EMRlogic Live

EMRlogic Live has moved!

2012-10-19T17:56:00.000-07:00

Please find EMRlogic Live now on HubSpot at http://go.emrlogic.com/blog. All previous posts have also been moved. If you view the blog via RSS Feed, it should transfer automatically. In the event you need to re-set it, you'll find a link on the new blog site.

Thank you in advance for following us!
Alistair Jackson

Meet TransforMED

2012-10-15T13:48:00.000-07:00

In our recently published paper, "The Roadmap to Inclusion" (available here for free download, see article #01-A8) we discuss a 5-phase continuum for ECP inclusion in the transformation of health care. We call the third phase, "position your practice for team delivery of care". None explains better what it means to transform your practice culture than TransforMED.

Why is it important that you get to know and understand the work of TransforMED? Several reasons:

1. TransforMED is a subsidiary of the American Academy of Family Physicians (AAFP), and a trusted leader in Patient-Centered Medical Home (PCMH) transformation. Its mission is the transformation of health care delivery to achieve optimal patient care, professional satisfaction and the success of primary care practices.

2. The Ohio Department of Health has recently selected TransforMED to provide tools and resources to assist in its Patient-Centered Primary Care Initiative. TransforMED will provide medical home facilitation services and resources to accelerate adoption of the PCMH model of care and help practices earn PCMH recognition by the National Committee on Quality Assurance (NCQA).

3. Ohio is one of the seven states/regions selected for the Comprehensive Primary Care Initiative, therefore a visible, observable and instructive example of how primary care will use PCMH transformation to shape the future of health care, including eye care.

4. Integral to the National Eye Care Communications Project and the CPCI, we believe independent Eye Care Providers must work intentionally to strengthen referral relationships with local Primary Care Physicians, especially those who are pursuing their own practice transformations to the PCMH model.

5. TransforMED is delivering the same message to PCPs practices as we are delivering to ECP practices. Read more here then continue to peruse the TansforMED website.

To your success!

Alistair Jackson, M.Ed.

Jim Grue, O.D.

The Romney Factor?

2012-10-12T02:00:00.000-07:00

There's a new myth circulating: that Romney, if elected, will abolish health care reform. As they say, don't believe everything you hear. The truth of this matter is more than likely quite the opposite. Abolish or accelerate?

The confusion originates with an old failure, the failure to distinguish between health care reform and health insurance reform. Obamacare is about health insurance reforms. Who gets covered and who pays? How? When? You know, the usual menu when it comes to money. That's very different from the basic tenets of health care reform: transparency, portability, interoperability, higher quality at lower cost. These are shared values that players and parties tend to agree on more than they differ.

As for the money side of the equation, we would naturally expect a Republican president to replace Obamacare with something like "Romneycare", right? Something's going to happen to redefine and rebrand the program. But what will those changes be?

Here's what the American Academy of Family Physicians had to say following last week's presidential debate (see the full statement here):

“Regardless of the election outcome, health care reform will continue. The AAFP calls for reforms that ensure Americans’ access to health care by building the primary care physician workforce, laying a path that enables all Americans to have health care coverage, and improves the quality and lowers the cost of health care services.”

Would you believe that, rather than abolish the reform movement, a new government could expedite it? How so? In reality, it's the federal government that is keeping the pace of change moving as slowly as it is. You've seen the delays: stage 1 certification was released months later than planned, now stage 2 is delayed (until October 2014) far behind the original schedule. The switch to ICD-10 codes has been postponed. By and large, the reasons are good ones, giving time for more public input, allowing room for industries to adapt.

An important pilot project in which the AAFP is deeply integrated - the Comprehensive Primary Care Initiative - involves both private and public payers. CPCI is a 2-year initiative at the behest of CMS. Were it up to the private payers, this project would wrap up in about 6 months.

More or less across the board, private industry would drive change much faster than government agencies permit. Without the political process and federal agencies applying the brakes, reform measures would accelerate not dissipate.

Alistair Jackson, M.Ed.
Jim Grue, O.D.

MU2 and Direct Messaging, Part 2.

2012-10-10T02:00:00.000-07:00

Last day, we looked at the clear inclusion of Direct Messaging as a Stage 2 MU requirement that helps you meet the objective for transitions of care. While SMTP is the primary standard being used by the HIEs, we believe that Direct Messaging will be the preferred communications option for independent healthcare providers, including ECPs.

In the Stage 2 Final Rule we also read that Direct Messaging will be central to Care Coordination and Patient Communications. Again, I am quoting from Dr. John Halamka's bog post, August 23, 2012:

Care Coordination data must be receivable using the Direct protocol and incorporated in structured form.
"(B) Data incorporation. Electronically incorporate the following data expressed according to the specified standard(s):(1) Medications. At a minimum, the version of the standard specified in § 170.207(d)(2); (2) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3); (3) Medication allergies. At a minimum, the version of the standard specified in § 170.207(d)(2)."

Our recent posts on the Comprehensive Primary Care Initiative are all about coordinated care. It is through care coordination that communications rubber meets reform road. As PCPs establish care teams, participating physicians (ECPs) must be able to exchange patient health information. Above we see specified meds, allergies and problems. But there's much more that can also be conveyed through Direct Messaging, and it's this "much more" that stands to set you apart as the ECP of choice for the care teams in which you wish to participate.

Health Information Exchange with Patients is required using the Direct protocol. EHR technology must provide patients (and their authorized representatives) with an online means to view, download, and transmit to a 3rd party the data specified below.

If you've been following our blog, you'll have seen us reference Microsoft HealthVault. Your patients (and you personally) can register for a free HealthVault account and a free Direct address. Your CEHRT software needs to allow you to send your patients their Summary of Care Record using Direct. And while this is a requirement for MU Stage 2, it is available from leading EHR vendors today.

Alistair Jackson, M.Ed.

MU2 and Direct Messaging, Part 1.

2012-10-08T02:00:00.000-07:00

In today’s and next day’s post, I would like to highlight some of the MU Stage 2 Rules that specifically concern Direct Messaging. To give due credit, the information that follows comes from John Halamka’s blog on August 23, 2012. Dr. Halamka, in turn, is commenting on the MU Stage 2 Final Rule. I’ll be picking out only the Direct Messaging items, so if you want a bigger picture, please use the link provided to go to Halamka’s blog.

