An epic debate

An epic debate is under way in the Supreme Court. It's about challenging the current health care bill. The results will significantly affect all Americans and obviously all health care providers. Whatever happens with the decision, it is clear that the Supreme Court is following the same discussion going on elsewhere.  That discussion revolves around parts of the bill that may overstep the constitutional right of the federal government to mandate that every individual must purchase health insurance. Parts of the health care bill are favored by everyone on both sides of the political spectrum. Many indicators point to the likelihood that the individual mandate could be declared unconstitutional.  

Of particular interest, the Chief Justices are asking whether such a declaration would make the entire bill unconstitutional, or if there is a way to preserve the rest of it. Justices on both the right and the left are in agreement that, if possible, the rest of the bill should remain in effect, provided there are legal grounds to achieve that end. 

This Supreme Court debate mirrors some of our previous blog posts, that the controversy here lies within the insurance reform part of the bill (who gets covered and how it gets paid) not within the health care reform part, which directly affects how health care is delivered and reimbursed. It will be some time before we know the Supreme Court's formal decision. Whether or not the individual mandate is struck down, there will be significant efforts on both sides of the political spectrum to keep the health care reform process moving ahead. 

So, our message once again to eye care providers (indeed all health care providers) is this: 

• know the distinction between health insurance reform and health care reform;
• understand that, even if the insurance reform portion is eliminated or modified, this does not eliminate the basic tenets of health care reform that are already transforming the way you must practice;
• continue to pursue the EHR technologies delineated within the HITECH Act regardless of your volume of Medicare or Medicaid billing.

Jim Grue, O.D.

Accountability: it cuts both ways

Accountability is a basic tenet of today's transformation of health care. Why? Perhaps because the lack of accountability inherent in a paper-based fee-for-service honor system is the root cause behind the near bankruptcy of Medicare.


Last week, we saw that accountability in health care reform is not just about Providers becoming accountable to low cost and high quality; Payers are also accountable. We've seen fraudulent providers get caught and penalized; now we're seeing unreasonable insurers stopped in their tracks. Secretary Sebelius called on two insurance companies to drop unreasonable rate hikes in nine states.

"Thanks to the Affordable Care Act consumers are no longer in the dark about their health insurance premiums," said Secretary Sebelius.  "Now, insurance companies are required to justify rate increases of 10 percent or higher.  It’s time for these companies to immediately rescind these unreasonable rate hikes, issue refunds to consumers or publicly explain their refusal to do so."

In these nine states, the insurers have requested rate increases as high as 24 percent. These increases were reviewed by independent experts to determine whether they are reasonable.  In this case, HHS determined that the rate increases were unreasonable, because the insurer would be spending a low percentage of premium dollars on actual medical care and quality improvements, and because the justifications were based on unreasonable assumptions.

In light of the March 19 HHS press release and this week's Supreme Court hearings on "health care reform", it's worth re-emphasizing that the Affordable Care Act and many other examples commonly cited in the media as health care reform are more accurately called "health insurance reform". Health care reform and key concepts like accountability, transparency, portability and interoperability are not up for discussion. Like EHRs and the new technology of health care, these basic tenets are here to stay. Expect to see them everywhere, including in your own back yard. And prepare your business for them accordingly.

Alistair Jackson, M.Ed.

Know Your Community: Accountable Care Organizations

My colleagues Dr. Chuck Haine and Alistair Jackson have written previously about Accountable Care Organizations. (See the Archives for Chuck's post from December 23, 2011 and Alistair's from February 17, 2012.) My question for you is, have you taken the time to see if there is an ACO in your area?  ACO’s represent a new patient referral and reimbursement system whereby the ACO receives a bundled payment for the care of the patient instead of each provider being able to bill fee-for-service to Medicare. The ACO then becomes responsible to distribute payments to the providers involved in the care of the patient. This in turn means two things: one, that the ACO chooses the participating providers and, two, that the ACO controls access to patients.

My point today is this: if you don’t learn how to become part of this new delivery system, it will affect your access to patients.  You owe it to yourself at least to be finding out if you have an ACO in your locality, or if any of the health systems in your area are working toward forming one.  


