Acronyms of Change, Part 7 (CCD and CCR)

CCD and CCR refer to the Continuity of Care Document and the Continuity of Care Record. Why the distinction? The CCD is a patient summary clinical document you are expected to give to the patient upon request, and the CCR is a version intended to be shared among health care providers.

The CCD consists of a mandatory textual part, which ensures human interpretation of the document contents, and optional structured parts for software processing. The structured part is based on the HL7 Reference Information Model (RIM) and provides a framework for referring to concepts from coding systems such as from SNOMED and LOINC.

The CCD patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system or setting to aggregate all pertinent data about a patient and forward it to another practitioner, system or setting to support the continuity of care. Its primary use case is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.

The CCR standard is a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one caregiver to another. It contains various sections such as patient demographics, insurance information, diagnoses and problem list, medications, allergies and care plan. These represent a "snapshot" of a patient's health data that can be useful or possibly lifesaving, if available at the time of clinical encounter. The CCR standard is designed to permit easy creation by a physician using an electronic health record (EHR) system at the end of an encounter.

And lastly for clarification, the Continuity of Care Document (CCD) is an HL7 implementation of the Continuity of Care Record (CCR) and not a competing standard. 

Alistair Jackson, M.Ed.

Acronyms of Change, Part 6 (CQM)

Clinical Quality Measures (CQM) are based on specific evidence-based practices that have been shown to give the best results to the most people. To demonstrate meaningful use successfully, Eligible Professionals are required to report clinical quality measures specific to their health care environment. As an Eligible Professional (EP), you must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures. CQM results (numerators, denominators, and exclusions) must be reported to CMS as part of the attestation process. 

You'll recall, I'm sure, the advent of the Physician Quality Reporting Initiative (PQRI) which has now been renamed PQRS. The "initiative" has become the "system". PQRI was what we called spring training or a pay-for-reporting practice run in anticipation of true pay-for-performance. In the sense that reporting of CQMs is now an attestation requirement, you are being paid for it. However, as is common to most elements of Stage 1 certification, the concepts are really just being introduced. Moving to stages 2 and 3, the bar is rising and more  is being required at each step. We are certainly not yet at full-blown pay-for-performance.

Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report CQMs to CMS by reporting them through either the Registration and Attestation System or via participation in the new Physician Quality Reporting System-Medicare EHR Incentive Pilot. 


However, note that you are only able to participate if you are able to report CQMs based on a full calendar year. This likely means you had completed your Year 1 MU Attestation as of December 31, 2011 and were eligible to begin your year 2 as of January 1, 2012. If you started your Year 1 MU period on January 1, 2012 and are prepared to continue with PQRS through December 31, 2012 the participation in the Pilot may also be possible.


For more details on this new program, see its Quick Reference Guide. More details about CQMs are available here on the CMS.gov website. Or, you may read about Core Measure #10 here.


Alistair Jackson, M.Ed.

Acronyms of Change, Part 5 (CDS)

Clinical Decision Support (CDS) is destined to become one of the major differentiators between the last wave of EHRs and the next wave. But be well advised: you ain't seen nothin' yet!

For Stage 1 of Meaningful Use, your EHRs needed to "implement one clinical decision support rule" (Core Measure 11). CMS stated within that measure's Additional Information that it would not issue additional guidance on the selection of appropriate clinical decision support rules for Stage 1, other than to say that drug-drug and drug-allergy interaction alerts (for example, from e-prescribing) could not be used to meet this objective.

For the most part, EHR vendors met this requirement through the use of "structured data", a low-level type of clinical decision support. Structured data is, without doubt, the simplest, easiest kind of CDS. It means that data is placed in a reportable field versus an open, free-text field. Drop-down menus, for example, constitute structured data. It's what you already expect computers to do and that's why "you ain't seen nothin' yet!"

In our white paper, Behind the Stimulus Program, Dr. Grue and I wrote at length about this critical topic. While we'd love for you to read the entire paper, see especially pp.12-20. 

