Looking back, looking ahead.

As we near the end of January and the predictions for 2012 have subsided, I hope you'll pardon me if I remain so impressed with Dr. Farzad Mostashari that I want to direct you again to his blog. There are two posts in particular I deem must-reads for all kinds of us: the doubters, the latecomers, Eligible Professionals and would-be thought leaders for eye care EHRs. We can all benefit from taking stock of what's really happening in the health care reform world around us.


The first is Farzad's January 7 post, in which the National Coordinator looks back at "12 Months of Health Information Technology". Let me whet your appetite by just listing the top ten highlights of the year. If you want to read the full post, click here. (I hope you will.)

1. January: Launch of the Medicare and Medicaid EHR Incentive Programs
2. February: Launch of DIRECT
3. March: The National Quality Strategy
4. April: Launch of the Standards “Summer Camp”
5. June: Spurring Health Information Technology  Innovation
6. July: Health Information Technology Workforce
7. September: Breach Reporting and Increasing Security Awareness
8. September: Consumer eHealth Comes to the Fore
9. October: Regional Extension Centers Surpass their Goals
10. November: Growth in the Adoption of EHRs

The second must-read post is from January 25, "Health IT Taking Flight". Again, click here to read the full article. In the meantime, here's a summary of the five big trends expected in 2012:

1. Meaningful Use Takes Off. 
2. Health Information Exchange Turns a Corner.
3. Connecting the Dots on Health IT and Payment Reform. 
4. Consumers Use eHealth to Get More Involved.
5. Innovation Drives Improvement. 

We've said it, others have said it and it's worth repeating: health care reform is not "coming soon", it's here now and it's here to stay. Don't confuse health care reform with insurance reform (Obama Care). If for any reason you're still sitting on your laurels, it's time to leap into action. If they're low, forget about your current Medicare volume or Medicaid percentage and get involved with certified EHRs regardless. Remember that CMS was only the launchpad. Private payers are already on board the train too. All of healthcare is transforming. If you're in healthcare, you must morph in order to survive.

Alistair Jackson, M.Ed.

Meaningful Use: Not Just for EHRs.

In the January 2012 edition of Optometric Management, Dr. Walter West wrote an article entitled, "Meaningful Use: It's not Just for Electronic Health Records". His essential question is whether or not providers are fee-focused or patient-focused in their use of diagnostic equipment. It's the easiest thing in the world, after acquiring a new piece of expensive equipment, to find suddenly that a lot more patients are suspects for the disease your new instrument is designed to screen. Dr. West issues a challenge to review your clinical protocols and ensure that your use of diagnostic equipment truly improves the quality, safety and efficiency of patient care.


I wholeheartedly agree, yet want to take this notion a step further: health care reform is designed to eliminate unnecessary testing. Let's understand that significant cost overruns in health care are attributable to tests being done multiple times at multiple facilities. The reason may not just be poor judgement or an ulterior motive on the part of a doctor. The patient may want a second opinion and go to another hospital, for example. Hospital A cannot access the records at hospital B so cannot offer simply another review of the original tests; the tests are duplicated. Same result. Same diagnosis. Double the cost. It happens all the time, sometimes at a cost to Medicare of $20,000 or more per instance.


Now granted, eye care has not primarily caused this problem. However, it must be fixed across the board. At the heart of the issue are two things: a lack of portability of patient health information; a fee-for-service reimbursement system that cannot differentiate between excellent care, mediocre, poor or fraudulent care. The answer? EHRs and a pay-for-performance model. 


Long story short, as we move into Stages 2 and 3 of EHR certification, health care reform will root out sub-optimal practices, whatever the cause. Exams will be submitted every time for electronic audit, and reimbursement will be contingent upon achieving best results. Billions of dollars are being spent on the transformation of healthcare in order to lower costs, raise quality and improve patient outcomes. Each provider has a part to play in achieving those very same goals.


Alistair L. Jackson, M.Ed.

De-mystifying 5010 versus ICD-10.

Although the published CMS resources on the transitions to 5010 and ICD-10 are actually quite clear, we still run across fairly pervasive confusion between the two. They are related but are not one and the same.

5010 is a transaction set that governs claims submission. It replaces the current 4010 series. Payers are converting to this higher standard as a precursor to the introduction of ICD-10. The compliance date was January 1, 2012 but an "enforcement discretion period" effectively extends it to March 31, 2012.