SMTP is the required transport standard for all certified EHRs and has been included in the Base EHR definition, meaning that all EHR technology used by EPs, EHs, and CAHs and that meets the CEHRT definition will, at a minimum, be capable of SMTP-based exchange.

The SMTP standard is what mainly interests Health Information Exchanges. It’s not our primary interest today but sets the stage for the emerging importance of “transport”, which we also refer to as exchange or communications. As we have stated in our 5-phase continuum, we move from a stage 1 focus on EHRs to a stage 2 focus on communications.

There are two optional approaches for the transitions of care certification criteria SMTP/XDR and XDR/SOAP. The specific language reads, "The Secretary adopts the following transport standards:(a) Standard. ONC Applicability Statement for Secure Health Transport (incorporated by reference in § 170.299).
(b) Standard. ONC XDR and XDM for Direct Messaging Specification (incorporated by reference in § 170.299).(c) Standard. ONC Transport and Security Specification (incorporated by reference in § 170.299).

Today, I want to focus on (b) ONC XDR and XDM for Direct Messaging Specification. Note in the following that the ONC is providing “flexibility and options” for software vendors to help you meet the “transitions of care” MU objective. We believe this is particularly significant for independent eye care providers who need to be able to communicate both within and without health care systems. HIEs that primarily serve the interests of large health systems will neither favor nor facilitate the independent ECP. Therefore, Direct Messaging will become your friend and alibi.

To permit additional flexibility and options for EHR technology developers to provide their customers with EHR technology that has been certified to support an EP, EH, or CAH’s achievement of the “transitions of care” MU objective and associated measure, we have adopted two optional certification approaches for transport standards. • The first option would permit EHR technology to be certified as being in compliance with our original proposal: certification to both the Applicability Statement for Secure Health Transport specification and the XDR and XDM for Direct Messaging specification.
• The second option would permit EHR technology to be certified to: the Simple Object Access Protocol (SOAP)-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 standard and the XDR and XDM for Direct Messaging specification."

Join me next day to read more about the applicability of Direct Messaging to two vital areas: care coordination and patient communications.

Alistair Jackson, M.Ed.

Stage 1 Cornerstones to Stage 2 Communications

2012-10-01T02:00:00.000-07:00

Today's post is simply a pointer to a worthwhile reminder well said. Read Mike Jenkins, "MU stage 1 is the cornerstone of a much larger change".

Here's the short version:

Meaningful Use stage one is not about direct savings. Instead, this is building the stage for real reform down the road. ...

The HITECH Act and Meaningful Use stage one are about moving a lot of physicians from paper to online. The goal here isn’t to realize an immediate improvement in outcomes, but to lay the foundation for these improvements. Stage two is released and, guess what, it builds the walls. Meaningful Use stage two is about moving this data out of the physicians’ offices and hospitals and making it available electronically to patients who can then transport it to other physicians and hospitals in a format that can be readily consumed.

With such a plethora of information on the healthcare changes that we naturally want to resist anyway, it's easy to get shortsighted and myopic. One of our goals is to help you keep your eye on the big picture, moving forward knowing that you can reach the goal line way ahead of the pack. We help forward-thinking eye doctors win in the new healthcare game.

Alistair Jackson

So you wanted EHRs on your mobile device?

2012-09-29T08:56:00.000-07:00

In our work with forward-thinking eye doctors, we commonly encounter questions like:

Does your software run on the iPad?
Can I use a tablet PC?
Is e-prescribing connectivity available for my PDA?

While these are valid questions, they are often driven by a consumer mindset or perhaps by applications within healthcare that are more simplistic than what we encounter in the full scope of eye care. We've all seen the ads on TV about sending everything to the cloud and, of course, how dead simple it is to record all necessary health information on a tiny handheld device.

This week, we received a chilling reminder of the flip side of that magic and convenience: breach of ePHI through mobile devices. (See a link to the full story below.)

"The Massachusetts Eye and Ear Infirmary and Massachusetts Eye and Ear Associates Inc. (MEEI), will pay $1.5 million to the Department of Health and Human Services (HHS) for potential violations of the HIPAA Security Rule."

In the event ePHI is a new acronym, it means "electronic Protected Health Information". As we've discussed in recent posts, EHRs are doing a great job of helping us document patient health information, and the next step is to start communicating it among health care providers. Unfortunately, as acronyms go, it's easy to miss the fact that the P in PHI means "Protected" not simply "patient".

How well do you protect health information? Does your statement of HIPAA practices extend past that patient consent signature? Do your office computers have automatic log-offs? Are your mobile devices password protected? Do staff members use Instant Messenger for in-office or personal communications while at work?

At EMRlogic, since we have access to ePHI, we are held to the highest standards of accountability. Conducting annual HIPAA-HITECH security assessments and all-staff security awareness training is an expensive undertaking, one that can easily be allowed to slide. But oh what an economy relative to an ePHI violation, even a potential one!

How about your own business? Are you in good shape or running an uncalculated risk? Chances are high that you haven't gone far enough with the way you protect health information. May I humbly suggest you click here, read the full story on MEEI, think it through and, as they say, "if the shoe fits, wear it." Take steps this week to protect yourself as well as your patients.

Alistair Jackson, M.Ed.

Direct, how do I get it? (continued)

2012-09-26T02:00:00.000-07:00

Continued from Monday ...

In addition to the two types of Direct solution - integrated and standalone - there are two license types: individual and organizational. One state mini-grant program was based on the Provider’s state license number, so the Direct addresses awarded were individual addresses. However, communications tend to be better received at an administrative level in the practice than by the individual doctor, especially if the practice is a multi-doctor office. It’s a staff member who will check, receive and route a Continuity of Care Document (CCD) to the doctor who’ll actually be seeing the patient.

This last point perhaps begs the question, “Why would doctors want an individual address and not just an organizational one?” The answer is the directory listing. If the doctor wants to be individually listed in the directory, then an individual address is required. The reasons why you may want an individual listing are many but e-prescribing once again offers a good analogy.