There are many ACO's functioning now already. Another group will begin getting bundled payments from Medicare on July 1, 2012, then another on Jan 1, 2013.  Since many ACO's are still at the formative stage, it's the perfect time for you to get involved.  Once they're functioning, it may be too late to open the door for your participation.


ACO's are a good example of how health care reform doesn't apply only to providers who take Medicare. You may not be concerned about stimulus incentives since, based on your current Medicare volume, your eligibility is low. Correspondingly, you may be even less concerned about  a small Medicare penalty. But what if, by virtue of the fact that you do not have certified EHRs and cannot communicate as required with other health care providers, you do not qualify to participate on a chronic care team? Losing access to patients is certainly a more serious matter than a 2% Medicare penalty. This is why we have maintained that the EHR Incentives program is really not about the money - it's about the survival of your business. Know your community and get involved in its healthcare programs. They're going to affect your business for better or for worse. It's within your grasp to make it for the better.


Jim Grue, O.D.

Know Your Community: Beacon Community Projects

Is there a Beacon Community project near you?  If you don’t know, you might want to Google "Beacon Community Project" and find out.  


There are 17 projects across the country and all involve large health systems. These are government demonstration projects that are establishing the way all health care resources in a community will work together. Beacon Community projects are determining the clinical research to be used in future meaningful use and health care reform legislation. If this is happening in your community, it is certainly in your interest to know about it and also to be part of it. 


If programs being driven by a large health system seem irrelevant to your eye care practice, be sure to ask yourself, "Do I want a model program being established in my community, one that's going to drive the future delivery of health care, including eye care, and not be part of it?"


Jim Grue, O.D.

A meaningful attitude

Many eye doctors see meaningful use (MU) as a list of extra tasks to be done if (and only if!) one wants to qualify for stimulus dollars. This being the case, you would probably overlook the advantages and opportunities those MU tasks offer.  The CCD is a great example of a new requirement with a hidden punch. You need to give it to your patient at the end of the exam, and also must make it available to the patient in an electronic format.  Sure, you can provide the CCD as a minimum requirement to "get the money", or you can see beyond and also realize that this document brings a significant benefit for your business. 


If you have to provide the CCD then so does every other health care provider who sees your patient. If you ask patients to provide your office with an electronic copy of the CCD from their physician, the electronic CCD can completely populate your EHR's problem list, medication list, allergy list and lab tests. Instantly, almost 10 minutes of data-entry work goes away. You no longer need the patient to arrive early to fill out health forms in your waiting room, and you no longer have to pay a staff person to enter the data. It's all done for you and you need only confirm the information is accurate. At a time when most doctors are worried that EHRs will slow them down in the exam lane, here is a clear example of how certified EHR technology will speed you up.


How are you handling meaningful use? As they say, "attitude is everything". Be assured, there are other opportunities you haven’t previously recognized and of which you can still take advantage.


Jim Grue, O.D.

Key Changes to the ONC HIT Certification Program

You probably already know that the current EHR certification program is a temporary certification program. The anticipated sunset of the temporary certification program is expected to occur upon the effective date of a final rule for the stage 2 proposed rule. At that time, the permanent certification program would become effective and known as the “ONC HIT Certification Program”. 

Proposed changes for stage 2 aim to increase regulatory transparency and add flexibility for the HIT community. ONC is proposing changes to the certification processes for EHR Modules that remove certain certification requirements and provide clear direction for certifying to proposed new certification criteria. The revised process would provide flexibility to quickly utilize newer versions of “minimum standard” code sets. Also proposed is an increase in certification transparency and clarity by making publicly available the test results used to certify EHR technology and clearly representing EHR technology that has been certified. Public comment is also invited on full cost transparency for certified Complete EHR and EHR Module.

Here's another interesting request for public input, a statement that corroborates our recent post on EMR switching. ONC writes in its Stage 2 Fact Sheet, "Data portability (including the migration from one EHR to the next) is a key factor in the EHR technology market where agility and innovation is necessary. We request public input on ways to improve data portability, including comment on a proposal to improve data portability for providers."

A final note: our discussion of Stage 2 is based on the proposed rule making. The 2014 Edition EHR certification criteria are opening for public comment through May 7. Only after this date will a final rule be published.