The 5010 changes apply to all HIPAA "covered entities". Confusion arises here because clearinghouses can appear to change the rules. They may tell software vendors or providers that the deadlines don't really apply or aren't as hard and fast as they're made out to be. What this means is that they, the clearinghouse are the covered entity and the provider is not. (If a provider does not use a clearinghouse and submits claims directly to the payer, then the provider is the covered entity.) So, when a clearinghouse is used, compliance applies strictly to the clearinghouse. The clearinghouse may then choose to extend grace to the provider by continuing to accept claims in the older format. As long as the clearinghouse completes the conversion to the new format (5010) and submits to the payer in that format, the requirement has been met.

ICD-10, by contrast, applies to diagnosis and procedure codes. They will replace the current ICD-9 codes but not CPT codes for outpatient billing. The compliance deadline for this step is October 1, 2013.

In both cases, the software vendor has work to do. Being ready for 5010 compliance is much simpler than ICD-10 compliance since the latter means reorganizing the EHRs around ICD-10 structures. ICD-10 is a better, more logical system (used worldwide), a much more comprehensive one than the current ICD-9s.

For the provider and provider staff, here's an important call to action. Yes, you need to be talking to your software vendor and hopefully hearing right and reassuring messages about the integration of ICD-10 codes into the EHR. But understand too, ICD-10 compliance is not all in your vendor's court. There's a significant learning curve for billing staff, akin to learning the metric system after growing up on imperial measures. Find the courses and workshops offered locally and at major conferences and tradeshows and get moving on that. This is another big piece in the transformation of health care that ultimately means the survival of your business.

For more detailed information on both 5010 and ICD-10, the CMS website has excellent resources - FAQs, checklists, widgets. Click here to go there ... and all the best!

Alistair Jackson, M.Ed.

More open doors for Optometrists: Medicaid.

When the HITECH wagons were first circled, we heard about the two incentive streams, Medicare and Medicaid. The AOA EHR Affiliate Program (aka "the state roadshow") also promoted both streams. There was a big problem however: Optometrists were not eligible for the Medicaid stream. Even though many were being faithfully reimbursed for their Medicaid claims, Optometrists were not recognized as Eligible Providers under any state Medicaid program.

In the fall of 2011, that began to change. Illinois was the first state to open its doors recognizing OD's as Eligible Providers. Thanks are due to the Illinois College of Optometry and Illinois Eyecare Institute for blazing that trail. Other states have followed suit, including Minneapolis and Alabama. We can expect a wave of acceptance across the country now. As of early January, 43 states had launched their Medicaid programs.

What does this mean for you as an Optometrist?

• It means you may have an option to go the Medicaid route. I say "may" because you need to check this out in your state, maybe even be ready to give it a push through your state optometric association.
• Eligibility for Medicaid programs requires that a minimum of 30% of your patients are Medicaid patients. 
• Understand that the Medicaid incentive programs are different than Medicare. They vary somewhat by state but, generally speaking, the timelines, the rules and the reimbursements are favourable. Click here to read some insights from the Wisconsin Medicaid program that may be applicable to your own state's program. 
• Yes, you can switch from Medicare to Medicaid. You can do it up front or mid stream. Click here to read a good article on switching incentive programs.

Whether you choose Medicare or Medicaid, it's important to move with respect to EHR adoption and the transformation of health care. If you don't qualify for either program, don't be fooled. With or without the incentive money, it still matters. Embracing EHRs is about the survival of your business in the health care reform world.

Alistair Jackson, M.Ed.

Information at the speed of trust.

It's not in the DNA of EMRlogic Live to be a mere signpost to what everyone else is saying about eye care or EHRs or Health Care Reform. But today I came across an article that jumped out at me as worth pointing to. After all, we're no longer vacationing on Eye Care Island. Let's think about these comments by National Coordinator for Health Information Technology Farzad Mostashari at the Jan. 10 meeting of the Health IT Policy Committee. Read the full article here.

Excerpts:

• In 2012, meaningful use will soar...
• Mostashari predicted interoperability and exchange would be the “second and more complex challenge,” following meaningful use. The emphasis will be on containing the costs and reducing the risks and liability of exchanging health data. Information “will flow at the speed of trust,” he said.
• In 2012, the business case for care coordination, which requires the exchange of healthcare information, will be driven by payment reform, not only through federal efforts, but also by the way states and private plans will pay providers.
• The health IT czar said exchange would go slowly at first, with providers sharing only with providers they know on a first-name basis. “It will then go from a trickle to a flow, to a flood, as trust builds over time,” he said.
• Consumer health IT will be a another emphasis for this year
• We will be moving forward on the next generation of quality measurement...
• We need the infrastructure for measuring quality, but also for improving quality.