We know that a Provider pays for an eRX license based on the NPI# and, in some states, DEA # as well. Any Provider can also have a Provider Agent and the Provider Agent does not pay. Strictly speaking, a practice could use one doctor for all prescriptions with every other doctor logging in as a Provider Agent. However, the Rx will be filled under the licensed Provider’s name. Most doctors don’t want the name of a partner doctor showing up on their prescriptions, therefore, they will purchase their own license. Similarly, doctors will want the option of having a PHI communication (Protected Health Information) sent to them individually not always to the practice’s admin address.

Lastly, if you've been following our discussion around care teams, there’s the question of ECPs going to PCPs to establish the sharing of Summary of Care Records (SCR is the new term for CCD). In all likelihood, many PCPs will not know about Direct. If the PCP is tied into a health system, the process of beginning to share SCRs outside the health system or HIE may be very convoluted. We anticipate that ECPs will need to help PCPs “go Direct”. To facilitate this and remove the sales barrier of having to buy a Direct license, your HISP (as ours has done) may offer a 90-day free trial to the PCP. All going well and the value proven, the PCP will purchase a license at the conclusion of the 90-day trial period.

Wishing you the best as you pursue Direct and position yourself as a local leader and "must-have" eye care provider for care coordinators everywhere around you. Remember, if you need help along the way, that's what the National Eye Care Communications Project is all about. It's open for all. Learn more here and join us for a webinar or working session every 2nd and 4th Tuesday of the month, 8pm Eastern.

Alistair Jackson, M.Ed.

Direct, how do I get it?

2012-09-24T11:22:00.000-07:00

If we've done a half decent job of convincing you that you need to get your hands on Direct, you may still be wondering how you get access to these secure communications capabilities.

The first thing to note is that you must work with a Health Information Service Provider (HISP). In some cases, the HISP may be identified and accessed through your state office. For the state Health Information Exchange, there are usually several state-approved HISPs. More importantly, the state office may still have a grant program for which you can qualify. We know of some states that offered a mini-grant for a first year free license. However, as time passes, the incentive programs will expire and more and more we'll see HISPs that simply operate in all states.

Once you've identified a HISP (your software vendor may also be working with a preferred HISP, as we are) you'll find that Direct is available in two ways: one, as an integrated solution within your EHRs and, two, as a non-integrated solution. The latter is an online solution that you'll access through either a web portal or some sort of email client. Note that if you're getting Direct free through your state HIE, you're probably being offered a standalone solution as regards your own EHR. It may connect to the state HIE but it's only your software vendor that can embed the functionality into your eye care EHR. So, the integrated solution is only available if your software vendor has done the integration work.

So what are the advantages of an integrated solution versus a non-integrated or standalone one? An integrated solution through your vendor will offer significant workflow efficiencies, such as having the communications at your fingertips within the exam record. A non-integrated portal will not give you such an embedded solution in your clinician workflow. Software vendors won’t likely interface directly with every state-based HIE or HISP so when states do provide a free portal, it is a non-integrated web-based portal.

Perhaps the best example I can give of free versus integrated would be e-prescribing. In the early days of the NEPSI program, we saw a free online solution. That was a 5-year pilot program that eventually became a paid service. More important, it was never an integrated solution and did not qualify most users for Meaningful Use. Certified Complete EHRs require a fully integrated eRX solution. Though Direct is not (yet) part of MU Attestation, the question of efficiency remains important for doctors, and embedded solutions mean greater efficiency.

To be continued ...

Alistair Jackson, M.Ed.

Does eRX History Violate HIPAA?

2012-09-17T20:13:00.000-07:00

Does viewing your patients' e-prescribing history violate HIPAA? If this seems like a strange question, imagine the surprise of one of our clients, an optometrist in a retail setting, who was told he could not use his certified EHRs on the premises because its ability to show a patient's eRX history was a HIPAA violation ... and that, if he continued, his lease would be terminated!

There are several questions here: Is this truly a HIPAA violation? Does it actually have anything to do with EHRs and Meaningful Use? From where does such misunderstanding emanate?

HIPAA.

Your legitimacy in viewing a patient's eRX history is not a function of the ability of the EHR to show it, rather a function of your permission to do so. If you have obtained the patient's consent through her/his signature of your statement of HIPAA privacy practices, there is no violation of HIPAA. The Privacy Rule (full text available on the HHS website) sets rules and limits on who can look at and receive a patient's health information. Here are two relevant points for this discussion:

Your health information can be used and shared: (1) For your treatment and care coordination, and (2) To make sure doctors give good care and nursing homes are clean and safe.

Certified EHRs.

In the case under consideration, the management claimed other doctors had completed Meaningful Use Attestation and had not needed to view the patient's medication history.
While it is a true statement that no MU objective requires an Eligible Professional to look at a patient's eRx history, a certified Complete EHR must embed an e-prescribing solution. It is not acceptable to use a standalone e-prescribing solution when the EHR being used for Attestation is a Complete EHR.

We must also ask the question, could an EHR be certified by the Office of the National Coordinator if its use constituted a HIPAA violation?

Misunderstanding.
The management in question above further insisted that the doctor provide a statement of proof of necessity along the lines of "The doctor must attempt to get a patient's history of medications and allergies through the eRx software."

In our opinion, this is a misunderstanding of the privacy rule, pitting HIPAA against MIPPA . Yes, it is valid to seek to protect patient privacy. However, as seen above in the HHS rule, health reform is about improving treatment and care coordination. A doctor can only be alerted to medication allergies and contraindications if other medications are known.

Protected Health Information is protected for a reason but "protecting" patients against those whom they have chosen to ensure their treatment and care coordination is indeed a misunderstanding of both the letter and the spirit of the health laws.

Alistair Jackson, M.Ed.
Jim Grue, O.D.

One more cup please! (CPCI, Part 3)

2012-09-14T02:00:00.000-07:00

Today is the third part of a series looking at the Comprehensive Primary Care Initiative. See Monday and Wednesday for parts 1 and 2.

The CPCI will test two models simultaneously: a service delivery model and a payment model. For now, we'll look only at the payment model:

Payment Model. The payment model includes a monthly care management fee paid to the selected primary care practices on behalf of their fee-for-service Medicare beneficiaries and, in years 2-4 of the initiative, the potential to share in any savings to the Medicare program. Practices will also receive compensation from other payers participating in the initiative, including private insurance companies and other health plans, which will allow them to integrate multi-payer funding streams to strengthen their capacity to implement practice-wide quality improvement.

