Eye Care Communications, Part 4

Continued from Part 3 ... 


Last week, we looked at EMRlogic's National Eye Care Communications Project, understanding what this project is and why we need it. We began by looking at it through the eyes of a new and very important pilot project, the Comprehensive Primary Care (CPC) Initiative. We discussed the importance of pilot projects and of ECP involvement in them. We looked again at the big picture: primary care and the Medical Home model. Today, we conclude with the role that the NECC Project plays in helping you transform the culture of your practice.

Practice Transformation

An important term used on the CMS Innovation website is “practice transformation”. For example, from page 13 of the participant solicitation guide for the CPC Initiative (italics ours), 

“The Innovation Center is working with national experts in practice transformation and primary care to develop resources and activities to support the CPC Initiative practices in achieving the aims of the program … Just as importantly, the market-based learning communities will help practices to set up a routine schedule of testing and implementation of changes to support the fundamental transformation required for comprehensive primary care.”

Another significant aspect of the NECC project is to assist local eye care providers in the process of the culture change – practice transformation – required to be a participant in a team delivery system, as compared to thinking the way we have traditionally thought as independent private practitioners under a fee-for-service system.  Providers in any area of medicine who have participated in structured team delivery understand that team-based care is a “culture change” that requires a redefining of your role as a health care provider.  This paradigm shift is not done overnight; it takes time and effort.  

The collaboration mechanism of NECC Project allows providers to discuss issues, share ideas, brain storm, test concepts and work through this process with like-minded providers doing the same. One of the values of this collaborative process is creating a portfolio for each provider that answers the question, “what do I bring to a team?”  Traditional issues such as doing a great exam, having all the right equipment, and writing a letter to the primary care physician on every diabetic patient are just givens on a chronic care team. You are not going to get on a team if you don’t do and have those things. What teams are looking for is providers who understand what it means to share the responsibility that every patient gets the best possible outcomes. That goal is achieved only by utilizing every resource from every provider on the team with a process in place to drive continuous improvement.  This fascinating process opens many doors for independent eye care providers. It offers whole new levels of capability to a local team, capabilities the team doesn’t know exist unless you show them. The NECC Project will help you embrace those concepts and capabilities and see the new possibilities emerging with these new delivery systems.

In summary, just as your state and national associations are working diligently to make sure eye care is involved in the new delivery and reimbursement models, the NECC Project asserts that you need to be equally diligent in your local community. Position and prepare your practice, be involved in shaping the delivery system as it emerges in your local community.  Additionally, the NECC Project strongly encourages all participants to stay in close communications with your state association. It is important for them to know what you are doing and finding locally, and important for you to know what they are doing on your behalf at the state level.


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

Eye Care Communications, Part 3

Continued from Part 2 ... 


This week, we are looking at EMRlogic's National Eye Care Communications Project, understanding what this project is and why we need it. We began on Monday looking at it through the eyes of a new and very important pilot project, the Comprehensive Primary Care (CPC) Initiative. On Wednesday, we discussed the importance of pilot projects, and of ECP involvement in them. Today, we look again at the big picture: primary care and the Medical Home model.

Medical Home or Medical Community?

Nationally, one of the challenges that the Office of the National Coordinator of Health Information Technology is facing is the resistance of large health systems to implement DIRECT, as these communications provide equal access to all health care providers in communicating with all other health care providers. The exchanges set up by health systems are primarily designed to funnel patients into their system rather than create equal access to patients. This phenomenon is resulting in a new term in the healthcare literature and media. 


The new term differentiates the Patient-Centered Medical Home model, which is structured around communications through a closed exchange, and alternatively introduces a Patient-Centered Medical Community model, which utilizes DIRECT communications with equal access for all health care providers. It is a primary goal of the NECC Project to ensure that local eye care providers are aware of this distinction and to encourage participants to influence the creation of a medical community that includes independent providers, especially independent eye care providers. 


To be continued ... 


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

Eye Care Communications, Part 2

Continued from Part 1 ... we are looking at the National Eye Care Communications Project, understanding what this project is and why we need it. We began on Monday looking at it through the eyes of a new and very important pilot project, the Comprehensive Primary Care (CPC) Initiative.


