EMR & EHR Blog for Physicians

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To give you some perspective of what this means, here are some numbers from the report to ponder about:

Claims:

Presently 75% electronic utilization
Provider cost savings electronic vs. paper: $3.73
Payer cost savings electronic vs. paper: $0.73

Eligibility:

Presently 40% electronic utilization
Provider cost savings electronic vs. paper: $2.95
Payer cost savings electronic vs. paper: $1.38

Claim Status:

Presently 40% electronic utilization
Provider cost savings electronic vs. paper: $3.33
Payer cost savings electronic vs. paper: $2.56

Claim Payment:

Presently 10% electronic utilization
Cumulative Provider and Payer cost savings electronic vs. paper: $4.80

Claim Remittance:

Presently 26% electronic utilization
Provider cost savings electronic vs. paper: $1.49

TOTAL:

Total unrealized industry savings: $29,718,502,500
Present transaction types by percentage: 57% paper / 43% electronic

This begs the questions: aren't billing and payment transactions already electronic? Didn't HIPAA simplify administrative aspects of healthcare years ago? If so, what really happenned?

According to the report, these are common misperceptions about the business side of healthcare. The facts are quite different indeed. While Health Insurance Portability and Accountability Act of 1996 (HIPAA) addressed administrative simplification, and it was hoped that this would provide the mandated framework necessary to unify the system in transition to automation, it did not provide any detailed operating rules, leading to significant operational variances from payer to payer. It not only resulted in inconsistent formats but has also mades it almost impossible to create interoperable and fully electronic systems.

The Administrative Simplification provisions of the healthcare reform legislation are designed to accelerate the standardization of transactions and solidifying a set of operating rules that will eliminate these kinds of inconsistencies.

Healthcare industry can accrue these benefits irrespective of whether or not the perceived benefits of EHRs are realized. As we have seen the meaningful use of EHR definition and certification process has ben dogged by political controversies and / or clinical concerns. I have no doubt in mind that they will get resolved in the mid to longer term timeframe, but surely they will not get resolved in the short term.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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I cam across an interesting article on a very important topic that is very relevant in the light of recent discussion and legislation on 'meaningful use' of Electronic Medical Records (aka Electronic Health Records).

It was a survey that involved sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders. There were 6 major findings:

1. EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging;
2. EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange;
3. Managing information overflow from EMRs is a challenge for clinicians;
4. Clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination;
5. Realizing EMRs' potential for facilitating coordination requires evolution of practice operational processes;
6. Current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).

The third goal of 'meaningful use' focuses on improving care coordination by enabling exchange of meaningful clinical information among professional health care team by requiring the EHR to possess the following capabilities and functions:

1. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
2. Perform medication reconciliation at relevant encounters and each transition of care.
3. Provide summary care record for each transition of care or referral.

Given the survey findings listed in the earlier part of this blog, I am personally skeptical how many of the current versions of EHR Software solutions can pass the three capability tests (as above). The jury is out and we will better know which EMR / EHR Solutions will effectively meet the goal as far as co-ordination of care is concerned in the next few months.

If any EMR / EHR vendors or current users of EMR / EHR solutions would like to share their understanding, knowledge or perspective on this topic, please feel free to leave a comment.

We will continue exploring different aspects of 'meaningful use' over the next several weeks.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Now that the HHS has issued two sets of long-awaited and much-anticipated federal regulations on list of "meaningful use" criteria that healthcare providers must meet to qualify for federal IT subsidies and the standards and certification criteria that those EHRs must meet for their users to receive the EMR incentives, one is left wondering what is the real value of CCHIT certification and do those EMR vendors who went in for CCHIT certification and spent over $40000 each for the certification without waiting for the meaningful use get any headstart?

Here is a summary of an article that was published by Modern Healthcare today:

CCHIT may have had close ties to HHS in the past but that is history. David Blumenthal, the current head of the ONC, in a meeting was responding to a question about existing CCHIT certifications of Electronic Health Records and HHS' prior recognition of CCHIT as a certifying body.