Of particular importance here are two things. The first is the care management fee. Do you think PCPs are motivated to take on care coordination? You bet they are! The second is the inclusion of private insurance companies. For those who do little by way of Medicare volume, it's essential to understand that health care reform is not about Medicare alone; it only starts there. The transformation is ubiquitous; it's for every patient, every provider and every payer.

Elsewhere, we'll learn about bundled payments, a new approach to reimbursement that is centered around coordinated care. Coordinated care and the patient-centered medical home are inextricably linked within the CPCI. So we must foresee that, as noted above, the service model and the payment model go hand in hand. Change one and you change the other. Are you preparing for the obsolescence of fee-for-service direct billing? Are you ready to participate in team-based care? Getting ready means EHRs, communications and showing your value as a health care provider to the primary care physicians in your patient catchment area. This is not about stimulus money; it's about scoring winning goals in the new health care game.

Alistair Jackson, M.Ed.
Jim Grue, O.D.

More coffee anyone? (CPCI, Part 2)

2012-09-12T02:00:00.000-07:00

We told you last day that we now know the names and locations of 500 primary care practices in seven states involved in the Comprehensive Primary Care Initiative. Understanding the significance of this announcement is tied to knowing something about the purpose of the initiative. Below, I've taken only two of six things the PCPs are being incentivized to do:

Deliver Preventive Care: Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.

Coordinate Care Across the Medical Neighborhood: Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Under this initiative, primary care doctors and nurses will work together and with a patient’s other health care providers and the patient to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.

The first point emphasizes preventive care, which Optometry in particular is all about. Prevention is a major tenet of healthcare reform because it lowers cost. Therefore, we should have no doubt that healthcare reform is relevant to Optometry.

Second, "other health care providers". That also includes you ... but provided you are plugged into the meaningful use of electronic health records.

EHRs are not an end in themselves. You gather data in EHRs in order to share it. You share it in order to participate. Participate in what? Coordinated care. Why? As we'll see next day, coordinated care will become the predominant payment model. Without the ability to participate in team-based care delivery, you will lose access to your patients.

Alistair Jackson, M.Ed.
Jim Grue, O.D.

Good morning! Coffee anyone? (CPCI, Part 1)

2012-09-10T02:00:00.000-07:00

On August 4th, we published a post entitled, "PCPs, your new best friends". We wrote about a health care pilot program called the Comprehensive Primary Care Initiative and its importance for eye care. Last week, while many of us were either taking part in or traveling to Vision Expo West, something significant happened: CMS published the names and addresses of every participating PCP practice.

There are 500 primary care practices participating in the CPC initiative, representing 2,144 providers serving an estimated 313,000 Medicare beneficiaries.

Arkansas: Statewide
66 Primary Care Practices | 228 Providers | 4 Payers
Estimated 51,000 Beneficiaries Served

Colorado: Statewide
73 Primary Care Practices | 335 Providers | 9 Payers
Estimated 41,000 Beneficiaries Served

New Jersey: Statewide
73 Primary Care Practices | 252 Providers | 5 Payers
Estimated 42,000 Beneficiaries Served

New York: Capital District-Hudson Valley Region
75 Primary Care Practices | 286 Providers | 6 Payers
Estimated 40,500 Beneficiaries Served

Ohio & Kentucky: Cincinnati-Dayton Region
75 Primary Care Practices | 261 Providers | 10 Payers
Estimated 44,500 Beneficiaries Served

Oklahoma: Greater Tulsa Region
68 Primary Care Practices | 265 Providers | 3 Payers
Estimated 45,000 Beneficiaries Served

Oregon: Statewide
70 Primary Care Practices | 517 Providers | 6 Payers
Estimated 49,000 Beneficiaries Served

Why is this so significant? Because it spells out for us in clear terms where the transformation of health care is taking us. Join us next day for more details. Or, if you can't wait to learn more, read here.

Alistair Jackson, M.Ed.
Jim Grue, O.D.

Two words: Stage 2 (Part 3 of 3)

2012-09-07T02:00:00.000-07:00

Today's post is a continuation from our last two days, a discussion of some highlights of Meaningful Use Stage 2 presented by Dr. Farzad Mostashari, ONC Director. Please see Part 1, published Monday, September 3 and Part 2, published on Wednesday, September 5, 2012. We are considering several key concepts in Meaningful Use Stage 2. These are not new concepts, rather concepts that have come into the limelight in Stage 2.

Part 3 of 3.

Sharing "across vendor boundaries ... and with patients".
In various blog posts over recent months, we have been somewhat outspoken about large health systems. We believe there is significant resistance, especially on the part of health systems, to the open exchange of health information. We've observed massive efforts to create health data repositories - health information exchanges that readily accept data into the system but demand a query in order to get information back out. That's a control tactic, one that we believe is not in the interest of higher quality, lower cost. So, we say three cheers to this statement! "By 2014, providers will have to demonstrate, and vendors will have to support, the actual exchange of structured care summaries with other providers—including across vendor boundaries—and with patients."

Let's not miss that last part ... "and with patients." The communications door is opening wide to include your patients. Again, no longer is it about giving patients a printed copy of their CCD; it's about sending them an electronic copy the same way you would to another provider - a secure electronic transmission. Can you say Direct? Or how about HealthVault? This is precisely why we have been such strong advocates of the Direct Project, why we have implemented Direct into our EHRs and why we are encouraging our providers to start using personal HealthVault accounts. It's the only way to be ready when your patients begin asking that their Summary of Care be sent to their HealthVault account.

Data silos and "walled gardens".
While I cannot put words into the mouth of the ONC Director, I believe - my opinion - he is addressing the above-mentioned reluctance of some large health systems and state HIEs to embrace the free and direct sharing of health information. This is leadership. This is a heads-up about the transformation of health care. One way or the others, folks, this is where we're going! "As we stated unequivocally in the final rule, we will pay close attention to whether the requirements in the rule are sufficient to make vendor-to-vendor exchange attainable for providers. If there is not sufficient progress or we continue to see barriers that create data silos or “walled gardens ,” we will revisit our meaningful use approach and consider other options to achieve our policy intent."