The Bible of CDS is Clinical Decision Support - the Road Ahead, edited by Robert A. Greenes, M.D., PH.D., Harvard Medical School and Brigham & Women’s Hospital Boston, Massachusetts and published by Academic Press © 2007. 

Dr. Greenes presents six methodologies that comprise the gamut of clinical decision support, which we have unpacked into layman's levels as follows. The first three, we have dubbed "The Easy Ones: No-Brainer CDS". These are:

1. Information Retrieval
2. Evaluation of Logical Conditions (Alerts & Reminders)
3. Associative Groupings (Structured Data & Reports) 

These lower-level types of CDS are the things we already expect our software to do. We're not surprised by them. Our legacy practice management systems can do these kinds of things even if the clinical applications for EHRs make them seem a little more sophisticated.

The second set of three methodologies falls into what we call "The Tough Ones: Wow-Factor CDS". These are:

1. Predictive Analyses
2. Heuristic Modelling (Smart Records)
3. Algorithms & Multi-Step Processes (Clinical Workflows)

 These are the types of CDS that will separate the sheep from the goats, the victims from the thrivers as we move into MU Stages 2 and 3. As an eye care provider, you already know that software systems birthed in other areas of healthcare have great difficulty bolting on a really good optical point-of-sale module. Software for eyecare must be designed from the ground up with embedded optical and inventory capabilities. 


The same is true of EHRs for health care reform. Bolting on CDS to a legacy-style record-the-results EHR will not do justice. More vendors will join the casualty list on account of this rising bar. Expect a second round of EHR conversions as successful Stage 1 players fall prey to  these new standards. And if you're shopping, be sure CDS is on your list ... not just as an item or feature you can check off, rather as a fundamental design element.


Alistair Jackson, M.Ed.

Acronyms of Change, Part 4B (DIRECT)

In our last blog, Part A of the same topic, Alistair provided a good basic understanding of DIRECT, a term you may not have been familiar with but one that, if you aren’t familiar and aren’t making the right choices now, may cost you dearly in the future.  As the core communication standard chosen by the Office of the National Coordinator of Health Information Technology, DIRECT must now be used by every state Health Information Exchange (HIE) in view of creating an eventual national HIE. DIRECT is worthy of our close attention. 

Why could HIEs cost you a lot of money in the future? First, because there is no long-term money anywhere in health care funding for the ongoing maintenance of the information exchanges. In the national system proposed by the government, DIRECT would be the national standard and would make it possible for all health care facilities and providers to exchange health information using exactly the same recognized and established communications protocols as established early on by the state HIEs.  If this becomes the national functional standard, then it is thought that the cost of using the exchange will be in the range of hundreds of dollars per provider per year. No provider wants to pay this fee, but the alternative is much more costly. Under the government's proposed plan, the financial benefit to be incurred would far exceed the cost paid for using the exchange. Independent or small group providers would realize a net financial gain by using exchanges standardized around DIRECT.

There is competition however, competition that you may easily feel you should support if you aren’t well informed. You may already have been approached by a large health system in your area telling you that patient health information is available through a free web portal, one that lets you simply log in to see all your patient information. Some ODs are already doing this. At first glance, it appears to be a great benefit, very convenient. Unfortunately however, it is the first step in the large health systems trying to take control of the state HIE. The model is to create an information exchange that requires independent providers to access the state and national exchanges through the local health system's communication network. 

There is growing evidence that these networks can indeed support the cost of you accessing patients from within the health system, as it is essentially marketing for the health system and a business plan that can increase referrals into the system. There is also however strong evidence that these same health systems are establishing exchange capabilities that create a profit center for the future. It is likely that, if large health systems successfully control the state exchanges, we will see fees in the thousands of dollars per provider per year to use the exchanges for access to the national system when it involves patients from outside the local health system. 

When your local health system makes a very generous offer to give you a free portal to view patient information, recognize that by doing so you are casting your vote for the future choice that will probably be the most expensive for you. Begin with the end in mind; we recommend DIRECT  Accept a modest fee early on in order to circumvent exorbitant fees later on.


Jim Grue, O.D.