We already know that 2011 was a big year for EHRs adoption and Meaningful Use attestations. A recent report showed 614 optometrists and 385 ophthalmologists have received Medicare stimulus grants. 2012 promises to be bigger yet, much bigger.


The lesson from Mostashari is not however that MU will grow; it's that health care reform is continuing down its predictable path. This year we'll see: 

• interoperability through health information exchanges (HIEs); 
• care coordination through accountable care organizations(ACOs) and the medical home; 
• consumer health IT - the electronic patient record (EPR); 
• the advance of clinical quality measures (CQMs) for improving patient outcomes.

Without question, the train has left the station. I hope you're on board.


Alistair Jackson, M.Ed.

Beyond workflow: a primer on thoughtflow, Part 1.

The concept of workflow is common speak by now when considering practice management and electronic health records software. There's not a company out there that would admit to ignoring workflow, the seamless passage of data from the front desk to the back office as the staff and doctor team work together. We all know too, truth be told, that things fall through the cracks, costing the practice money every time. Eliminating silo thinking and practice is a challenge that none of us has yet mastered, even though some close the gaps more successfully than others. Adoption of EHRs has introduced a whole new set of desired efficiencies: instrument linking; the integration of imaging and drawing functions; and a host of new online possibilities, to mention a few.

One of the most interesting dynamics we have encountered in our work with eye care providers, especially as we have sought to surpass traditional EMR capabilities (e.g. recording results), is that doctors think very differently during a patient encounter than when they are discussing patient care, say with colleagues in a continuing education or focus group setting. In other words, there's an important gap between how doctors think they think and how they actually do think and make decisions in the patient care setting.

In the coming weeks, we will be delving into some important ideas and concepts originated by Dr. Sam Bierstock, a nationally recognized authority on healthcare clinical information systems in both the ambulatory and hospital environments, specializing in physician adoption of clinical technologies. According to Dr. Bierstock, “Thoughtflow is used to distinguish between how clinicians work versus how clinicians think and then work."

Imagine the importance of thoughtflow as we move to EHRs with embedded clinical decision support.

More soon. Stay tuned!

Alistair Jackson, M.Ed.

Q1 2012, A Landmark Period in U.S. Healthcare.

I'm going on record. "History will mark the first quarter of 2012 as one of the most significant periods ever in U.S. health care." 

January 2012 marks a formal beginning to one of the most fundamental effects of the health care reform movement, one of the most significant changes we have seen in our professional careers. 

Medicare has approved the final rules for establishing Accountable Care Organizations (ACOs) and will be accepting applications until January 23, 2012 for those organizations that plan to begin operation on April 1, 2012.  There will be another application deadline in March for organizations beginning July 1, 2012. 

So why is this significant for us as eye care providers?  Because it directly affects our access to patients.  ACOs are structured around coordination of patient care and a whole new reimbursement system that replaces the standard medicare fee-for-service payment model.  ACOs are able to participate in the cost savings they generate as long as they are simultaneously able to demonstrate they are improving the quality of care delivered. The demonstration period for ACOs is now past and any health care organization anywhere in the country that meets the criteria can apply for participation. 

Once ACOs are up and running in your area, they will affect your access to patients.  If you understand the process, properly prepare and actively demonstrate your value to your local ACOs, they can be very good for your business.  If you don’t prepare, no one is going to send you an invitation, and the ACO could limit your access to both your current patients and potential future patients.

You owe it to yourself to become knowledgeable about ACOs, what they are, how they will function, and what they mean to the future of your practice. For the benefit of your business, you need to be involved in a local ACO. 

Jim Grue, O.D.

EHRs and the continuum of care, Part 2: the problem with paper-oriented EHRs.

One of the main problems with paper exams is that they are structured around an exam-specific episode of care. A new form is used for each encounter. Connecting the knowledge contained in these separate exams is through a written problem list, and sometimes other lists such as a medication and allergy list. A sequence of events, a change over time or a variation in clinical flow can only be seen by human eyes observing the flow of data from episode to episode.

In EHRs, we see some ability to tie consecutive episodes of care together and reduce end-user need to enter repetitive data and join the dots, so to speak. We see features like Carry Forward and Populate Normal being incorporated. This helps in some measure but also has some pitfalls. It is still a system in which significant clinical findings are separated into episodes of care rather than being presented in ways that show trends and make the continuum of care intuitively obvious. 