Blumenthal mentioned that to qualify to receive incentive payments, the EHR would have to be certified by a body certified by the Office of the National Coordinator and that ONC is working towards creating a process to recognize that body.
Blumenthal mentioned that even though CCHIT was recognized in the past as a certifying body, its future status will be governed by the regulatory process that is ongoing right now. He termed as premature the talk about the implications of any particular set of certification criteria that CCHIT or anybody else has put forward or will put forward.

Mark Segal, Vice Chairman of the Electronic Health Record Association of HIMSS said the stimulus law, gives the ONC the authority to go ahead and retroactively accept any EHR systems certified under the old CCHIT process as certified under the new stimulus law provisions.

The ONC rule-makers explained the rationale behind this decision to scrap the previously accepted certification criteria and process. HHS, they wrote, decided not to accept CCHIT certification criteria due to "our approach of aligning adopted certification criteria with the proposed definition of meaningful use."

Segal said there still are "a reasonable expectation that CCHIT will be one of those" organizations that will again be recognized by the ONC. He also mentioned that CCHIT certification criteria come quite close to matching those new criteria being developed by the ONC. As a result, if an EHR is already certified up until now means it already has a lot of the functionality in place.

I do believe that the EMR Vendors who spent the time and financial resources in advance of the recent formal release of regulations, they are at an advantage as compared to a large number of vendors who do not have any certification, whatsoever. A number of smaller EMR vendors got certified in 2006, but as the competition is heating up, are already on the way to getting their EHR certified under the CCHIT 2011 Certification Program.

As I have earlier mentioned in another blog of mine, just because a Physician implements a Certified EMR does not mean that it is used in a meaningful manner, one of the EHR selection criteria must therefore include the ease with which the EHR allows demonstration of meaningful use to CMS.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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1. List of "meaningful use" criteria that healthcare providers must meet to qualify for federal IT subsidies based on how they use their electronic health records. 
2. The standards and certification criteria that those EHRs must meet for their users to collect the money.

Phased Approach to Meaningful Use

What has been proposed is a phased approach that encompasses reasonable criteria for meaningful use based on currently available technology capabilities and provider practice experience, and builds up to a more robust definition of meaningful use, based on anticipated technology and capabilities development.

Under this phased approach to meaningful use, the criteria of meaningful use would get updated through future rulemaking. The initial meaningful use criteria have been referred to as "Stage 1."

(Stage 2 criteria are expected to be proposed by the end of 2011 and the Stage 3 definition may be proposed by the end of 2013.)

Stage 1 Meaningful Use Criteria

The Stage 1 meaningful use criteria focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.

Stage 2 and Stage 3 Meaningful Use Criteria

Stage 2 meaningful use criteria shall expand upon the Stage 1 criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease).

Stage 3 meaningful use criteria shall focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.

Stage 1 Meaningful Use Defined in Detail

Goal 1: To further the care goal of improving quality, safety, efficiency and reducing health disparities.

1. Use CPOE (which entails the provider's use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization. For Stage 1 criteria, it will not include the electronic transmittal of that order to the pharmacy, laboratory, or diagnostic imaging center)
2. Implement drug-drug, drug-allergy, drug-formulary checks.
3. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®. It also includes past diagnoses relevant to the current care of the patient.
4. Generate and transmit permissible prescriptions electronically (eRx).
5. Maintain active medication list.
6. Maintain active medication allergy list.
7. Record the following demographics: preferred language, insurance type, gender, race and ethnicity, and date of birth.
8. Record and chart changes in the following vital signs: height, weight and blood pressure and calculate and display body mass index (BMI) for ages 2 and over; plot and display growth charts for children 2 - 20 years, including BMI.
9. Record smoking status for patients 13 years old or older.
10. Incorporate clinical lab-test results into EHR as structured data.
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
12. Report ambulatory quality measures to CMS (or, for EPs seeking the Medicaid incentive payment, the States).
13. Send reminders to patients per patient preference for preventive/follow-up care. Patient preference refers to the patient's choice of delivery method between internet based delivery or delivery not requiring internet access.
14. Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules.
15. Check insurance eligibility electronically from public and private payers.
16. 16. Submit claims electronically to public and private payers.