Nationwide health information exchange.
Let's be clear about the "policy intent". It's about nationwide not statewide health information exchange. It's about open access not controlled access. And it's about direct exchange not circuitous exchange.

Alistair Jackson, M.Ed.

To read Dr. Mostashari's full article, see Meaningful Use Stage 2: A Giant Leap in Data Exchange.

Two words: Stage 2 (Part 2 of 3)

2012-09-05T02:00:00.000-07:00

Today's post is a continuation from last day, a discussion of the highlights of Meaningful Use Stage 2 by Dr. Farzad Mostashari, ONC Director. Please see Part 1, published Monday, September 3, 2012. We are considering several key concepts in Meaningful Use Stage 2, not new concepts, rather concepts that have come into the limelight in Stage 2.

Part 2 of 3.

Common datasets, structured and coded data.
If you've done much reading up on Stage 2, you'll have seen these terms used frequently. What are common datasets? Consider that, over the course of your life as a physician, your every patient will see potentially hundreds of different doctors in a variety of settings: family physicians, dentists, eye care providers, hospital and emergency room physicians, and specialists of many descriptions. Since these many doctors will use a host of different software solutions, how do we have any hope of achieving the meaningful exchange of health information? The answer is datasets, data structured to share a common language. If you call it one thing and I call it another, it's the common dataset that tells us we mean the same thing. ICD-10, SNOMED and LOINC codes are good examples of how information from disparate systems can be communicated effectively, even if the human languages are foreign to each other.

Another example: as providers exchange CCDs or SCRs, the documents are validated against a NIST standard. It's this standard that allows one EHR to consume the data sent from another, creating a new patient file or adding to an existing one. This consumption of data marks a fundamental difference - that "giant leap" - between receiving then viewing a fax (the good ol' fashioned way) and seeing that new data entered automatically into your electronic health record, no keystrokes, no mouse-clicks (the new speed-you-up way).

What about structured data? Structured is most easily understand in contrast against free- text. In a free-form field, you would type your notes. It's completely up to you what you type. If you use voice entry, same result. The problem with free text - or unstructured data - is that it is not searchable. New smart technologies are introducing the ability to structure free text but this is far from an available norm today. Structured data is basically organized in such a way that analytics tools can be used to make sense of the data, see trends, determine best outcomes and best practices, for example.

Datasets, structured and coded data remind us that EHRs are not simply about recording results in a neat, legible record, rather about sharing and analyzing data in order to improve healthcare. Core values in health reform: higher quality, lower cost, better patient outcomes.

To be continued ...

Alistair Jackson, M.Ed.

To read Dr. Mostashari's full article, see Meaningful Use Stage 2: A Giant Leap in Data Exchange.

Two words: Stage 2 (Part 1 of 3)

2012-09-03T02:00:00.000-07:00

At an ONC-sponsored "summit" in late May in Washington, Director Farzad Mostashari, M.D. told the audience that many of the things we'd been looking forward to, needing, in order to move healthcare to where it must go, could be wrapped up in two words: "Stage 2". In my opinion, he has delivered as promised.

In Meaningful Use Stage 2: A Giant Leap in Data Exchange, Dr. Mostashari reflects on a number of the key concepts that both he and we have been discussing for some time now. But before we go there for a high-level review, let me re-state that our distinct purpose here on EMRlogic Live is to sift the greater reform discussion down to its eye care essentials. Here at least we are, and without apology, looking at the transformation of health care in terms of what it all means for eye care providers, whether optometrist or ophthalmologist.

Let me also be clear in acknowledging that Meaningful Use per se, Stage 1 or Stage 2, has nothing to do with any specialty. MU distinguishes between the Eligible Professional (EP) and the Critical Access Hospital (CAH) but not between the primary care provider and the specialty care provider, at least not yet. Nevertheless, there are implications for primary care and specialty care. Those are of particular interest to us. We see those implications unfolding largely through pilot projects and new initiatives, all of which are part of the package we call "the transformation of healthcare".

Let's look at some key concepts that have been around for many years but which come now to the forefront, in the limelight of Meaningful Use Stage 2:

Exchange and interoperability.
The discussion is no longer simply about "meaningful use" but now about "meaningful use and health information exchange". Meaningful use of EHRs, insofar as they involve the electronic documentation of health information, is now more or less assumed. Remember when software for your practice meant scheduling and billing software? Today, that's not what you go looking to buy. You're looking for EHRs and just assume they also do scheduling and billing, and a bunch more stuff as well. Same deal here. Of course EHRs gather the information you need! The new question is, "Can they communicate?" As of today, for most the answer is no. Stage 2 is about changing that answer to yes.

Summary of Care Records.
In Stage 1, we saw CCDs and CCRs. With some fine tuning, they're now essentially consolidated into SCRs, Summary of Care Records. "The Meaningful Use Stage 2 final rules define a common dataset for all summary of care records, including an impressive array of structured and coded data to be formatted uniformly and sent securely during transitions of care." In Stage 1, CCDs and CCRs were used for, respectively, patient-oriented and physician-oriented continuity of care. The focus on transitions of care has not changed; it's now just more doable, the higher standard now more achievable and, therefore, expected. So again, we're moving from documenting to communicating. It's time to internalize the idea that your EHRs are not about merely gathering but also exchanging health information. And to be clear, that's not about printing, faxing or emailing a traditional referral letter. The SCR is about the use of a common data set, a standardized interoperable document sent as a secure electronic transmission.

To be continued ...

Alistair Jackson, M.Ed.

A perfect scenario ... perfectly bad!

2012-08-29T15:27:00.000-07:00

A friend phoned me today with a question about medical homes and coordinated care. After hearing his scenario, I responded, "Perfect!" Unfortunately, it was a perfectly bad scenario that describes exactly how unprepared optometrists will start losing access to their own patients. I'm sorry to say it, here's the bad news ... then some good news.

An optometrist sees a patient for a regular eye health exam, does the usual diagnostic testing, and then some, and determines the patient needs to see an ophthalmologist. The patient visits the ophthalmologist who happens to be involved in a care team through an ACO or medical home. Although the patient had chosen the optometrist for the initial visit, the ongoing care is now turned over to the care coordinator whose job it is to coordinate all the care of the patient. The care coordinator schedules a follow-up visit with the care team's optometrist instead of going back to the referring optometrist.