Acronyms of Change, Part 4A (DIRECT)

DIRECT was created by the Office of the National Coordinator to specify "a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet." In simple terms, this is the how of Portability. And for those already familiar with certified EHRs, it is via DIRECT that the Continuity of Care Document (CCD) and Record (CCR) will be exchanged.


As we move from EHRs into HIEs, DIRECT represents the standard by which protected patient health information will be shared. A primary care physician who is referring a patient to a specialist (e.g. an MD to an OD) will use the DIRECT standard to provide a clinical summary of that patient to the specialist and to receive a summary of the consultation. DIRECT is not about the actual content exchanged, only the means by which it is exchanged. The standard will meet Meaningful Use requirements. While the standard appears in Stage 1 it will be enforced moreso in Stage 2 and beyond. The formats for information exchange will include CCDs, CCRs, HL7 lab results, PDFs, TIFs, text and more. 


One very interesting and instructive element within the Direct Project is the workgroup on Best Practices for Content and Workflow.

"The goal of the Direct Project is to enable a wide network for directed health information exchange, with a backbone of universal addressing and universal transport, to improve health and health care. This goal requires a balancing act between two subordinate goals that often conflict: 

1. Opening exchange to a wide variety of exchange participants, including physicians who may not (yet) have complete electronic health records 
2. Enabling rich clinical workflows based on semantic interoperability with structured healthcare contents

The first goal argues for placing minimal barriers on content, to allow upgrade from fax and paper to electronic transactions. The second goal argues for restrictions on content to defined healthcare standards to enable rich clinical experience, cognitive support, and improved outcomes."

These two subordinate goals must, of course, be reconciled. In the meantime, they serve as a reminder that we are moving toward defined clinical standards undergirded by Clinical Decision Support and which end with pay-for-performance outcomes, also known as outcomes-based reimbursement.



Today's post has been largely informational. Be sure to check in for part B on this topic, a relevant heads-up perspective from Dr. Grue about why you need to get interested in ONC Direct.

For more information about the Direct Project, please see the Direct Project Boot Camp slide presentation or visit the Project Wiki and the project website."

Alistair Jackson, M.Ed.

Acronyms of Change, Part 3 (ACO)

We've heard enough about ACOs that most of us probably know the acronym means Account Care Organization. Accountability is another theme we're familiar with since it's the first A in HIPAA. Portability and accountability are major themes in health care reform.


While eligible professionals and hospitals are incentivized by stimulus grants, ACOs are driven by the Shared Savings program. You'll find that the "large health systems" I've referred to in parts 1 and 2 of this series are also the kinds of organizations that will rally under the banner of an Accountable Care Organization.


In his December 20, 2011 post (see Archives), my colleague Dr. Jim Grue wrote, "There are a number of team delivery models functioning but the ACO model based on the Medical Home structure is rapidly dominating the market. For ECPs not to lose ground on key survive and thrive issues, it is important to understand what preparatory steps are needed right now." While you're reading that, also read the Dec.23, 2011 post by our third "musketeer" Dr. Chuck Haine who wrote about the Pioneer ACO. We'll cover the Medical Home model in more detail at a later date. For now, let's understand the shared savings motivator.



The Affordable Care Act (ACA) required CMS to establish a Medicare Shared Savings program by Jan. 1, 2012 "that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery”. Participating entities, i.e. ACOs, that meet quality and performance standards are eligible to receive payments for shared savings. 

An ACO refers to a group of physicians, hospitals and other suppliers of services that will work together to provide coordinated care to Medicare beneficiaries. The statute lists several groups of providers of services and suppliers that are eligible to participate as an ACO:

• ACO professionals in group practice arrangements.
  
• Networks of individual practices of ACO professionals.
  
• Partnerships or joint venture arrangements between hospitals and ACO professionals.
  
• Hospitals employing ACO professionals.
  
• Such other groups of providers of services and suppliers as the Secretary determines appropriate. 
  

