EHR

EHR: How to Become a meaningful user

Despite reports to the contrary, you can quality for federal incentives for EHR.

Jeff Grant, Shell, Wyo.

The final rules for "Meaningful Use" (MU) of electronic health records (EHR) were recently released by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health Information Technology. The rules were published in the Federal Register (the federal government's publication for rules, proposed rules and notices) on July 28, 2010 and became effective in late September. CMS provides a complete summary of the EHR incentive program on its website at www.cms.gov/EHRIncentivePrograms/, which includes links to an overview and definitions of such terms as certification, eligibility and meaningful user, as well a section that answers frequently asked questions.

Blogs, online forums and professional journals have circulated much information and misinformation about the ability (or inability) of optometrists to become "meaningful users of certified EHR technology," and, thus, their ability to qualify for the Medicare and Medicaid incentive payments.

The final rules, which I explain here, should clear up the most common misconceptions related to optometry.

Myth: O.D.s aren't considered "eligible professionals."

The definition of an "eligible professional" (EP) under the Medicare program, in both the original legislation and in the final rule, specifically includes optometry. It references Section 1861(r) of the Social Security Act, in which optometrists are mentioned, along with dentists, chiropractors and other clinicians.

So, optometrists definitely qualify for the Medicare incentive. Qualifying for the Medicaid incentive, which could be as much as $20,000 more than the Medicare incentive, but is based on the amount of your health information technology (HIT) investment, is a bit more questionable. The Final rule from CMS states:

"Thus, in keeping with the statute [the Social Security Act], a physician would be limited to doctors of medicine or osteopathy legally authorized to practice in their State, and, in cases where States have specifically adopted the option of 1905(e) in their State plans, optometrists."

So, not only is your ability to qualify for the Medicaid incentive questionable, but since it is based on your health information technology (HIT) investment, it might not actually pay you more money even if you can qualify. For these reasons, this article will focus on the Medicare incentive.

Myth: With no "optometry-specific" requirements, you can't qualify.

Misinformation and misunderstanding runs rampant around this issue. A recent article stated that "certification rules for optometry won't come out until 2013," implying that it might be better for you to wait for the optometry-specific rules. But no such rules exist on the radar screen.

The Certification Commission for Health Information Technology (CCHIT), one of the organizations that certify EHR systems, did note that their EHR certification program would not offer "ophthalmic-specific" certification criteria until at least 2013 (if ever). But two separate issues exist here. The first is the certification of EHR systems. The second is related to the MU criteria.

Right now, all EHR systems are being certified broadly as complete EHRs for either inpatient or ambulatory care, rather than for specific specialties.

ONC's final rule does address comments received about specialty certification needs:

"At the present time, we believe that the definition of Certified EHR Technology already includes some of the flexibility these commenters request … we believe we have integrated a balanced and appropriate amount of flexibility into the definition of Certified EHR Technology, which will also allow us to make additional refinements over time. We believe that it is possible, based on industry need, for us to specify in a future rulemaking sets of applicable certification criteria for Complete EHRs and EHR Modules designed for particular clinical settings."

So, while the ONC left the door open to maybe establish specialty-specific module certification sometime in the future, no present plans exist for such certification.

The MU criteria are the same for all eligible professionals. So, again, no special optometric requirements currently exist. Nor do special requirements exist for orthopedics, rheumatologists, ophthalmologists or other specialists. A meaningful user is an EP in any specialty who meets the MU requirements (or their exclusion criteria), which I will explain later.

Something else to keep in mind: Nowhere in the CMS final rule or the ONC final rule do any statements exist regarding specific deadlines for any specialty-specific criteria. So the message is clear: Don't base your EHR acquisition decision on anticipated optometry-specific EHR or MU rules.

Myth: Most optometrists don't have enough Medicare volume to make EHR a worthwhile investment for their practice.

Some optometrists don't have enough Medicare volume to get the full incentive to make EHR a worthwhile investment, and some may see no Medicare patients and, thus, receive no incentive. However, it is wrong to assert that "most" optometrists won't be able to receive any incentive money, as some observers suggest.

The reason: It takes only $24,000 in allowed Medicare charges in your "First Payment Year" (an entire year, mind you) to get the maximum first-year incentive payment of $18,000 (you're paid 75% of the allowed amount). That's only $2,000 in allowed charges per month, and many optometrists charge far more than that. Even if you have only $1,000 per month in allowed charges in your first payment year, that would still earn you an $8,000 incentive payment for that year.

The fact is that most optometrists can receive some incentive payment.

What do you have to do to become a meaningful user?

While the CMS and ONC require you to use a "Certified EHR Technology," it is important to understand that many of the certification criteria required are functions that will be performed by your EHR vendor. The top-tier EHR vendors are all working feverishly to become certified.

On August 30, the ONC announced the first two Authorized Testing & Certification Bodies for EHR systems:

► CCHIT, Chicago, Ill.
► Drummond Group, Inc., Austin, Texas

These entities have begun accepting applications for certification, and at press time, several vendors had earned the "Health and Human Services (HHS) Stage 1" certification for their EHR systems.

In addition to operating a "Certified EHR Technology," you will have to demonstrate that you are a meaningful user of the EHR technology in order to receive incentive money. Fortunately, most of the MU requirements are either processes you already have in place or those that require only minor changes to your clinical operations.