Yes, we can hear the outcry. Unfair. Wrong. Bad business. And no doubt there's some merit to those cries. It'll happen nevertheless. The reason may constitute an unfair betrayal but it may also be legitimate.

This scenario sits in the middle ground between legislation and reality. The legislation says patients may choose their Medicare provider but the reality is they'll often just go along with the recommendation of their doctor's office. Remember that medical homes and care coordinators are incentivized, so some will be rather convincing about the reasons to see team doctors. Also remember that there may be legitimate new reasons to have patients switch specialty providers.

What if the referring optometrist does not use EHRs? Or, the O.D. has EHRs but doesn't use them for communications. The optometrist may know nothing about care teams or medical homes, so hasn't attempted to connect with the local provider network. All of these are reasons a provider cannot be included - doesn't qualify - when it comes to team delivery of care or bundled payments.

On the other hand, let's say that optometrist is you, and you have implemented not only a certified EHR but also DIRECT communications capabilities. Admittedly, in this case you'd have been proactive enough not to end up here in the first place. But supposing you did somehow, you'd now be in a position to step in and prove value to that care team, perhaps even add more value than the incumbent optometrist.

Do you have questions or scenarios for which you'd like to see an explanation? Submit them through the Comments and Reactions area below this post, or email us. We'll be happy to respond.

Alistair Jackson, M.Ed.

ACOs, Unlikely Homes for Medical Homes - Part 3 of 3

2012-08-24T02:00:00.000-07:00

Continued … see part 1 of this discussion, published Monday, August 20

OK, so you’re a skeptic and the numbers from last day look just too good to be true. Let’s take a more conservative view. While the above scenarios are supported by actual clinical tests and situations, let’s suppose they are best-case scenarios and therefore extreme. If the savings were only 15% of the above, the medical home provider could still see over $100,000. Let’s say then that the medical home decides to keep 50% of the shared savings and divide the other 50% among the other team members. This means adding only $50,000 to the income of the primary care physician. Current average PCP income = $135,000. Add $75,000 net for care coordination. Add $50,000 from shared savings. $260,000. We now have a program that, even when viewed from the most conservative vantage point, is structured to bring the income of the primary care physician from $135,000 to $260,000. In essence, the program is designed to double the income of primary care physicians who decide to participate in medical home style delivery and reimbursement systems.

We can start to understand now why payers are willing to work together to fund the coordination of care through pilot programs like the Comprehensive Primary Care Initiative (CPCI). We can also see why 200 primary care physicians attended the first organizational meeting of the CPCI in one small city in Ohio. And we can also understand why ACOs would not embrace this process or why, in fact, they would put as many barriers as possible in place to prevent such a system from being implemented. As we have stated already, the regulations by which ACOs can be established are so complex that almost all ACOs are large health systems. These health systems primarily generate their income from specialty care while the savings are being generated through primary care, coordinated care and the medical home.

It is clear to see that the maximum cost savings, and the biggest boost to improving quality of care is going to work when the medical home is a separate business entity from the health system. Predictably, we would not expect to see ACOs embrace the medical home. On the other hand, we would expect to see – and are seeing, in fact – huge popularity of the CPCI among independent primary care physicians. ACOs are resisting expansion of the medical home even publishing negative studies to resist the concept from being established as part of the new delivery system.

Jim Grue, O.D.

Alistair Jackson, M.Ed.

ACOs, Unlikely Homes for Medical Homes - Part 2 of 3

2012-08-22T02:00:00.000-07:00

Continued … see part 1 of this discussion, published Monday, August 20

When a new medical home is formed, a rather complex set of formulae is used to predict the cost of care in the traditional delivery system. Going forward, the actual cost of coordinated care is tracked, so eventually it is known whether the coordinated care or the traditional care was more expensive. The hypothesis is that coordinated care is able to deliver better quality at a lower cost, so let’s assume that the coordinated care, in fact, ends up less expensive. At least in these early years, the formula for shared savings dictates that the medical home gets paid 85% of the savings. Yes, almost the complete amount saved through the medical home’s coordinated care approach is given back to the medical home. This will no doubt change over time; a big return is intentionally structured as a major incentive in order to convert quickly to the new model, a similar approach to the EHRs incentive program – money speeds adoption.

Now let’s look at the savings possible. Almost all providers, new to the medical home concept, are concerned that the primary care physician will act as a gatekeeper, preventing them from seeing the patient or doing the required tests. In reality, nothing could be further from the truth, which we’ll see below. Cost savings are not generated by reducing or eliminating necessary care. In fact, the maximum savings are generated when the coordinator ensures that the patient receives the very best care. It is difficult to think of an example where poor care is less expensive than the best care. If a patient isn’t properly diagnosed and treated then invariably there are more visits to eventually get it right. If the best surgery is not performed, the result is simply more after-care at higher expense. So the first mandate of a care coordinator is to make sure all care received by every patient is the best available. This alone will generate savings.

The next step is to eliminate duplication of care that doesn’t result in better outcomes. A familiar scenario will serve us well here: in eye care, if an optometrist does specialty tests then has to refer the patient to an ophthalmologist, in almost all cases, the ophthalmologist repeats every specialized test. In the case of ODs and retinal specialists co-following patients, both typically see the patient on an ongoing basis and both continue to perform the same specialty tests. This happens right now because the two specialists get to decide what tests they want, not to mention that it’s in the economic interests of both to perform the tests. If we were in a position to coordinate the care of this patient, we’d know exactly how to increase those shared savings! We’d make sure the appropriate tests were being done but by one provider only and we’d have the results shared by all providers seeing the patient. The only time a test would need to be repeated would be if there was a question of its accuracy, which then gives the coordinator the incentive to ensure that the office that performs the tests is the one that proves over time its ability to get the most consistent, accurate results.

Scenarios like this one are replicated in different ways throughout medicine every day. So, the care coordinator has two simple tasks that create huge savings: ensure every patient receives the best available care at every visit; identify and reduce or eliminate redundant costs which do not improve the quality of care.