Two Levels of Involvement

There are two levels at which providers can participate in the CPC Initiative: direct involvement at the primary care level and indirect involvement at the secondary care level. The primary care level is, obviously for Primary Care Physicians. This is the participant role for which PCPs must apply, show eligibility and ultimately be selected. However, ECPs can also be involved indirectly. Indirect involvement means an interactive support role for the PCP, helping her or him understand DIRECT and becoming a partner with whom to exchange patient health information. We believe that by eye care providers being involved in the process from the very beginning, two things will occur.  First, the abilities the eye care provider brings to the primary care physician can actually make the physician a more qualified candidate for team delivery of care and, therefore, more likely to be accepted as a team participant.  Second, if the primary care physician is selected for participation, it will position the eye care office to be selected for inclusion in the care team, coordinated by the primary care practice.

Pilot Projects

The reason we see so many pilot projects throughout the transformation of  health care is that nobody knows how exactly the new connected-care and coordinated-care relationships should be structured. If we knew it already, there would be no need for pilot initiatives or incentives. Two things that we do know from the pilots to date are that, first a provider must be utilizing a certified EHR in order to be part of a team and, second, each provider must have the ability to share patient health information electronically.  Beyond this, there is a set of eligibility requirements that the primary care physician must meet in order to apply – and the local eye care provider can help!  

How can the ECP help the PCP? Many primary care physicians are using certified EHRs but have not been sharing patient health information electronically. So, the eye care provider can actually work with the physician to help implement that capability and serve as a test office once they have set up their communications.  This is an important issue as many local physicians are only aware of exchange communications capabilities within large local health systems. Many are not even aware that one of their communications alternatives is through DIRECT. Again, the eye care provider can actually assist the primary care physician in becoming more knowledgeable about this alternative. 

Additionally, pilot projects are put together with a lot of flexibility on the local level so they can be structured to meet the needs of the local community.  How they will be structured occurs largely at the local level.  Input of the local ECP is important early on as the individuals structuring the pilot may not even be aware of what an ECP can bring to the table, or the value that the ECP can add to the team.  The most effective time to be involved is in the formative stage where you can influence the process the most. The most important question you must ask yourself is whether or not the pilot project or the care team is going to be structured ideally for your office without your involvement.  If you think that may not or will not happen, then you know what you need to do. 


To be continued ...


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

Eye Care Communications, Part 1

EMRlogic has launched a National Eye Care Communications Project. This week's posts are dedicated to explaining what this project is and why we need it. We'll look at it through the eyes of a new and very important pilot project, the Comprehensive Primary Care Initiative.

The National Eye Care Communications (NECC) Project is a collaborative platform allowing providers, working in cooperation with their state associations and other professional groups, to share their experiences. The NECC Project emphasizes projects, activities and capabilities destined to affect independent eye care statewide and nationwide that must be supported at a grass-roots level. We offer the Project as an adjunct to local activities, a roadmap that clarifies the end game of health care reform and connected care. 

For several years, the health care media has been full of news about federally-driven and sponsored initiatives intended to lay a foundation for the future of health care. Much of that news has gone unnoticed by providers at a local level. As some of these important projects, the Beacon Community Program for example, draw to a close we are seeing the emergence of new pilot projects at the state and local levels. One such new initiative is the Comprehensive Primary Care (CPC) Initiative, a multi-payer initiative in AR, CO, NJ, NY, OH/KY, OK and OR, fostering collaboration between public and private health care payers to strengthen primary care. It is critical that independent eye care providers understand the pivotal role of the primary care physician in the transformation of health care and, correspondingly, the role of the ECP and other specialist providers in the team-based care delivery model. Understanding this relationship is the key to the successful future of independent eye care. The CPC Initiative gives us a clear window into this vital pilot project.