Goal 2: Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health

1. Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, allergies) upon request. Electronic copies may be provided through a number of secure electronic methods (for example, personal health record (PHR), patient portal, CD, USB drive).
2. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP. Electronic access may be provided by a number of secure electronic methods (for example, PHR, patient portal, CD, USB drive). Timely is defined as within 96 hours of the information being available to the EP either through the receipt of final lab results or a patient interaction that updates the EP's knowledge of the patient's health. 
3. Provide clinical summaries for patients for each office visit.

Goal 3: To improve care coordination by enabling exchange of meaningful clinical information among professional health care team.

1. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
2. Perform medication reconciliation at relevant encounters and each transition of care.
3. Provide summary care record for each transition of care or referral.

Goal 4: To improve population and public health by having the patient's health care team communicate with public health agencies.

1. Capability to submit electronic data to immunization registries and actual submission where possible and accepted.
2. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.

Goal 5: To ensure adequate privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law and provide transparency of data sharing to patient.

1. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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The American Recovery and Reinvestment Act of 2009 (ARRA) provides $17.2 billion in Medicare and Medicaid incentives designed to facilitate widespread implementation of certified Electronic Health Record (EHR) systems in physician practices and hospitals. Physicians, facilities, and other providers will receive money through Medicare or Medicaid programs for their "meaningful use" of EHR Software.

What constitutes "meaningful use" still hasn't been precisely defined. And there's still a lot of uncertainly. However, this hasn't prevented EHR vendors from aggressively marketing their EMR / EHR solutions to physicians and medical clinics, small and large.

What are these vendors doing to overcome physician hesitancy to implement EMR? They are guaranteeing that their EMR products will exceed, or at least meet, the requirements imposed by CMS. These warranties aim to lower one of the highest barriers to early EMR adoption: uncertainty about future standards.

Here's a sampling of the current vendor guarantees:

• ChartLogic Inc. says: "I guarantee that ChartLogic EMR users will be able to meet the "meaningful use" requirements needed to receive the stimulus money."
• eClinicalWorks similarly commits to supporting its customers' ability to meet the HITECH Act's "meaningful use" standards. In its license agreement, it warrants that its software will support the "meaningful use" criteria of the American Recovery and Reinvestment Act (ARRP).
• Athenahealth Inc. guarantees that its her users will receive Medicare meaningful use incentive payments authorized under the HITECH Act within the economic stimulus law. Athenahealth states:

"For each month for which you don't receive your qualified HITECH Act Federal Stimulus reimbursement dollars during the first year of funding, we will credit our monthly service payments, for up to six months. This offer applies to HITECH Act reimbursement payments only. Additional terms, conditions and limitations apply."

Note that the guarantee does not cover Medicaid incentive payments because of variations at the state level.

• Praxis EMR guarantees qualification under the ARRA's meaningful use guidelines within 90 days of publication, or your money back.
• Practice Fusion guarantees that physicians using its EHR will qualify for meaningful use before HITECH payments begin in January 2011.

A careful reading of these warranties reveals that every vendor pretty much guarantees that its EHR Software will qualify for "meaningful use" under the ARRA. However, the burden of proof that the qualified EHR is being used in a manner that proves "meaningful use" still lies with the physician.

Today, many physician organizations are expressing strong views about what they would like a working definition of "meaningful use" to include.

For example, the MGMA recently recommended that the federal government conduct a small pilot project among vendors and physician practices, to ensure that the process of demonstrating meaningful use will be achievable and practical. And they want the feds to complete the pilot program before any incentive programs for meaningful use of electronic health records begin. Additionally, the MGMA wants attestation and/or survey instruments to serve as primary methods for demonstration, instead of imposing arbitrary reporting thresholds on physicians. (Read more about MGMA's perspective on meaningful use of EHRs.)