Alistair Jackson, M.Ed. 

Acronyms of Change, Part 8 (CEHRT)

Here's another acronym I couldn't resist sharing: CEHRT: Certified EHR Technology. The Office of the National Coordinator is looking to revise the definition of CEHRT, based on feedback from stakeholders and the recommendations from the HIT Standards Committee. The new definition would take effect beginning with the EHR reporting periods in 2014, and would provide more flexibility for eligible health care providers. 

The proposed revised definition of CEHRT would require eligible health care providers to have a "Base EHR" that includes fundamental capabilities all providers would need to have, as well as the additional EHR technology necessary to meet the meaningful use objectives and measures for the stage of meaningful use that they seek to meet and to capture, calculate, and report clinical quality measures, but not more than necessary to meet those objectives. A Base EHR would include such fundamental capabilities as:

1. the ability to provide clinical decision support; 
2. the ability to support physician order entry; 
3. the capacity to exchange health information with other sources; 
4. and the capacity to protect the confidentiality, integrity and availability of health information stored and exchanged. 

The revised definition of CEHRT would also enable eligible providers to upgrade and adopt EHR technology certified to the 2014 Edition EHR certification criteria as early as 2012 if they so choose.

That's the information piece. Now, what are the takeaways? 

1. There's nothing more constant than change. Expect continuous change as we move through the transformation of healthcare. That's not a bad thing. In fact, it's a good thing. Change means someone is listening and adapting.
2. Note well the repetition of clinical decision support. It's an incidental mention here but make no mistake, it's a key underpinning showing what is expected of CEHRT.
3. Note also the frequency of exchange language. The transformation of healthcare is all about taking us outside the four walls of our practice to the wider community. Exchange means the portability of health information, locally, at the state level and, in due course, nationally.
4. Just as healthcare at large is continuing to evolve, stay after your own change process. If you've implemented EHRs already, don't stop there! Keep moving on. And the next step is your state Health Information Exchange. Find out more from your state association and check back here; we'll soon be talking about an eye care demonstration project for a state HIE.

Alistair Jackson, M.Ed.

EMR switching? The second wave.

I want to reference today a great discussion by John @ EMR and HIPAA, EMR Switching Encouraged by Meaningful Use. My colleagues and I have long believed we'll see a second wave of software purchasing (switching) driven by usefulness, or what one commenter called "functional disappointment".


First-wave buyers are often driven by easy-to-assess factors, such as screen appearance or price. Coming from paper, we may be satisfied to see during a demo that the software covers the expected items, i.e. the checklist you have on your paper exam form. After that, if the software is certified, it's easy to conclude that "it must be good". Throw in a big name and a low price and you're ready to make your leap of faith.


Second-wave buyers are ready to look deeper. You may already have experienced this with your cell phone, car or house. My wife and I bought our second home not because the first home didn't have everything on our checklist but because of missed criteria we did not have on our checklist the first time around.


What are those missed criteria for EHR buyers? Without attempting an exhaustive list, here are some things to consider:
1. Meaningful Use is for the government; usefulness is for you. Buy for both.
2. We're moving from recording results to "improved patient outcomes". That means software has to be smart.
3. "Smart" starts under the hood. If the software doesn't show evidence of a robust rules-based engine, look elsewhere.
4. All software programming uses rules to a greater or lesser degree, so engage some qualified IT people to advise you on what's under the hood. 
5. Remember that cloud computing is a delivery method not a software guarantee. While there are good things about browser-based solutions, they can still be seriously underpowered in their decision-driving capabilities.
6. As we move to stage 2 of meaningful use, communications will be the litmus test. I believe that in stage 3, clinical decision support will be the final test. This is where "smart" will emerge from under the hood to the surface and where the inferior solutions will fall by the wayside.
7. The stages of meaningful use govern phases of certification. These phases do not limit vendors from releasing useful functionality today. Therefore, look for signs of advanced communications and clinical decision support today.


Alistair Jackson, M.Ed.

Connecting America for Better Health

Did you notice? "Connecting America for Better Health" is the new tagline on the CMS EHR Incentive Program logo. Significant! Indeed, it's now all about connected care.