The Comprehensive Primary Care (CPC) Initiative 

The CPC initiative is one of many coordinated-care pilot projects shaping team delivery of care and participation in shared savings.  CPC, like every other team delivery model, is based on team members sharing electronic patient health information. For this reason, the NECC project emphasizes first and foremost that independent eye care providers must be equipped, both conceptually and technologically, to share and communicate electronic patient health information. The national standard for this kind of communication is DIRECT. The DIRECT standard was established by the Office of the National Coordinator and is offered by a variety of Health Information Service Providers (HISPs) throughout the country.  Since communicating electronically via this national standard is a pre-requisite for participation in the CPC Initiative, it is better for the local provider to have implemented this capability already, rather than wait to start once the primary care physician seeks to qualify as a CPC participant.

Learn more here about the Comprehensive Primary Care Initiative. Pay particular attention to the shared savings opportunity. The fundamental concept behind team delivery is that the quality of care will increase and the team will find ways to decrease the cost of delivering care. Conceptually this makes sense, but in practical terms, you need to be positioned to share in the savings. Shared savings is what makes team delivery work. Otherwise, for the healthcare providers, all savings that the team generates are lost income. The shared savings program repays directly to the providers 85% of the savings that the team creates. You will not share in these savings if you don’t position your practice correctly and get involved with care teams.


To be continued ...

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

A use case for eye care

We mentioned last day that EMRlogic had presented at the ONC's Direct Demonstration Showcase in Washington, DC. Why was our use case selected? First, because it met the requirements of a closed-loop referral involving the primary care physician (PCP), a specialist provider (ECP) and a patient (PHR). Second, our use case was unique and interesting. We designed it to demonstrate the value independent eye care providers can bring to team-based healthcare. Here are the essential points of the use case:

• 28 yr old patient presents at rural optometry practice (ECP) for routine exam. Patient reports blurred vision. Problem list from CCD indicates gestational diabetes. 
• Patient reports one year since routine post-partum visit. ECP alerted via software's Clinical Decision Support (CDS) that best practice standard not met. Patient referred back to PCP for follow-up. 
• PCP orders routine lab tests. 
• PCP office receives lab results via Direct into EHR inbox. Office manager reviews and assigns to PCP and attaches lab results to the patient medical record. 
• PCP forwards lab results to patient’s PHR using Direct. 
• PCP notifies patient via Direct message to contact office for follow-up visit.

This use case is just one example of why independent eye care providers, many of them beyond the geographical reach of large health systems, are so important to the healthcare system we want and need. 


Notice that the patient did not go to the doctor because she felt she was sick. She went, in fact, feeling healthy. The signs and symptoms of her gestational diabetes were gone. Breast-feeding over, hormones back to normal, she went to her eye doctor simply to have her prescription renewed. It is the eye doctor seeing the "healthy" patient who has a unique opportunity to return the patient to her family physician for needed follow-up and preventive care.


In the same way that the software's CDS can alert the eye care provider to the need for follow-up care, it can equally well advise him or her of the ocular side effects of prescribed medications. (See a clear example on our web site's home page.) In team-based healthcare, other physicians will look to ECPs to provide this insight. None of us can know this for every drug ... but software can. That's one thing computers do exceedingly well. 


Back to the basics: 

• EHRs are more helpful than paper charts. 
• The use of EHRs is not an end in itself.
• You must move beyond EHRs to the exchange of health information.
• Sharing and communications are cornerstones of team-based coordinated care.
• Team-based delivery implies team-based reimbursement.
• You cannot get paid if you cannot or do not participate in care teams.
• You must prove both ability and value before you will be accepted onto care teams.

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

"DIRECT saves time."

Last week, EMRlogic participated in the 2012 Direct Implementation and Adoption Summit in Washington, DC, a meeting of the ONC State HIE Program. We played our part in the Direct Demonstration Showcase. The showcase featured 15 use cases, each one selected to demonstrate how the Direct protocol is being used to improve the secure exchange of protected health information at a national level. (You can see more about our role here.)


The last day of the meeting began with an open mic, inviting comments from attendees. The first comment came from a Rhode Island executive, a short but profound statement: "Direct saves time."


Our use case was a great example of that, not due to the case details but because our technology has achieved what the ONC Director, Dr. Farzad Mostashari said would be realized system wide in Stage 2. As we continue down Reform Road, moving from electronic health records (the collection of PHI) to electronic communications (the exchange of PHI), we indeed have the opportunity to save time ... and effort as well.