If we have a patient developing a traditional cataract, the caregiver must know how quickly the cataract is progressing. The key clinical indicators are type, severity, change in refractive status, change in visual acuity, and other causal factors. In order to make appropriate clinical decisions for this patient, we need information from a sequence of exams. In a paper chart, the provider would flip through the various exam forms. In almost all electronic health records, the user still must “flip” through previous exams to get this information, even though the data is electronic. The problem is that electronic “flipping” tends to be much slower than it was to flip pages in a paper chart. Complaints that EHRs are slow come largely from this separation of related data and the increased time it takes to re-assemble and re-assess.

Maintaining an episode-of-care concept in the design of EHRs has proven to be a fundamental flaw and a major inhibitor to their adoption. A key tenet of health care reform is to challenge episodal care. Reform is recognizing that each episode of care actually has little value in the continuum of care. Health care reform is designed to change the focus from the patient seen on a particular day with numerous tests, to an emphasis on long-term outcomes and how effectively a team of providers can get the best patient outcomes. 

Health care reform is changing reimbursement from paying primarily for episodes of care to paying for long-term outcomes, also known as pay-for-performance. A system based on episodal care does not create the most efficient and effective health care. It creates an expensive, fragmented health care system shown consistently not to deliver the best quality of care. EHRs that win the day will be those that help us easily see the most important value in the data: the trends.

Jim Grue, O.D.

EHRs and the continuum of care, Part 1: the patient-specific knowledgebase.

Given Health Care Reform, the best core design element an exam record can been built around is that of a dynamic content-driven knowledgebase. The knowledgebase can handle continuous growth to encompass the ever-expanding body of medical knowledge and make it available at the point of care.

However, this is only one side of the knowledgebase concept.  The purpose of a health record is to create a patient-specific knowledgebase of relevant health information.  There is a clear role for the carry-through of knowledgebase concepts into the patient-specific data set.  Clinical decision trees structured on the input side allow us almost unlimited ability to present new and existing knowledge to the end user and, beyond presentation, provide clinical decision support.  Once selections on a particular patient are made, we have begun, effectively, to create this secondary knowledgebase, one that is specific to the patient. Much of the purpose of health care reform is to acknowledge the value of this patient-specific knowledgebase and create a health care delivery system that shares this information. Every provider involved in the care of the patient must have access to this knowledgebase.

If you’re already involved with EHRs you’ll be familiar with the Continuity of Care Document (CCD), which is really about sharing patient health information between providers. In the year ahead, you’ll hear a lot more about Health Information Exchanges (HIEs) at the state level. HIEs are all about expanding and coordinating the sharing of patient health information, en route to sharing not just at the state level but the national level.

Lest we get caught up in acronyms, here’s a salient point: it’s no longer good enough for EHRs just to record results; they must drive better results. The Health Care Reform term is “improving patient outcomes”.  Stage 1 certification doesn’t yet push hard on this standard. The level of clinical decision support required at stage 1 is very basic and, for many EHRs, is covered by the e-prescribing interface. Going forward, the bar will rise significantly and the value of a rules-based and content-driven knowledgebase approach will emerge.

Jim Grue, O.D.

Which 2011 incentive will YOU claim?

Perhaps you worked hard in 2011 to demonstrate meaningful use of EHRs and you've already attested. On the other hand, maybe you've chosen a more incremental approach and your goal was just to get started working with EHRs while you focused your efforts on implementing e-prescribing.


Both EHRs and eRX have associated incentive programs but the two are mutually exclusive. Both are related to your billing volume and both are claimed through CMS but you cannot receive both incentives in the same year. 


Demonstrating Meaningful Use is the greater incentive but also the harder of the two. So if you didn't undertake that one, the e-prescribing bonus is a worthy alternative. 


The e-prescribing incentive program is called the Medicare Improvements for Patients and Providers Act (MIPPA) and you may qualify for the bonus if:

• you're using integrated e-prescribing within your EHR, or
• you're using a standalone or online e-prescribing program independently of an EHR, and 
• you met the required minimum by billing G8553 for at least 25 unique electronic prescribing events

Note: there is no attestation process for MIPPA; it is tracked via the G code included in your Medicare claims submissions.

There are plenty of sources for more information about MIPPA. At EMRlogic, our eRX integration partner is DrFirst. They offer a very nice overview here. I hope you'll go for the carrot but, if you don't, make sure you understand the coming stick!

Alistair Jackson, M.Ed.

An Executive Opinion

It seems to me there has been far too much attention given to what parties other than doctors and patients want from health care reform. Why should the doctor become a data-entry clerk for the benefit of others? Software systems typically provide a myriad of fields to be filled in, which have no value to the doctor or the patient.

