Jarrod Shapiro, DPM Practice Perfect Editor Assistant Professor, Dept. of Podiatric Medicine, Surgery & Biomechanics College of Podiatric Medicine Western University of Health Sciences, St. Pomona, CA

Using EMR "Meaningfully"

When my wife and I had our second child, we also happened to buy a house just before the birth. When we moved in, we knew our house also included a kitchen with a bunch of cabinet doors. This seemed to be a strong check in the "Pro's" box. Now a little over a year has gone by and my daughter is a walking, talking, exploring entropy machine. As it turns out, she loves to explore each of those cabinets – all of which at the time of purchase seemed fantastic with their potential for increased storage – the contents of which now seem to hold some new poison or danger for my daughter. Sometimes I think she is deliberately trying to kill herself!

In some ways, it seems electronic health records (EHR) systems have become somewhat like my kitchen with its many cabinets. In the last ten to fifteen years, more and more physician offices have converted to EHR systems and many large companies have sprouted up to handle the demand. Medicine bought its new "house," the EHR, with all its purported benefits, to make practicing medicine easier. Now, with all the new health care laws and policies comes along the meaningful use baby, with all its hassles  and hazards for doctors.

For those who are not familiar with meaningful use – most likely those at the student and resident level – a quick review is in order.

Review of Meaningful Use

Part of the 2009 federal stimulus package included an act called the HITECH Act (Health Information Technology for Economic and Clinical Health act). This act set the use of EHR as a national goal and incentivized adoption of EHR by healthcare professionals and hospitals. This act provides monetary incentives to doctors and hospitals who use EHR (who accept Medicare reimbursement). However, in order to receive this money (up to $63,750 over 6 years), doctors have to show they are using their EHR in a "meaningful" manner.

What is "meaningful" you ask? There lies the challenging part.

What If I Just Say No ?

Oh yeah, just in case you didn't know, starting in 2015, those physicians who do not start using an EMR program will be penalized 1% of their Medicare payments, increasing to 3% over 3 years. Welcome to the new world of healthcare, kids.

What Does Meaningful Use Look Like?

As mandated by the government, meaningful use will take place in 2 stages. Stage 1 has been ongoing for some time now. CMS recently, as of September 4, 2012, published the final rules for Stage 2. Doctors and hospitals have to demonstrate their meaningful use for 90 days during their first year and for a full year during their second year. Requirements for Stage 1 must be completed before Stage 2 can be undertaken.

For stage 1, doctors and hospitals must have a "certified" EHR system and satisfy 20 of 25 objectives and must report on 6 total "clinical quality measures" (a core set and a menu Alanproviders will have to meet 17 of the 20 core objectives and 3 of 6 additional menu objectives.

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Core Requirements (current Stage 1) Read more: 2009 HITECH Act:

1. Use computerized order entry for medication orders.
2. Implement drug-drug, drug-allergy checks.
3. Generate and transmit permissible prescriptions electronically.
4. Record demographics.
5. Maintain an up-to-date problem list of current and active diagnoses.
6. Maintain active medication list.
7. Maintain active medication allergy list.
8. Record and chart changes in vital signs.
9. Record smoking status for patients 13 years old or older.
10. Implement one clinical decision support rule.
11. Report ambulatory quality measures to CMS or the States.
12. Provide patients with an electronic copy of their health information upon request.
13. Provide clinical summaries to patients for each office visit.
14. Capability to exchange key clinical information electronically among providers and patient authorized entities.
15. Protect electronic health information (privacy & security)

Menu Requirements:

1. Implement drug-formulary checks.
2. Incorporate clinical lab-test results into certified EHR as structured data.
3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
4. Send reminders to patients per patient preference for preventive/ follow-up care
5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
6. Use certified EHR to identify patient-specific education resources and provide to patient if appropriate.
7. Perform medication reconciliation as relevant
8. Provide summary care record for transitions in care or referrals.
9. Capability to submit electronic data to immunization registries and actual submission.
10. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission.

The purpose of all these objectives are to demonstrate health care improvements in 5 major ways:

1. Improve quality, safety,  and efficiency
2. Engage patients and families
3. Improve care coordination
4. Improve public  and population health
5. Ensure privacy and security for personal health information

The Cost !

I'm all for improving our health care industry and improving the health of Americans. I wonder, though, what this will do to the vast majority of currently practicing physicians, especially those in small group or sole proprietor businesses.  Instituting an EHR system is not a cheap prospect. According to one survey that reported the start-up costs for EHR in North Texas, for a 5 physician practice, the cost was $162,000 with $85,500  in maintenance expenses during the first year (Fleming, et al. 2011). They also estimated that it would take physicians 134 hours/person to prepare for use.

How Widespread has Compliance with the Program Been ?

CMS reported last week that total payments for the health records incentive program are now just short of 10.7 billion dollars.  More than 190,000 hospitals, office-based physicians and other "eligible professionals" have received payments, including 7,689 Podiatrists.  Podiatrists have received a total of $80,919,012 through December 2012.  I found it particularly interesting that 19,871 Nurse Practitioners received $257,398, 673 and 1,743 Physician Assistants received $17,238,000.  You can see where the workforce is growing.

I work in a relatively small multispecialty practice as part of a university, and we have multiple levels of individuals responsible for maintaining our EHR system and implementation of meaningful use, and it's a beyond-full-time job for them (much less the hassle for providers). I just don't see how this type of thing is possible for the single doctor.

Yes, There are Now Safety Latches on My Kitchen Cabinet Doors

As I write this editorial, we are installing safety latches on all of our cabinet doors. Interestingly, at work, I'm part of a committee looking into a new EHR system for our multispecialty practice building. In both cases, what sounded like a move forward – new house with lots of storage / electronic health system advancements – is turning out to be a lot more trouble than anticipated. It's a brave new world, one that might not be as friendly to doctors as we'd like.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References:

1. Fleming N, et al. Health Affairs, Mar 2011; 30(3): 481-489.

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This year brings numerous decisions and deadlines for doctors. They affect almost every area of medical practice, including electronic health records (EHRs); e-prescribing; coding; deciding whether to accept Medicaid patients; and deciding whether to offer employee health insurance. See which deadlines apply to you.
Also of interest: Where Meaningful Use Stage 2 Is Most Likely to Trip You Up Using EHRs: Dictating Creates Worse Care Hate Your EHR? Was It a Big Mistake? Here's What to Do Penalties For Physicians: They Keep Piling On

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