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.