Picture this sequence of events: 

• you receive a Continuity of Care Document from a primary care physician for a patient you have never seen in your office 
• your software consumes the CCD and, in so doing, automatically creates and populates a new patient file, complete with patient demographics
• your software also creates an exam record, complete with the new patient's problem list, medication list, allergy list and lab results.

Remember how you worried that EHRs would slow you down? Indeed they can. And remember when you thought your software required too many clicks? That may be true as well. But here's an example of how the intended exchange of CCDs can save you hundreds of clicks and 15 minutes per patient. The time saved is not just provider time but also staff time and patient time.

Any way you slice it, that's a significant benefit to your business. Think of it not only as saving time but also leveraging effort. As you engage in communications and understand where connected care can take your practice, recognize that every time another office enters patient information into their software, you have the opportunity to leverage their time and effort.

Direct saves time ... and effort.

Alistair Jackson, M.Ed.

Communications, Connected Care and ACOs, Part 1

What are ACOs? 

Accountable Care Organizations (ACOs), in the opinion of most national authorities, are the direction healthcare care delivery and reimbursement is going. An ACO refers to a group of physicians, hospitals and other suppliers of services that work together to provide coordinated team-based care to insurance beneficiaries. Several groups of providers and suppliers 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 and suppliers as the Secretary determines appropriate. 

ACOs are popping up everywhere. CMS is not the only organization driving them. In fact, the majority of ACOs in existence today are commercial ACOs not tied into CMS initiatives such as the Shared Savings Program. See the CMS list of 27 ACOs and compare it against the other list of 80 ACOs. The lists show locations, so be sure to see which ones are in your back yard.

• CMS releases list of 27 ACOs  
• 80 Accountable Care Organizations to Know

Another group, estimated at 150, will begin getting bundled payments from Medicare on July 1, 2012, then another on Jan 1, 2013. 

How will ACOs affect my eye care practice?

It's important to understand the effect of this trend on your practice. There are two important points:

Reimbursement. The way providers get paid for patients covered through an ACO will change. The ACO will receive a “bundled” payment for the care of the patient and the ACO will pay the providers delivering the care. You will no longer be able to bill the insurance company under a fee-for-service payment system.

Access. Your access to patients covered by the ACO will be affected. A fundamental concept of the emerging healthcare delivery system is that outcomes for patients with chronic conditions is best delivered through teams of providers communicating closely about the patient, with the patient an integral part of the process, in order to determine the best management plan. Coordinating this team delivery of care is one of the main functions of the ACO. If you are not part of the team delivery system, you will likely lose access to these patients. As a part of the coordination of care, the ACO not the patient actually schedules the patient's routine appointments with team members. 

The ACO also is responsible for ensuring that every provider who sees the patient has the appropriate patient medical information. This is information shared among all team members. The ACO, as part of its reimbursement, gets a specific fee for doing this coordination. Thus, the ACO is becoming your new referral center.

There are three things you need to be doing before you'll be considered by an ACO to be part of a care team:

1. You must be using a certified EHR;
2. Your EHR must have the capabilities to communicate electronically with the ACO; 
3. Most likely, you will need to demonstrate a changing culture in your practice, that you are embracing the implications of being an effective team member versus a standalone practitioner, as is now the dominant model.

To be continued ...

Alistair Jackson, M.Ed.

Communications, Connected Care and Beacon Communities

What is the Beacon Community Program? 

The Beacon Community Cooperative Agreement Program is part of a larger health care improvement revolution that demonstrates how health IT investments and Meaningful Use of electronic health records (EHR) advance the vision of patient-centered care, while achieving the three-part aim of better health, better care at lower cost. The HHS Office of the National Coordinator for Health IT (ONC) is providing $250 million over three years to 17 selected communities throughout the United States that have already made inroads in the development of secure, private, and accurate systems of EHR adoption and health information exchange. Each of the communities, with its unique population and regional context, is actively pursuing the following areas of focus:

• Building and strengthening the health IT infrastructure and exchange capabilities within communities, positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years; 
• Translating investments in health IT in the short run to measureable improvements in cost, quality and population health; and;
• Developing innovative approaches to performance measurement, technology and care delivery to accelerate evidence generation for new approaches.