Today's takeaway is that ACOs matter. Granted, they appear to be all about larger health systems, hospitals and group practices. But we must be clear that, as the health care reform game plays out, ACOs will take control of access to patients, in the name of "savings", shared savings. Those patients need eye car too and if you're not involved in a local ACO, those patients will be awarded to others who are. Remember that even though hospital-based EHRs don't do as good a job of eye care as your EHRs do, they are nevertheless certified and meet Meaningful Use criteria. That means you can - and will - lose patients to those providers and systems. Be alert to that and prepare for this certain future.


Though not oriented to your eye care interests, Medscape Today offers an informative series on ACOs and Shared Savings. Find it here.


Alistair Jackson, M.Ed.

Acronyms of Change, Part 2 (REC)

I finished last time with a cautionary note about RECs. So what about RECs? What are they and where do they fit in? RECs are Regional Extension Centers and they were designed as a vehicle to help launch at least 100,000 primary care providers into the meaningful use of EHRs. The Office of the National Coordinator has already invested $677 million into the creation of 62 RECs nationwide. What's the chance there's one in your state? Something else you definitely want to know about!

Back to the cautionary note. If there's funding available through RECs to help me get into EHRs, why wouldn't I want to be a part of that? 


First, note that RECs are destined to get Primary Care Providers meaningfully using EHRs because the feds understood that without PCPs in the game, the overall transformation of health care would fail. RECs are seen by many doctors as a trusted advisor but, make no mistake, there are vendor relationships in the mix and the vendors are going to be those able to serve general health care. That means hospital-based systems, PCPs and the specialists who fall within hospital-based care. RECs, by and large, have not been approached with solutions that serve the interests of outside specialties. 


Second, we need to understand that most PCPs are in hospitals and are part of large health systems. Therefore, the dominant EHR systems do not and will not serve the eye care specialty niche, especially not the independent private-practioner ECP. That means, if we want to help ourselves, we must do more than simply get on board with the local REC and our state HIE. In our experience, the RECs and HIEs want to support eye care as a unique specialty. But we must also want to help ourselves and be prepared to do the work that gets us our desired results. And that leads to today's questions.


If a large health system involved at the REC level could also drive standards for the state HIE, would that likely be in the interest of private practitioners like you? Not likely. And what if you, as an independent, needed to pay the same access fees as larger organizations for the privilege of accessing your state's Health Information Exchange? Would that be a problem? Very likely so! 


Therefore, it is incumbent upon the Optometry profession, its state and national organizations, to demonstrate ways in which independent practitioners may participate in their state HIEs other than by being absorbed into the large health care groups. At EMRlogic, we're doing something about that. How about you?


Alistair Jackson, M.Ed. 

Acronyms of Change, Part 1 (HIE)

You're no stranger to acronyms. They pervade every area of your life and mine. That doesn't mean it isn't hard to keep up with them all. Our health care reform world is no exception. I think most of us, by now, know what EHRs are. You may even be convinced by now that having certified EHRs in your practice is more than just a necessary evil.


While you may or may not still be wrestling that one through, it's time to keep pushing the envelope. I'm convinced that our lack of urgency in joining the transformation of health care stems from a lack of seeing where it's all going. If we look outside eye care, we don't need that infamous crystal ball.


We've heard it said that 2012 will be the year of the HIEs - Health Information Exchanges. Simply put, HIEs are about getting those of us who have embraced EHRs "talking". Communicating is a better word. Communicating electronically. Remember terms like "portability"? It's the P in HIPAA. So for years already, the feds have been telling us that sharing protected health information securely and electronically is important. And that's what HIEs are being designed to do. The end goal, of course, is to do this nationally but, since that's such a big undertaking, it's starting at the state level. That'll give us a chance to see which models work best before we commit nationwide.


If I may suggest a takeaway for today, it'd be for you to find out what's happening in your state? The best case scenario is that your local professional association has all the answers already. Unfortunately, that's still rare, so be prepared to dig a little deeper. You may find that a Google search gets you well launched.


A word to the wise: after you've loved on your Valentine, understand the difference between your state HIE and an in-state REC. That's our next topic. Come back and learn how some professional organizations, sadly, are feeling really good about being led down the wrong path.


Alistair Jackson, M.Ed.