Studies have shown that these two things alone have the potential to reduce the total cost of care by as much as 30%. Those are big dollar amounts. When we consider that the cost of health care in the United States is approximately $7,000 per person per year, we start to see the potential shared savings. Using this figure, a medical home coordinating the care of 500 patients is coordinating $3.5 million dollars of care per year. If 30% can indeed be saved, the potential savings is over $1 million. The 85% rule tells us that the medical home could receive over $850,000 from shared savings. These are staggering numbers for PCPs whose average annual earnings are currently $135,000. Do we dare think PCPs are not all over this opportunity? If in doubt, check out the website of the American Academy of Family Physicians and see what they’re doing about the PCMH initiative.

To be continued …

Jim Grue, O.D.

Alistair Jackson, M.Ed.

ACOs, Unlikely Homes for Medical Homes - Part 1 of 3

2012-08-20T02:00:00.000-07:00

In the early days of Accountable Care Organizations, it seemed they would be the natural resting place for the patient-centered medical home (PCMH). That thinking has changed. While it appears ACOs may use some medical home concepts, there is growing doubt about the compatibility of the two entities. Let’s understand why.

Why would ACOs would be resistant to medical homes? First, the medical home concept promotes coordinated care and shared savings, core values in health care reform. Second and fundamentally, health care reform means a change in the financial positioning of primary care versus specialty care. In the current fee-for-service system, some would contest, primary care is underpaid while specialty care is overpaid. The balance is shifted by the core tenets of health care reform so that primary care becomes better paid, basically at the expense of specialty care. And hospitals and health systems, where ACOs typically reside, are predominantly specialist-oriented.

For the sake of simplicity in the following discussion, we’ll be viewing primary care and specialty care in separate business contexts even though we know that within hospitals, health systems and ACOs the two exist under one roof.

To begin, let’s use precise figures from the Ohio Comprehensive Primary Care Initiative (CPCI); it is modeled as a medical home and we know the numbers. Reimbursement for primary care physicians through the medical home model involves two key changes: the first is that the medical home gets paid a separate fee for coordinating the care of patients; secondly, the medical home gets to share in the savings created as a result of care coordination.

What is the effect on PCP income of getting paid for coordinating the care of patients? Let’s assume that the office of a primary care physician can coordinate the care of 500 patients. This requires the medical home to hire an additional staff person at a cost of $50,000. The CPCI in Ohio is paying $22.50 per head per month for care coordination. This generates $11,500 per month, or $138,000 per year, in additional revenue to the medical home. After the cost of the additional staff person, the new revenue leaves $88,000 for organizational profit. Supposing that the medical home provider has some miscellaneous expenses, we’ll allocate $75,000 toward profit. The average income for a primary care physician in the USA today is $135,000. Therefore, by becoming a medical home, a primary care physician practice increases its income to about $210,000. So we can see how becoming a medical home, versus remaining simply an independent PCP practice, can significantly increase the income of the primary care physician. Yet, we haven’t begun to consider the real income-increasing potential of a medical home: shared savings accounts. This is where it gets interesting.

To be continued …

Jim Grue, O.D.

Alistair Jackson, M.Ed.

Getting personal about Health Care Reform

2012-08-17T02:00:00.000-07:00

On August 13, Medscape News Today published a rather worthwhile read: Healthcare Reform: It is Getting Personal by Steven D Shapiro of UPMC. Here's the outline:

Abstract and Introduction
Patient-centered Accountable Care
Evidence-based Care Pathways & Clinical Effectiveness Research
Molecular Networks
Targeted Therapy for Cancer & the Cost–benefit Equation
Scientific Approach to Personalized Medicine
The Electronic Health Record & Analytics
Conclusion
Future Perspective

Don't let the number of topics fool you; it's not an overly lengthy article. Outside of molecular networks and cancer therapies, Shapiro covers many of the same themes we articulate here on EMRlogic Live, most of which come down to understanding the essentially predictable tides of change in healthcare, forsaking expensive and ineffective fee-for-service models and moving to a new era of patient-centered care that leverages the power available through health information technology.

In his Future Perspective, Shapiro wraps up with:

"Sharing of data is another hurdle. This includes both patients' willingness to share their personal genetic information, as well as physician and scientist willingness to work together. .."

Let me add to that the willingness of health systems to share data. Shapiro advocates that "Medical centers should strive for a central data warehouse" ... providing "a 'single source of truth'. In a perfect world, data repositories could be powerful tools. To the degree however that the warehouse is controlled (knowledge is power) or information kept for economic gain, we shoot ourselves in the foot.

Since it's getting personal, let's not do that.

Alistair Jackson, M.Ed.

You asked about ACOs - Part 2, Team Delivery of Care

2012-08-15T02:00:00.000-07:00

... continued from last day. For a brief discussion of ACOs and Communications, see Monday, August 13.

Team Delivery of Care

We clearly see a corollary in the development of team-based care delivery: the purists would like to see a system where all providers could form into teams to deliver care in the most efficient and cost-effective ways and in which all providers could participate in shared savings accounts. Large health systems want to maintain their dominance and even extend their control over the delivery system. What we are seeing arise is a number of programs that represent the gamut between these two extremes.

On the one extreme are ACOs which revolve around a myriad of regulations to the point that it is difficult even to understand exactly what ACOs can and cannot do. The bottom line is that this complex set of regulations restricts ACOs to relatively large health systems in order to fulfill all the requirements. This, of course, favors health system domination and, in fact, was pushed as a complex system by the large health systems.

On the other end of the spectrum is the new Comprehensive Primary Care Initiative, which was effected largely by the designers of health care reform and pushed by the Office of the National Coordinator. These stakeholders want to see competition in the health care marketplace and access by providers at all levels.

From an eye care perspective, we believe it is important for every eye care provider to have a general understanding of ACOs and health information exchanges, knowing that both are too complex and too diverse to be fully understood in terms of what they can and cannot do. Every eye care provider, on the other hand, should have an intimate knowledge of how DIRECT works and the significance of the Comprehensive Primary Care Initiative, as these are the two programs that most parallel the original goals of the health care reform movement. They also show how providers may work together, through coordinated care, to provide the highest level of care within a structure that openly communicates patient health information between providers. Seeing the significance of shared savings when controlled by primary care is a key to understanding the importance of team care delivery and reimbursement.