Why are Beacon Communities relevant to our Eye Care Communications project? 

The above description is taken from the Office of the National Coordinator of Health Information Technology website.  The basic task of the Beacon Community Program is to look at the total health care resources of these 17 selected communities and see how they can most effectively work together to get the best community-wide health care outcomes at the lowest cost. Their challenge is to develop innovative ways for health care providers and resources to work together to optimize patient outcomes, to develop ways of consistently delivering the highest quality care.  If you go to the link above and scroll down, you'll see a description of what each community project is asked to do. One of the broad goals of the Beacon Program is also to determine what items “bundled” payments must cover.

The results of the three-year project (2011 through 2013) are providing important information at the national level for developing health care policy.

Getting independent eye care providers involved in Beacon Community projects is a goal of the National Eye Care Communications Project.  Participation is essential if independent eye care is to be part of the developing model of care, and especially if independent eye care is to be included in the reimbursable services included in the bundled payment system.


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

Communications, Connected Care and DIRECT?

It's time to re-visit the topic of the Direct Project, or simply DIRECT. We opened this discussion back in February under our series, "Acronyms of Change". (See Archives, February 2012, Part 4A and 4B dated Feb. 20th and 22nd.) At EMRlogic, we're now fully engaged with DIRECT. The rubber is meeting the road among eye care providers.

What is DIRECT? 

DIRECT is a national communications standard created by the Office of the National Coordinator for Health Information Technology. The standard describes secure transmission protocols for exchanging patient health information. DIRECT also verifies the identity of both the sender and the recipient. It is the standard approved and required for all state Health Information Exchanges as a common method that providers can use to communicate securely between health care facilities whether within the state or across state boundaries.

What software is required?

The secure transmission protocols contained in DIRECT are used by software vendors to create end-user solutions which, in turn, can be incorporated into functional applications.  These software applications are distributed by certified companies and organizations in several formats:

• a web portal (e.g. webmail) 
• an email client (e.g. Outlook)  
• a software integration (e.g. an API for certified EHRs)  

A certified organization is referred to as a Health Information Service Provider (HISP). Typically, HISPs sell the application as an annual per-provider license fee. When information is exchanged between providers using different HISPs, the transfer is referred to as a HISP-HISP exchange.

How do I connect to DIRECT?

Some HISPs distribute their Direct-enabled applications in a particular region or state while others do so throughout the country. Your state HIE office can provide information on the HISPs approved in your state but be sure also to check with your EHR vendor. As noted above, EHRs integrations are available and can only be implemented through a direct partnership between the HISP and the EHRs vendor. Integrations represent the highest level of communication between two EHRs and are required on both ends in order for the patient health information to be consumed into the receiving EHR.

The National Eye Care Communications Project is working in partnership with Secure Exchange Solutions (SES) and can help arrange a software installation at your office. 

How clinically complicated is the process?

You will likely find that communicating with other health care practices through DIRECT is easier than your current methods. DIRECT is simple and intuitive and, in addition, will maintain a log of your communications and provide completely secure exchange capabilities.  

DIRECT is content agnostic. This means the focus is on secure transmission regardless of the contents. DIRECT does not know what is being transmitted and has no interaction whatsoever with what is sent. Your EHR will create a communication of some type, e.g. a CCD, Summary of Care or consult. Depending on the type, the system may automatically associate the file with a folder read by the DIRECT software, or you may manually attach the file created by your EHR. Next, you will use the directory built into DIRECT to find the office to which you want to send the information, select and send. 

The DIRECT software does the encryption, applies the required certificate, and password protects the communications package. DIRECT sends your “package” through a secure internet connection and, at the receiving end, verifies that the receiving office is who they are supposed to be. Once verified, DIRECT decrypts and unlocks the communications package so it can be either humanly read, or consumed into the receiving EHR system.  


Alistair Jackson, M.Ed.

Communications, Connected Care and HIEs, Part 3

... continued from our previous two posts.

State HIEs that support ONC Direct

ONC Direct is the easiest standard to meet for eye care and the most effective at transmitting eye care information. Once a practice is able to communicate through ONC Direct that practice can communicate with every office, clinic or hospital in health care that is Direct-enabled. 