The patient wants to receive the best care as soon as possible at minimum financial or medical risk. The doctor wants to provide the best care possible with the same minimum financial or medical risk. The doctor needs access to the most meaningful information at the right time and in the context of the patient complaint. Why re-enter data about things already known rather than using pertinent and new information to treat the patient?

If health care reform is to work it must benefit the doctor and the patient first then satisfy the requirements of the government and the payer, not the other way around. Effective systems must provide relevant information at the point of care not require entry of more than the minimum information.

The doctor and the patient should be considered the first beneficiaries of reform.

John McCormick, Sr.

Editor's Note:  Our guest contributor today, John McCormick is a Director at EMRlogic. Prior to joining EMRlogic, John served as COO at Cambridge-based InterSystems. His vision and leadership have been instrumental in building EMRlogic’s knowledgebase-driven and active content-powered EHRs. 

EMRlogic LIVE - Toward a Vibrant Community

As we turn the page on a new year, I think it's worthwhile to re-state the goals of this blog. You can see them articulated point-by-point by clicking the "About EMRlogic Live" button, top right. But here's what I shared with my colleagues the other day. "As always, there's much said [in the news and other blogs] about healthcare in general. Our job is to narrow the focus to what is happening specifically in eye care. There are lots of sources and opinions at a broad level; we seem to be a unique source for eye care – that's what our blog is all about. That's where we set ourselves apart."


Here's another goal we'd like to achieve: to transcend the one-way flow of thoughts and insights and open wide the door for EMRlogic Live to become a vibrant community forum. It's hard to know who's following or if we're making a difference. I'd love to see the Comments and Reactions area take off, readers get involved and EMRlogice Live become a place where practitioners share, ask questions and challenge.


In the event you try (or have tried) to comment and have trouble doing so, please email me . We'd like to know. Your input is valued and appreciated.


Alistair Jackson, M.Ed.

I see that hand. Yes, Mr. Consumer, you had something to say?

Agreed, HIEs will play big in the year ahead. The biggest change 2012 is going to bring is a dramatic increase in consumer acceptance of the new technologies around health care reform.  The driving forces of health care reform started with payers, then went to the government as primary promoter, then private insurance carriers joined the push. We are now seeing the emergence of the strongest force yet, the consumer.  Although many of the core capabilities of the health care reform delivery system are new to eye care, many are already well embedded in large health systems throughout the country. And the public is starting to realize the benefit of these new technologies.

In recent days, I have asked five acquaintances three questions:

• First, I asked if their physician gives them a copy of their exam results when they leave the office. Four of the five answered no, but added they do receive a card that allows them to go online anytime afterward and see all their test and exam results.  
• Second, I asked, “Do you actually go online and look at your results?” All said yes, that they do so after every visit. One commented further, "I can’t wait to get home to look at the results. I can see every lab result. I can look any time and see what I am supposed to be doing. I also know when I need my cholesterol checked again, and when every test is planned for the future. For the first time, I feel like I'm in control of my healthcare and can make good decisions to stay healthy.” 
• The third question I asked is, “What would you think if you went to a healthcare provider who didn’t make your results available online after your visit?”  In various ways, all gave the same answer: I probably wouldn’t go back.  

Think about that! The consumer accepting and now demanding these technologies is a far more powerful incentive than any stimulus program the government or insurance company can put in place. 

Jim Grue, OD

Predictions anyone? Where next?

We're suddenly into a very exciting 2012. Why? At our company at least, the news of successful attestations began trickling in before the old year was done. 90 days from October 3 brought us right to the door of the new year. It'll be very interesting to see the numbers, the announcements and press releases that emerge as the 2011 Meaningful Use statistics get tabulated.


Predictions anyone? I predict a new wave of hope and belief in Health Care Reform. The naysayers have had their day and the facts are now all but undeniable: reform is here, it's here to stay and it has come to eye care as well.


There's another reason to get excited about 2012. Every vendor that's going to be a certified EHR player has now been through the first wave. With the early adopter phase behind us, we're all more prepared for the second wave. We've smoothed out the wrinkles, we've created our supporting documents and resources and we've achieved the desired result: money in the pockets of customers who believed in us and took those first steps.


2012 will not be without its new frontiers however. We're over the Stage 1 EHRs hump but here comes the HIE hump. We've proven the case for EHRs but now need to get communicating at a whole new level, the statewide level. 2012 will be the year when Health Information Exchanges appear at center field and certified users will start demanding to play ball in the big leagues.


Alistair Jackson, M.Ed.