A Meaningful Use Surprise

Recently, we came across a Meaningful Use surprise.

Question: When does my second year of Meaningful Use begin?

Answer: On January 1st following completion of your initial MU reporting period.

To be clear, this means for example that you could complete your initial 90-day MU period on March 31st, 2012 and have no obligation to continue meaningfully using your EHRs until January 1, 2013.

Why was this a surprise? The dates are not the surprise, rather the permissibility to start, stop and re-start as much as 9 months later. Since the intent of the HITECH Act is to drive continuous and permanent change through the use of certified EHRs, it is surprising to see a start-stop-restart design in the process. 

It is our strong recommendation that you do not stop meaningfully using your EHRs. While permissible by the letter of the law, we believe there is no advantage - indeed a disadvantage - in stopping the good habits you've developed. Beginning in year 2, Meaningful Use will indeed become a continuous and permanent expectation.

Alistair Jackson, M.Ed.

Incentive Payments - How and When?

We're all interested in the how and when of incentive payments, right? CMS has published an updated and thorough response. If you want the full meal deal, read it here. ECPs with a lesser appetite and attesting through Medicare may want the snack version:

When? 4-8 weeks following successful Attestation. "For eligible professionals (EPs), incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology."  

A "yes, but ..." to help you get the maximum payment. "However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year. Payments will be held until the EP meets the $24,000 threshold in allowed charges for the calendar year in order to maximize the amount of the EHR incentive payment they receive. ..." 

So who actually gets paid? "Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments."

A Case in Point.
So here's a common scenario. You started your initial MU period in 2011 but, for one reason or another, you were unable to attest successfully. Now you need to start over. Have you lost the 2011 money? When can you expect to receive your money assuming you attest successfully in 2012?


First, no you have not lost the 2011 money. Remember that 2012 is equally acceptable as your Year 1. Though obviously your payment is delayed, you lose nothing. (The same is not true of 2013 or 2014. You will lose money by delaying past Oct.3, 2012.)


Second, as stated above, you can expect to receive your Year 1 payment within 4-8 weeks of completing your initial MU period (90 consecutive days) and attesting successfully.


Third, however, your payment could be withheld until you do enough Medicare billing to qualify for the maximum $18K. This is where attesting at the beginning of the year may not be advantageous. If your Medicare volume is low and you don't achieve the $24K threshold until later in the year, then attesting early will not get you your money earlier.


Time is Your Friend.
The flip side of the hold-off argument is that there are other reasons to start early. Why begin your 90-day MU period as soon as possible? As some have already seen, you may find it harder to embrace EHRs than you thought. You can face learning challenges - your own, or on the part of staff. You may need significant workflow adaptations - don't underestimate how far-reaching this is. You may need to work with your software vendor to get numerators and denominators or Clinical Quality Measures reporting properly. 


Bottom line: expect the unexpected. Demonstrating Meaningful Use is not a plug 'n play operation. Give it time. The more the better.


Alistair Jackson, M.Ed.

Goodbye Fee-for-Service, Hello Pay-for-Performance

One of the basic tenets of the transformation of healthcare, obvious from the outset, is that the current fee-for-service reimbursement model would diminish and pay-for-performance (P4P) would augment. P4P is manifesting itself under the auspices of titles liked "shared savings" and "accountable care" (the new "managed care"). We have long expected a shift of consumers from fee-for-service to new managed care models as quickly as the models became available. In the state of Louisiana, we are now seeing Medicaid patients being moved from fee-for-service into the kind of managed care models that will eventually become Accountable Care Organizations (ACOs) and patient-centered medical homes.  The state is so eager to get the associated savings that they are driving the transition using older managed care models. Not good but they, like many states, need the savings.


Jim Grue, O.D.

Part Of Louisiana Medicaid Overhaul To Begin.

The New Orleans Times-Picayune  (2/2, Barrow) reports, "The first leg of Gov. Bobby Jindal's Medicaid overhaul goes live today." The change "overhauls much of the traditional fee-for-service system in which the state makes direct payments to health care providers who treat Medicaid patients. ... When implemented statewide, the system will affect more than 800,000 people and shift $2.2 billion in Medicaid insurance spending - about a third of the total $6.7 million budget that comes mostly from the federal treasury - to the private firms."