As stated earlier, all state HIEs must eventually support ONC Direct. At the present time, some states support the ONC Direct communications standard and some do not. Therefore, it’s important to understand that ONC Direct is not dependent on the state HIE in order to function. Any provider who wants to utilize this national communications standard can do so by signing up for ONC Direct through a health information service provider (HISP).*

In this case, there’s a roadblock to foresee. When health systems are part of an HIE that is not yet supporting ONC Direct, individual providers may not want to pay additional fees for ONC Direct. Health system or state HIEs tend to be the ones putting in place a repository and their fees are already expensive. Providers want the HIE to provide all communications. So, the best way to proceed in these situations has to be evaluated on an individual or community basis. One key consideration however is that ONC Direct allows cross-state communications whereas as state HIEs may be limited within the state. Any HIE that currently supports ONC Direct is easy to connect with as all providers who have ONC Direct can communicate with any other provider, no matter where in the country.**

Note * 
Think of a HISP as similar to your local ISP, or Internet Service Provider. You know the Internet is there but you need an ISP to connect you to it. In the same way, a HISP connects you to the health information exchange and ensures the secure transmission of the patient health information you are sending to another provider.

Note ** 
Our next post is dedicated to ONC Direct. In the meantime, see two previous posts on this topic in Archives, February 2012, Part 4A and 4B dated Feb. 20th and 22nd.

Alistair Jackson, M.Ed.

Communications, Connected Care and HIEs, Part 2

... continued from our previous post.

Some HIEs offer free portals into large health systems for independent providers

"Free" sounds good, right? Beware, this is not good news. Since large health systems always look for ways to expand and exert more influence, there is a common first step in creating a health information exchange. Such systems typically benefit by communicating with independent health care providers within their geographical area. Therefore, we see many examples of the large system offering free or low-cost portals to independent health care providers within the local area. Health systems are willing to provide a portal free or at low cost because they tie outside providers into the system and usually increase referral relationships. Connecting independent providers through such portals also increases political clout at the state level for the large systems, helping them take the position that the state system should be structured with independent providers connecting to the state, and eventually the national system, through the local large health system.  

There are pitfalls in this model for independent providers though. The “free” portal allows providers to view patient health information for only the patients who are already part of the health system. The portal does not provide communications capabilities with other health care providers (or their patients) outside the health system. This need isn’t even discussed in many situations as the large health systems are not yet ready to provide outside services. We are seeing a trend, however: the systems that have reached this point are initiating substantial connection fees, applicable to outside patients and providers. These new fees appear to be making this the most costly exchange model.

State level HIEs that serve as repositories of selected patient health information 

The next level of involvement we see from large health systems driving the structure of the state HIE is their support of a state system that connects large health systems through a state-level repository of patient health information. Typically, we see this developing at the state level, where a repository is formed and the large health systems in the state agree what kind of data is going to be stored and exchanged at that level. In most cases, these repositories are proprietary and different in every state. Some states have multiple repositories as large health system compete and do not necessarily want to cooperate with one another, for a variety of reasons.  

States that are attempting this type of exchange vary tremendously in their ability to connect. Some states, such as Maryland, already connect every hospital system and are already exchanging some data between all connected hospitals. Other states that are attempting to build repositories are still deciding what information to exchange. They are still establishing mechanisms for the sharing of information, so are not actually exchanging much or any information between members.  

Again, there are pitfalls with this type repository system being the core of a state HIE.  One of the long term issues is that repositories have to be maintained and tend to be expensive, entailing significant ongoing costs. With health care dollars shrinking, and the eventual loss of federal dollars, the long-term sustainability of exchanges structured around a repository needs to be proven. The other problem is that, even though many large health systems are offering portals and proposing that independent providers connect to the state level health system through the portal, most have been unable to demonstrate how health information from the independent providers can be routed through the system and shared with other health care providers outside the local system. 


And this brings us to our next topic: HIEs that support ONC Direct. Continued in Part 3.


Alistair Jackson, M.Ed.

