providers look to avoid eRx penalties. Nobody wants to lose money.”, says an EMR analyst.

The stage 2 is set to commence in 2014 for providers who have successfully demonstrated their meaningful use stage 1 objectives in 2011. The proposed rule increases the number of core objectives from 15 to 17. The proposed core objectives build on the basic functionality requirement, making it considerably more challenging in comparison to the previous objectives. The optional or menu objectives requirements are reduced from 5 out of 10 to 3 out of 5, while it may seem to provide respite, these menu objectives are not only different, but much more complex than their predecessors. In addition to the functionality requirements, stage 2 will also require physicians to report on 12 clinical measures. The physician will have the choice to choose between 3 reporting options, including PQRI measures as one of the three.

The stage 2 basically builds on the requirements set in stage 1. While the stage 1 required providers to simply demonstrate their ability to exchange health information, stage 2 will require them to do it. Similarly the computerized physician order entry requirements have been increased significantly ensuring that the majority of orders by the provider will be electronic. Physicians are also required to encourage their patients to utilize the functionality of electronic health records by using web portals. More importantly, the stage 2 emphasizes on reporting in an effort to improve and measure clinical quality.

While it is unclear as to what this rule be, CMS has made their intentions obvious of expanding upon on the stage 1 requirements while the medical community awaits nervously.