The AP  (2/2, Deslatte) reports, "Nearly 246,000 Medicaid recipients, mostly children, across southeast Louisiana were switched to the managed care networks in this first phase of the insurance-based model, called Bayou Health." Of note, "Medicaid recipients who won't be covered by the networks include nursing home residents, disabled and elderly residents who receive home- and community-based care, those enrolled in specialty service programs and recipients who receive both Medicaid and Medicare services."

Thoughtflow, Part 3: legacy software or smart software?

By now, we all know that a smart phone is one you use to do a lot more than make phone calls. And the younger you are, the fewer your calls. It's now about texting, surfing and playing the social media game. Smart phones have left a trail of "legacy" phones in their dust.


There's another new game in town, the health care reform game. If you've been following a good blog or two, you know the epic proportions to which it's catching on. It's all about EHRs, Meaningful Use, HIEs, ACOs. And smart software is leaving a trail of legacy software in its dust as well.


As a long-time instrument guy, I can say that smart systems are defined as devices that incorporate functions of sensing, actuation and control. They are capable of describing and analyzing a situation, and taking decisions based on the available data in a predictive or adaptive manner, thereby performing smart actions. In most cases the 'smarts' of the system can be attributed to autonomous operation based on closed-loop control, energy efficiency and networking capabilities.


Eye care is, in my opinion, the most complex specialty in all of healthcare. We see more imaging data than any other specialty besides radiology. 'Complete EHR' solutions also include the retail side of business. 

So, what is smart software in eye care? I'd have to say it's software with thought flow. Smart software: 

• anticipates and populates data entry based upon symptoms and diagnoses, which translates into good usability and great speed
• draws from a knowledge base of eyecare best practices
• builds on behavior of predictive outcomes
• ensures that standard-of-care criteria are met
• can be customized for the care level of the practice
• drives consistency across all providers within a practice, aligning their efforts internally

In time, as best-practice standards become established, smart software will also provide advanced types of Clinical Decision Support and help align providers with external pay-for-performance standards. 

Alistair Jackson, M.Ed. 
with guest contributor Jon Dymit, Vice President/General Manager at Walman Instruments

Thoughtflow, Part 2: think and THEN work.

On January 18, we began a discussion on thoughtflow. "Doctors think very differently during a patient encounter than when they are discussing patient care, say with colleagues..." The way we think throughout the course of an exam affects the way we work. This week, I came across what's perhaps an even more obvious example: that doctors also think very differently from each other during a patient encounter. 


Let's jump into the exam lane where you're doing a typical front-to-back examination of the eye. You look at and record findings vis-a-vis the lids, the lens, the optic nerve and the macula (among others, of course). But here's the question: did you go down through the list looking entirely at the right eye then move over to the left eye? Or did you look at the lids OD/OS, followed by the lens OD/OS, then the optic nerve OD/OS, and so on? These are different ways of thinking, are they not? My simple example only scratches the surface of a whole host of ways in which providers think differently.


That's no surprise, no big deal. So what, you may ask? Well, no big deal if you're using a paper chart and the exam sheet let's you jump around any way you like. EHRs, on the other hand, have things like tab order and buttons that transfer OD ->OS. Did you want one button or 35 throughout the exam? In EHRs, we count clicks and analyze closely how much the software speeds us up or slows us down. One of the hurdles we had to overcome in designing our EHRs was that they were highly efficient for doctors (perhaps the majority?) who take the "vertical" approach but very inefficient for those who took a "horizontal" approach.


The point really is that EHRs must accommodate these different ways of thinking and then working. Traditional EMRs recorded results; next-generation EHRs must do that even better, more quickly, to a higher standard but then move beyond findings to thinking, supporting your clinical decisions, letting you see more patients in less time. That's thoughtflow. That's not just surviving but thriving in the health care reform world.


Alistair Jackson, M.Ed.