Communications, Connected Care and HIEs, Part 1

If you've been following our blog for any length of time, you've probably noticed an evolution in our message, towards communications. We've written about many topics under the umbrella of health care reform, including of course eye care EHRs. But in the big scheme of things, health care reform is not really about EHRs. Lest that sound like heresy, let me explain. 


Of course EHRs are at the core of reform. The incentive money is all about EHRs, so they must be - and they are - important. As my colleague Dr. Jim Grue likes to ask, "You don't think, do you, that the federal government is putting you through all this so you can have neater exam forms?" No way. There's more to it. In the end, it's about sharing what ends up in your EHRs. That's why we prefer to call it connected care. Communications. And that's why we've launched a National Eye Care Communications Project. What will follow over the next few posts is a series of talking points. For sake of brevity, we'll have to carry the point across two or more posts. We begin with HIEs.

Health Information Exchanges (HIEs) are structured for communications. How should you connect to your State HIE?

HIEs are possibly the most confusing area to understand amidst all the changes occurring in health care delivery and reimbursement. It is worth taking a few minutes to contemplate this topic though as, once you understand the variations and the reasons for them you will have a much stronger picture of how to position your practice for inclusion. You may also identify opportunities where your leadership could bring substantial recognition for your practice.

Every state is somewhere in the process of developing a state level health information exchange, which will eventually allow providers to securely exchange patient health information within the state. The plan is to tie all states together so, ultimately, any provider anywhere in the country can share secure patient health information with any other health care provider. Does this sound futuristic? You may be surprised to learn that Optometrists right now are participating in the first national eye care communications project and that Optometry may be the first profession to successfully connect providers in all 50 states. HIEs are not a thing of the future; they are a current reality, they are functioning and providing services to patients throughout the country.

What forms do we see HIEs taking?

Every state has received funds from the federal government earmarked for the development of a health information exchange. By accepting these funds, the states committed to the creation of a state-level exchange that will ultimately connect to a national exchange. There is one requirement of particular significance to eye care.  Every state that accepted federal funds must include and support ONC Direct as one of its communications methods. Exchanges may support as many methods as the state feels appropriate but must include ONC Direct. (We'll treat ONC Direct as a separate talking point to follow.)

Federal funding is not the only driver though. Large health systems have been exerting significant efforts to influence the way state exchanges work. It is important that we recognize large health systems have different communications needs than independent practices. What is best for a large health system may not be best for independent providers. We also must recognize that when all providers within a large health system utilize a single EHR, all those providers are already capable of sharing the patient health information of every patient within the system. There is no need for an outside system to supplement what they are already capable of doing. However, here is the problem still faced by this system, and all providers within it: they still have no way to communicate with providers outside the system.


To be continued ...


Alistair Jackson, M.Ed.

How will the CCD affect my exam?

Inquiring minds want to know. How will the CCD (Continuity of Care Document) affect my exam? In a word, significantly.

At the end of the exam, any provider who is meeting meaningful use is giving the patient a CCD. Simply doing that meets the MU requirement but, if we expand our thinking a bit, we can use the same technology to benefit your office as well as further the goals of connected care. Health care reform is all about improving quality and saving cost in delivering care. The CCD does that if we simply combine it with the communications requirement: to share it with other providers. Ask your patients to have their primary care physician send you an electronic copy of their CCD, and you can take off about 10 minutes from every exam. This assumes, of course, that you are using an EHR that has the ability to consume the data from the CCD.

We’d all agree, I’m sure, that there’s not an ECP in the country who wouldn’t want to stop making patients come into the office early to fill out paperwork that they don’t want to fill out. Paperwork then data entry. Who wouldn’t want to eliminate paying staff to enter that information? By asking for electronic CCDs, with one mouse click, you can have data that's more accurate than asking the patient, less time consuming, and more efficient.  Certainly, there are steps in this process you may not know how to accomplish today. Fortunately, we have groups of providers of ECPs that are doing this and are willing to assist other providers in learning the steps.

Jim Grue, O.D.