The proposed Stage 2 Meaningful Use requirements are out now for public comment, through May 7. As always, HITECHAnswers does a great job of staying on the front lines, announcing the news and rallying the experts. (I recommend that you follow HITECHAnswers for news and developments across healthcare in general but come to EMRlogic Live for the eyecare perspective.)


As we would expect, Stage 2 is about building on the Stage 1 platform. What does that mean? 


First, the approach of core and menu set measures with exceptions remains intact. There are some changes, of course, to the measures but you're now used to the overall format. 


Second, as indicated in the program's new tagline, there's a change of focus from using EHRs to communicating, using EHRs. Significantly, "Connecting America" is not just about communications between providers. Patients are being brought into the picture as well. And for you as an Eye Care Provider, that means not just hospital patients but your patients too. For example, you'll no longer give patients an electronic copy of their exam summary, you'll have to provide them electronic access to the same. That, in turn, means a patient portal. The measures will include a requirement that a given percentage of patients use the portal and also send a secure message back to the provider.


Third, we can expect to see an increased level of audits. Some auditing is already taking place but more is forthcoming. It's not yet clear to what degree more audits will be tied to stage 2 versus year 2. If year 2, the increase starts now. Timing aside, we know that the change process began with attestation, will slowly migrate to electronic reporting (auditing) and culminate in pay-for-peformance reimbursement.


Fourth, we'll see advances in the reporting of Clinical Quality Measures. In stage 1, you were able to report zeros. That will cease in stage 2. We'll see consolidation of the current reporting mechanisms. PQRS, for example, is now essentially an insurance billing function. Whereas to date it has been disconnected from the doctor's exam, a pilot program is in the works to integrate it into EHRs along with the reportable CQMs.


Fifth, ONC Direct, also known as the Direct Project, has as its goal "to replace the fax machine as the point-to-point communications tool for healthcare". Every Health Information Exchange (HIE) in the country will use ONC Direct. That means also that every Eligible Professional (you!) will use ONC Direct to send and receive the Continuity of Care Record (CCR) and Document (CCD). Your certified EHR already has this capability; it was required for the initial certification. In Stage 1, you had to send a test (which could even fail!) but in Stage 2, you'll have to actually use it and use it successfully.


Successful use of ONC Direct means that the HIE requirement goes from merely performing the CCD test to actually connecting with at least three external providers in your primary referral network, or establishing an ongoing bidirectional connection with at least one health information exchange organization.


Stay tuned for more on what's happening in eye care with ONC Direct and one statewide health information exchange.


Alistair Jackson, M.Ed.

Health care reform or connected care?

Ever get so down in the weeds that you lose the big picture? It feels like time to come up for air and remind ourselves what in the health care world is going on. What follows is an excerpt from my second post on EMRlogic Live, 11 December 2011. I hope it'll be a useful reminder. You can read the original posts via the Archives button to the right. Select December 2011 and scroll down to Parts 1 and 2 of "What are you doing about health care reform?"


But before you read on, let me make an important clarification. I suspect that the term "health care reform" may have become a bad word for some. In my last post, I distinguished between health care reform and health insurance reform. Given the debate around ObamaCare, the discussion of health care reform may have become tainted. For myself, I'm re-directing my thinking to a more neutral and potentially more helpful term: connected care. It describes in vanilla terms where we're going ... to a connected community of health care, the likes of which we have never seen. And it's a good thing.

"I asked an optometrist I considered to be a prominent figure in the eye care profession what he was doing about health care reform. Response? “You know, I just don’t believe the feds are going to pull it off.” Unfortunately, that answer belies what I’ve heard all too often. Ostrich syndrome.

Optometry has a problem. Though far from all, too many leaders are playing wait ‘n see. Ophthalmology is not playing that game. Instead, the MDs are running away with the evidence-based medicine that will be critical to the Clinical Quality Measures upon which all eye care pay-for-performance will be established.

In our 2007 white paper, A White Paper for Optometry: Medicare Pay-for-Performance & Value-Driven Health Care, we asked the question, “Is it in the best interests of either the patient or the health care system itself to emphasize surgical and advanced-treatment methods over early intervention and preventive methods?” Then we gave our answer. “Clearly not! Yet this is the natural course of the current trend toward pay-for-performance. Optometry must position itself to gain input into the outcomes selection process.”