According to recommendations submitted by HIMSS in April, it wants the following:

1. To ensure continuity, recognize CCHIT as the certifying body of EHRs.
2. To achieve incremental maturation of "meaningful use," adopt metrics that can be reasonably captured and reported beginning in FY11/2011, and then made increasingly stringent using intervals of not less than two years. HIMSS' definitions include specific metrics to enact, in phases, over a multi-year period.
3. To bridge existing gaps in interoperability of health information, coordinate with HITSP and IHE to create new harmonized standards and implementation guides.
4. Reconcile the gap between "certified EHR technologies," "best of breed," and "open source" technologies.

• Read the HIMSS definition for meaningful use of technology in hospitals
• Read the HIMSS definition for meaningful users of EHR technology
• Read the HIMSS letter sent to ONC and CMS
 

But where are we on the definition of meaningful use of an EHR?

HHS hasn't released a formal proposal for the final rules for meaningful use of EMRs. However, there are hints of what it might wind up including. National health IT coordinator Dr. David Blumenthal, speaking at the American Medical Informatics Association's annual symposium, said, "The meaningful use framework will be about the goals of care, not the technology." That's fairly vague, and Dr. Blumenthal didn't elaborate on the specifics.

My personal perspective on 'Meaningful Use'

Physicians should be aware that simply buying and installing an EHR doesn't always bring efficiencies to a medical clinic, or even prove meaningful use of an EHR. EMR software (also called EHR software) is only a piece of the complicated puzzle - it's only an enabler. Physicians would be well advised to do their homework to determine whether the promised ROI of the selected EHR system will actually be realized. And they should also recognize that the ball will be in their court when it comes to proving "meaningful use" of the EHR.

Contact us for a free 'no-obligation' Consulting Session to address any questions that you may have with regard to 'Qualified EHR', 'Meaningful Use', EMR Costs, etc.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Now with the Obama administration pumping in money in healthcare by incentivizing Physicians implementing certified EHRs and demonstrating meaningful use, many EMR vendors are again proclaiming the demise of Medical Transcription stating that after implementation of EMR / EHR Software, the Physicians can eliminate use of Medical Transcription services altogether.

While I agree that the role and nature of medical transcription will change in the new world, I do not believe that physicians and clinics can stop using medical transcription services altogether.

EMR solutions are based on point and click templates and capture data as discrete data elements. However, to any one intimately familiar with the nature of dictations and transcripts, it is obvious that there is a narrative part of the medical note which tells what the doctor is thinking during the patient encounter. How will this narrative be captured as part of eletronic medical records?

It has been shown that such narrative contributes to a detailed electronic medical record and supports meaningful use of the EHR. The narrative can either be produced in real-time using speech recognition software like Dragon, or it can be produced on the back end using traditional digital medical transcription services and input into the EHR by the transcription editors.

In a survey carried out, over 75% of the respondents indicated that they are interested in productivity aids that would help doctors to better document care within an EMR (beyond the standard point and click). Even though the accuracy of speech recognition software has improved significantly and it can be trained, most physicians find it a distraction - imagine the physician seeing the software wrongly transcribing and repeatedly interrupting his dictation to correct the transcript using keyboard and mouse - and do not want to take on the editing responsibilities.

Speed of charting has been one of the main sticking point with the physicians who complain that the EMR slows them down. Dictation is still the preferred method for physicians to document encounter notes. A possible solution that partly alleviates the concern of the physicians is to have the Medical Transcription Company introduce XML tags (in a semi-automatic manner), make the data elements ready for abstraction and then load the same into the EMR Software's database as discrete data elements. I would like to get feedback from readers if they have seen this technology solution successfully deployed.

According to Jay Cannon, EHR vendors need to work closely with the Medical Transcription service providers to deliver "hybrid clinical documentation solutions" that give physicians flexible choices for input, along with discrete, reportable data output for the EHR. I completely support this philosophy.

Our recommendation would be for prospective EMR customers to ensure that the EMR Software allows for an easy and unobtrusive interface for the provider to dictate and for the Medical Transcription Company to come in and transcribe right into the EMR or load final and structured documents into the EMR.

Do let us know of your comments and / or experience with implementing such a solution successfully.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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The American Recovery and Reinvestment Act of 2009 (ARRA) signed into law by President Barack Obama on February 17, 2009, specifically provides $17.2 billion in financial incentives designed to facilitate the widespread implementation of "certified" Electronic Health Record (EHR) systems into physician practices and hospitals. Physicians, facilities, and other providers will receive money through Medicare or Medicaid programs for their "meaningful use" of EHRs.