Of the 15 MU "core measures" that must be met in order to be eligible for the incentive payments, chances are that these five are part of your normal clinical documentation:

1. Maintain a problem list for more than 80% of all unique patients seen by the EP.

2. Maintain an active medication list for more than 80% of all unique patients seen by the EP.

3. Maintain an active medication allergy list for more than 80% of all unique patients seen by the EP.

4. Record demographics (preferred language, gender, race and ethnicity and date of birth) for more than 50% of all unique patients.

5. Maintain privacy and security (HIPAA) compliance. The following five core measures (numbers six through 10), also on the list, might require you to make some minor modifications to your normal documentation:

6. Record vital signs (height, weight, blood pressure), calculate body mass index (BMI) and display/print growth charts for more than 50% of all unique patients ages two and older who are seen by the EP. Any EP who believes that all three vital signs have no relevance to their scope of practice is exempt from this requirement.

7. Use Computer Physician Order Entry for 30% of your medication orders. You probably already record most "orders," and the final rule only requires that medications be recorded as an order. EPs who write less than 100 prescriptions during the EHR reporting period are exempt.

8. Record smoking status for more than 50% of all unique patients 13 years old or older seen by the EP.

9. Generate and transmit permissible prescriptions electronically (e-prescribing) for 40% of all permissible prescriptions. Any EP who writes less than 100 prescriptions during the reporting period is exempt.

10. Provide clinical summaries to patients for more than 50% of all office visits within three business days. While you probably aren't performing this step now, the clinical summary is something that your EHR software will need to generate.

Meeting the requirements of the other "core set" measures (numbers 11 through 15) may fall outside the scope of your current office procedures, but it is certainly not an insurmountable hurdle to comply with these requirements. These additional requirements are:

11. Implement drug to drug and drug to allergy checks. You merely have to "implement" these, as these are functions (checking for drug to drug and drug to allergy contraindications) that will be included in all "certified" EHR systems.

12. Implement one clinical decision support rule. You will also be required to electronically track your compliance with the rule.

13. Develop the capability to exchange electronically key clinical information (e.g., problem list, medication list, medication allergies and diagnostic test results), among providers of care and a patient-authorized entity, such as a caregiver.

14. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists and medication allergies) for at least 50% of patients who request it, within three business days of the request. Any EP who has no such requests during the EHR reporting period is exempt from this requirement.

15. Report clinical quality measures. This may be the requirement that will give practices the most headaches, especially those practices that have not participated in the physician quality reporting initiative (PQRI). Those practices that already participate in PQRI will be familiar with the requirements. CMS/ONC has made the first step relatively easy — merely requiring attestation of data generated by your EHR software in 2011. By 2012, though, your EHR software vendor must be ready to submit the data electronically.

In addition to these 15 items, CMS/ONC has listed 10 MU "menu set measures," of which you can pick the five you feel would be most advantageous to your practice (with the caveat that you must pick one of two "public health" measures — either number six or number seven, below). Some noteworthy exclusions exist to these measures, as the final rules state:

"An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply. For example, an EP that has an exclusion from one of the objectives … must meet four (and not five) objectives of the EP's choice … to meet the definition of a meaningful EHR user."

That's good news. Here is the list of menu set measures from which you can choose:

1. Incorporate clinical lab-test results into EHR as structured data.

Exclusion: An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period.

2. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach.

3. Send reminders to patients per patient preference for preventive/follow-up care.

Exclusion: An EP who has no patients 65 years old or older or five years old or younger whose records are maintained using certified EHR technology.

4. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists and medication allergies) within four business days of the information being available to the EP.

5. Perform medication reconciliation for any patient received from another setting of care or provider of care where the EP finds the encounter with the previous setting or provider relevant to the patient's current medical record.

Exclusion: An EP who was not the recipient of any transitions of care during the EHR reporting period.

6. Submit electronic immunization data to immunization registries and immunization information systems.

Exclusion: An EP who does not give any immunizations during the EHR reporting period.

7. Submit electronic syndromic surveillance data to public health agencies.

Exclusion: An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically. This merely requires a test of submission and a failed attempt meets the measure.

8. Perform drug formulary checks (your e-prescribing module probably already includes this capability).

Exclusion: Any EP who writes less than 100 prescriptions during the EHR reporting period.

9. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.

10. Provide a summary of care record for each patient who transitions to another setting of care or another provider of care.

As with the core set, the menu set provides the flexibility to pick those measures with which you are most comfortable, and the exclusions may significantly reduce the number of objectives that you must meet.

Worth your while

In summary, the changes required of you will be nominal, your Certified EHR Software will do much of the work for you, and you have flexibility in implementing certain measures during the first two years (during Stage 1). Enough compensation is certainly available to make it worth your time and effort ($44,000 per provider from Medicare).

Rather than focus on whether meaningful use rules are optometry-friendly, why not focus on the once-in-a-lifetime opportunity presented by the federal incentive, and the fundamental improvement in practice efficiency and patient care that a top-tier EHR application will allow you to enjoy?

And remember: If your sole motivation for implementing EHR is the short-term reward of incentive money, consider another approach. EHR should really be about all the other practice benefits, such as efficiency, better communication among health care professionals and improved management. Any incentive you receive is simply icing on the cake. OM

Mr. Grant is founder of HCMA, Inc., which specializes in management, operations and IT consulting for medical practices. E-mail him at jeff@hcma-consulting.com, or send your comments to optometricmanagement@gmail.com