Once again, we believe the way that independent eye care providers are going to be most successful is to understand ACOs and exchanges generally but DIRECT and the Comprehensive Primary Care Initiative specifically. The latter pair illustrate well how the emerging system is supposed to function. Then, being involved in the local community as the care delivery structures are being formed is the most important step. To that end, the National Eye Care Communications Project, while sponsored by EMRlogic, is offered as a vendor-neutral gathering where providers can share their learnings, their experiences and assist all participants in understanding the cultural changes necessary for business success in health care reform.

Jim Grue, O.D.
Alistair Jackson, M.Ed.

More on ACOs is available in Archives. See Categories: Accountable Care Organizations.

You asked about ACOs - Part 1, Communications

2012-08-13T02:00:00.000-07:00

One of the participating doctors in our National Eye Care Communications Project asked for more insight into ACOs, as what some have called "the real rising power" in health care reform.

In our attempts to understand national-scale bills or movements, such as health care reform, we must acknowledge a conceptual level where the creators and influencers would like to see things go, and also a practical level involving the passing of regulations, legislation and policy. These two levels rarely align. And this was never more true than in the case of health care reform. Let’s consider two parallel situations – communications and team delivery of care – in which we see clearly this difference between how a system is ideally designed and what was necessary to put it in place on a practical basis.

Communications

In the area of communications, we see two distinct programs emerging: the first is the health information exchanges being established in almost all states; the second is the national DIRECT communications network.

From a conceptual standpoint, the purists in health care reform would like to see a system in which every provider has equal and secure access to patient health information. From a practical standpoint, health systems see an advantage in being the central hub with information easily flowing in and where they have control over what flows out. The result is the first category of exchanges, repository-type HIEs, being developed by large health systems that tend to dominate the process in their states. The health systems share patient health information through the exchange, and independent providers send information into the exchange. Independent providers however, for the most part, only have access to view patient information through portals rather than easily receive information from the exchange.

In addition to the health information exchanges, we also see the emergence of the DIRECT system, which is being resisted in many states by the large health systems. DIRECT however is being pushed by the National Coordinator of Health Information Technology and also by some state HIE adminstrators as a way of granting to all providers equal access to patient health information. This is the system that gives independent eye care providers equal access to patient health information.

To be continued ... join us next day for part 2, Team Delivery of Care.

Jim Grue, O.D.
Alistair Jackson, M.Ed.

More on ACOs is available in Archives. See Categories: Accountable Care Organizations.

Taking the long view ... again.

2012-08-10T02:00:00.000-07:00

HITECHAnswers has published another worthwhile read for those of us who like to think big picture. It's First Glimpse at Stage 3 Meaningful Use Measures by Mary Mosquera, Senior Editor, Government Health IT.

I'm intentionally keeping my comments short today in the hope you'll click the link and read what Ms. Mosquera has to say. If you've been following the long-term trends, you already knew that clinical decision support would be the crown jewel of Stage 3 certification. No surprise, the Health IT Policy Committee confirmed that direction at its August 1 meeting.

To date however, most talk of CDS centers around drugs: drug-drug interactions; drug allergy alerts, and so on. And, in this area, an authoritative resource is sought, versus every vendor coming up with its own rules. Great concept! That might leave vendors a place still to set themselves apart - for example, helping with the everyday decisions made by providers that are not medication related yet lead to better patient outcomes.

In the meantime, read Mary Mosquera and maybe a related post or two. Enjoy!

Alistair Jackson, M.Ed.

A scary pilot program!

2012-08-08T02:00:00.000-07:00

If only we could say all news of health care reform was good news! Modern Healthcare recently announced a rather scary kind of pilot program: a RAC demo program. RAC, what's that? Recovery Audit Contractors.

The infamous RACs have been around for years already. Typically, they've gone into practices to do Medicare audits, primarily checking to see that patient records substantiate past Medicare claims. In many cases, records were found not to substantiate the claims, and significant penalties or "clawbacks" have resulted. This program was so successful in getting big dollars back into Medicare coffers that CMS could do nothing other than multiply its army of auditors. Now, CMS has taken it to a whole new level.

"After an eight-month delay, the CMS has set Aug. 27 as the date for the start of a demonstration program that will allow Medicare recovery audit contractors in 11 states to review the medical necessity of claims before the providers are ever paid.

The demonstration program, called recovery audit prepayment review, will focus on certain types of claims that the CMS says are prone to high rates of improper payments. The reviews will focus on seven states with providers prone to errors and fraud (California, Florida, Illinois, Louisiana, Michigan, New York and Texas) and four with large volumes of short inpatient hospital stays (Missouri, North Carolina, Ohio and Pennsylvania)."

Read more here: CMS sets start date for RAC demo program | Modern Healthcare

So what does this have to do with eye care? As is the case for all manner of change arising from health care reform, it has everything to do with eye care. It's only a matter of time before any aspect of the transformation of healthcare comes home to roost in your practice.

A primary concern for eye care as a profession is that we're second only to radiology in the volume of imaging used for diagnostic purposes. Imaging is a primary target for RACs since they're notoriously poor at showing what the claim says they show, especially if the images are kept as paper records.

A big lesson we see in just the brief quote above is that audits are now occurring statewide and across defined groups. How far a leap is it to move from provider groups "prone to errors and fraud" or that demonstrate "short inpatient hospital stays" to specialty provider groups? These examples prove that the analysis of broad-based provider data is alive and well at CMS. Do we think CMS has not yet identified or cannot easily spot professions or provider groups that claim every billable specialty test in order to maximize revenue?

The bad news here is the catch-all nature of the new RAC process. Once a group is identified, it matters no longer that you're the exception. By virtue of association, you've effectively failed the audit before it starts ... akin to guilty until proven innocent. Even if the verdict is favourable, going through the process is ugly.

Our message here is more for the eye care profession and significant provider groups within it than to individual providers: it's time to pay heed to the pilot program developments in healthcare. Too often we still hear, "that's down the road" or "we'll do that once it's important. Sometimes those are foolish words from sleeping giants.

Alistair Jackson, M.Ed.