Note the use of two terms in the paragraph above - ‘Certified' and ‘Meaningful use'. For the purposes of this blog, we will confine our self to the definition of ‘Certified' EHR (aka Certified EMR Software) as it has been evolving.

Certification Agency for EMR Software

Even though CCHIT or Certification Commission for Healthcare Information Technology had not been explicitly mentioned under ARRA, it had been widely believed that CCHIT will be named as the certification agency. The Certification Commission for Healthcare Information Technology (CCHIT®) is a private, non-profit organization formed to certify electronic health records (EHRs), aka electronic medical records (EMRs) against roughly 475 criteria spanning EMR functionality, interoperability and security. But the situation has undergone a sea change since August 2009.

Certification Criteria

By mid-August, the ONCHIT's Policy Committee had approved a final version of the Matrix that would serve as the basis for EHR certification as mandated by ARRA. The criteria are not consistent with those used by CCHIT to certify EHRs. They are outcomes-oriented, while CCHIT's criteria are feature, structure and process-oriented.

Certification Agency

In 3rd week of August 2009, the Department of Health and Human Services announced it would almost certainly assume responsibility for deciding which electronic health record systems qualify for bonus payouts under Medicare, as required by ARRA.

In August 2009, the Health IT Policy Committee also adopted recommendations that called for multiple entities to certify EHR systems. The certification and adoption work group said it envisions the establishment of 10 to 12 different EHR certification groups, in addition to CCHIT.

CCHIT to provide Interim Certification

The Policy Committee also proposed a transition plan to help health IT vendors develop products that meet the 2011 meaningful use requirements.

Under the "Preliminary HHS Certification" process, CCHIT likely would provide interim certification for EHR vendors. The transition plan would invite CCHIT to submit a proposal for developing the preliminary certification process.
As you can see, the certification process has been evolving rapidly. We will keep our readers posted with the developments as they occur.

To learn more about Certified EMR Software, send us an email at info@revenuexl.com with your question and we will respond within 48 hours.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Electronic Health Records - Meaningful use is phased out

The definition of ‘Meaningful use of Electronic Health Records' has undergone a vast change since it was first mooted. With 2011 fast approaching, the authorities have obviously found it hard to reconcile the views of different parties - legislators, vendors, physicians and consultants. So what are the authorities doing? Phasing out the requirements and getting started with basic criteria to be met for satisfying meaningful use paradigm.

According to David Hunt, M.D., Chief Medical Officer in the Office of the National Coordinator for Health Information Technology (ONCHIT), the federal government now intends to implement a basic level of initial 2011 criteria for meaningful use of electronic health records systems to determine who will receive Medicare and Medicaid incentives under the American Recovery and Reinvestment Act (ARRA).

The government's meaningful use definition will probably focus on goals that hospitals and physicians can achieve quickly and reasonably. Thus, the Centers for Medicare and Medicaid Services will primarily be seeking evidence in 2011 that providers have purchased and are using EHRs. This may simply mean that you have to be able to send data and CMS has to be able to receive it.

Meaningful use of EHR to get tougher in 2013

The meaningful use criteria are expected to get progressively tougher in 2013 and 2015. The current thinking is to spread the meaningful use criteria for EHRs over three major phases: 2011 as a period of "structure," 2013 a period of "process" and 2015 a period of "outcomes."

• Meaningful use criteria in 2013 will focus on process measures to demonstrate providers have started to meaningfully use EHRs

• Meaningful use criteria in 2015 will be heavily outcomes-oriented with eventual efforts to measure the actual impact EHRs have on the quality of care.

It is expected that CMS will publish proposed rules in December governing meaningful use incentives and certification of EHRs for meeting meaningful use criteria and collect public comment for a period of 60 days.

Certification Agency for EHRs

It is also expected that the Certification Commission for Health Information Technology (CCHIT) will be one of the many entities that will certify EHRs as meeting meaningful use criteria.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.