My sense about eye care is that we're moving in the right direction. MU attestations (1238 Optometrists and 655 Ophthalmologists in 2011) and the news of so many ECPs receiving their year 1 stimulus payments is encouraging. Surely our colleague above is less convinced today that the feds aren't going to pull it off.


2011 was the year of the EHR. We got over the initial hurdle and many of us are now seriously in the game. But if we've learned anything, it's that it's not over. There are more hurdles. And the 2012 hurdle is the HIE. Your statewide Health Information Exchange is your doorway into true connected care. Watch for more on this in the coming weeks. Remember that the purpose of EHRs was never about recording results - you've been doing that on paper for years already. The true purpose is to blow open the doors, create transparency and connectivity within the system. That's why we call it connected care.

Alistair Jackson, M.Ed. 

Health care reform or health insurance reform?

On February 21, CMS News issued a press release entitled, "Health Reform Expands the Insurance Market, Supports Consumer-Governed Nonprofit Health Plans". My purpose today is not to comment on the specifics of this announcement, rather to draw your attention to an area where we have observed confusion among Eligible Professionals.

The media and "we" generally do not distinguish well between health care reform and health insurance reform. The two are obviously related but are not one and the same. When you hear the political debate over ObamaCare, that's insurance reform. It's the money side of health care. Who's going to pay for what? How will patients be covered or reimbursed? What about shared savings programs? And in the case above, what are health insurance CO-OPs? 

The most unfortunate outcome of our confusion is that many doctors hear the debate and conclude that health care reform must still be up for discussion. They ask, "why should I rush into EHRs? If ObamaCare fails, everything will go out the window anyway." Well, insurance reform is still up for discussion but health care reform is not. Sadly, too many Eye Care Providers are still waiting to see how it all turns out. They're holding back on EHRs thinking they can wait a little longer with their familiar paper charts. They're convinced that EHRs and the Stimulus money don't matter because they don't do much Medicare anyway. Meanwhile, health care is transforming and putting their businesses in greater jeopardy with each passing week.

If health insurance reform is the cost side of health care, health care reform is the quality side of health care. Lower cost, higher quality. Improved patient outcomes. Health care reform is not up for discussion. It has been unfolding for many years already. It is well engrained in the fabric of health care today. It is here to stay. 2011 was the year of the EHR. 2012 is the year of the HIE ... connected care.

The health insurance reform debate is likely to carry on for years to come. The only real question that remains about health care reform is whether you'll be its benefactor or its victim.

Alistair Jackson, M.Ed.

EHR medico-legal liability: to fear or not to fear?

We have witnessed of late a big surge in the volume of articles and white papers addressing EHR-related medico-legal liability issues. Many are being taught actively in law schools. In one course I am familiar with, the basic strategy is to find any piece of conflicting information and use it to invalidate the whole medical record, leaving the litigant effectively with no defensible record. These are significant issues, ones we take seriously in the design of our software, activEHR. 

One of the top examples of conflicting information is different findings over time in the Review of Systems (ROS), History of Present Illness (HPI) and Personal, Family & Social History (PFSH). The simplest and most straight-forward solution is for the EHR to combine all areas where known conflicts regularly occur. In activEHR, for example, we incorporate the Review of Systems and Medical History into the problem list, limiting how often we move medical information within the exams. It is extremely complex for an EHR to maintain automatically the consistency of this information, and a heavy burden for providers to have to do it clinically.

At first glance, it would seem that the medico-legal aspects of an EHR should cause providers to shy away from them, but there is a flip side. Since paper charts can’t do as much as electronic, the same EHR courses at the same law schools also teach legal strategies for a litigant who comes to court with a paper chart. It is now becoming much easier to make a legal argument that the doctor is not up-to-date or using the latest technologies as demonstrated by the continued use of paper records. The health system has well documented evidence that electronic records provide important Clinical Decision Support (CDS) capabilities not available in paper charts. Therefore, for providers, there are pitfalls in both directions. The best solution is an EHR that's designed to limit liability and continues to provide a path toward portability, best-practice CDS, and transparency.

Jim Grue, O.D.