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

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

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

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

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

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

Jim Grue, O.D.

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

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

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

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

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

Jim Grue, O.D.

Which 2011 incentive will YOU claim?

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


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


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


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

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

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

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

Alistair Jackson, M.Ed.

An Executive Opinion

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

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

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

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

John McCormick, Sr.

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

EMRlogic LIVE - Toward a Vibrant Community

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


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


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


Alistair Jackson, M.Ed.

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

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

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

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

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

Jim Grue, OD

Predictions anyone? Where next?

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


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


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


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


Alistair Jackson, M.Ed.