Note 1: We saw when e-prescribing was being adopted that complete and reliable patient records were not always available, that it took time for the nationwide eRX system to populate and become truly useful. It took doctors getting on board, using the system as designed. We’ll see a similar situation here. Stage 1 certification mandated the CCD but only on a test basis and only in a humanly readable format. Until Stage 2 certification arrives, consumable CCDs will be the exception rather than the rule. If you’re enjoying this capability today, even on a limited basis, thank your software vendor. You’re way ahead of the curve! 

Note 2: The CCD, with which you may be familiar today if you're using certified EHRs, will morph in Stage 2. The Stage 1 CCD and CCR will be replaced with a new Summary of Care Record. You may see it referred to as a CDA document. CDA means Clinical Document Architecture. Regardless of the acronym, the Summary of Care Record will include the structured allergy, medication and problem lists.

Note 3: Moving to the CDA standard from the current CCD format will require only minor programming changes for vendors who prepared well at Stage 1. The CDA standard may prove to be superior one for both providers and patients, an outcome we would expect from a process given as much public and industry review as is being afforded through the HITECH Act.

Alistair Jackson, M.Ed.

A Critical Time for Optometry

Christopher Colburn, O.D. is the past president of the New York State Optometric Association (NYSOA).  His letter dated 25 April 2011 speaks a timeless message that every optometrist needs to hear, regardless of your home state. We have removed occasional content to help with brevity (as indicated by an ellipsis ...) but invite you to read the whole letter here on the NYSOA website.

A Critical Time for Optometry -- We Need Your Help 
The Patient Protection and Affordable Care Act, better known as The Health Care Law, will likely be modified over time. While news outlets focus on hot button issues, there is consensus that the law will not be entirely repealed. Overhaul of healthcare delivery infrastructure has already begun here in New York and elsewhere ... Health Information Exchange projects in New York have made significant progress, but little has been done with respect to developing a Health Insurance Exchange. Insurers in New York however have started to implement coverage requirements prior to deadlines specified in the Affordable Care Act.

This is a critical time to establish optometry as the primary eye care profession. We have the opportunity to participate in the development of Health Information Exchanges, Health Insurance Exchanges, Medical Home projects and the policy entities that will govern them. Our success depends upon broad participation by individual optometrists. Failure will require decades of fighting for inclusion.

While the presidents of your local societies and ... executive committee[s] are diligently monitoring and identifying opportunities to participate, we need individual optometrists to develop the relationships necessary for success. There are many opportunities to participate, often requiring little effort and minimal time ... 

Health Information Exchanges are up and running across the state. They are currently variable in their scope of information processing. Most are providing access to clinical laboratory results; some have access to radiological reports, and a few have access to actual images.

Optometrists' role in managing diabetes is of particular interest to Health Information Exchanges. Every optometrist should register with his or her regional Health Information Exchange. Doing so provides you with reliable clinical information, establishes optometry as a resource for future clinical information, and demonstrates optometry's integral role in the delivery of efficient quality care  ...   

Optometry has been conspicuously absent from most third party administrative structures. While we have successfully defined optometry to our patients and our legislators, we have permitted ophthalmology to define optometry for insurers. Optometrists must develop relationships within the administrative structure of insurers as well as entities that emerge to develop the Health Insurance Exchange ...

The Health Insurance Exchange will be impacted by, and will have impact on, all medical and routine healthcare services provided in the state. Rules defining primary care services and essential benefits will permeate through government and private insurance programs. Requiring access to comprehensive optometric services will secure our position as primary eye care providers. Allowing the exchange to be developed without our consultation will surely limit our participation within these programs. ... 

Medical Home demonstration projects are underway in many states including New York. Most have a very limited definition of primary care services within the Medical Home, but some have a more extensive definition. Ohio for example has included optometric services as a primary care component of the Medical Home. By doing so, patients serviced within a Medical Home in Ohio have direct access to optometric services.

Obviously if the Medical Home becomes a viable means of medical care, delivery it will be imperative that optometric services are defined as primary care services. Established relationships between optometrists and the primary care physicians charged with administering Medical Homes will provide the means to inclusion. ...
Now is the time to establish optometry as the primary eye care profession. Our success will be proportionate to the number of individual optometrists that choose to actively participate in the overhaul of our healthcare delivery system.  

Christopher Colburn, OD