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.

From Anti-EHRs to Pro-ACOs: a Must-Read Story

Have I ever told you about what I call "Noah syndrome"? You've heard about the ark and the flood, right? Poor old Noah was told not only to build the ark but also to warn everyone about the coming flood. Given many years of drought, everyone thought he was crazy. They taunted him and laughed. I suspect you know how that story ended! Sometimes I feel like Noah. The transformation of health care has seemed a far-off reality, a bit of a joke in the minds of some. Many older doctors especially have sworn they'd rather retire than switch. 'Paper works fine thank you. The world can just go ahead and change without me.'


Meet Dr. Jeffrey Selwyn. His is a story you really must read! With thanks to Diana Manos, Senior Editor for Healthcare IT News, here is "Not retiring at 65: Physician goes from anti-EHR to pro-ACO".


Enjoy!


Alistair Jackson, M.Ed.


P.S. How about you? Do you have a similar story from our eye care world? If so, I'm extending an invitation to tell it. Two options:
1. Click on Comments and Reactions below this post. You'll be given a window in which to tell your story... or just respond to this one.
2. Contact me via email. I'd be happy to talk offline, hear more and discuss how best to tell your story.

A National Eye Care Communications Project

Why does eye care need a national eye care communications project?            

The changes under way presently in the delivery and reimbursement of health care are occurring outside the normal purview of independent eye care providers. Nevertheless, they will affect the success of your business. The infrastructure of the new system is being formed in every state, in preparation for going national. The National Eye Care Communications Project is a collaborative effort that allows you to work with other eye care providers to understand these changes, and to transform the culture of your businesses, engage effectively in connected care, and build better practices.

What’s driving the change?

CMS is driving a significant transition, one being followed by other payers, away from fee-for-service toward bundled payments. Accountable Care Organizations (ACOs) are now being reimbursed for providing packages of services. In order to retain access to your patients covered under bundled payments, you must gain entry into your local and regional ACOs.

Bundled payment means another subtle transition: away from individual providers to team delivery of care and shared savings. The predominant model is the patient-centered medical home, found within ACOs.  Medical Homes are starting by targeting treatment of chronic conditions such as diabetes and heart disease but are designed to eventually coordinate the care of all chronic conditions.

What does the ACO have to do with the HIE? Why both?

The ACO is a local organization through which team delivery of care and shared savings are offered. Since all chronic care will eventually take place through this group, you will need to be part of it in order to retain access to your patients and grow your business. Part of your eligibility to belong to an ACO is your ability to communicate electronically with other providers. That’s where the HIE comes in. The HIE is the communications network that lets you move protected health information securely from your office to those of other health care providers, whether in your local area or across the country. 

Why should I participate? What does my office have to do?

Ultimately, your success will depend on what you do in your local community. We can expect the process to vary somewhat by state, by ACO and by community. Your participation in the collaborative process of the National Eye Care Communications Project will bring the following benefits, and more:

• you’ll understand the general principles at work as ACOs and HIEs take shape
• you’ll collaborate with other ECPs going through the same process in their communities and see what works and doesn’t work
• you’ll learn how to ensure the local ACO understands what you as an eye care provider bring to the care team, and that it values and encompasses your contributions.

Want to know more about this project? Contact us here.

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

Evolving to outcome-based reimbursement

Today, we provide a link to a Brookings Institution conference, "Health IT in an Era of Accountable Care: Update from the Beacon Communities". This is a series of videos comprising what is possibly the most inclusive and best available summary of the vast expanse covered by health care reform.  


The single most important message is that the Beacon Community Program is heavily involved in studying the payment reforms needed in order for healthcare to move from fee-for-service to outcome-based reimbursement.  This conference looks at models and recommends the exact components to be reimbursed in the future. It is of great concern that Optometry is not there suggesting a payment component for independent eye care, with supporting and demonstrable reasons.  

Event Summary                                                                                                            The Beacon Community Program – a major project of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC) – provides funding to 17 selected communities throughout the United States that have made inroads in developing secure, private, and accurate systems of electronic health record adoption and health information exchange. The Beacon Program supports these communities to improve care coordination, increase quality of care, and slow health care spending growth. 

As an alternative to watching the conference videos, you may read more here about the Beacon Community Program.


Jim Grue, O.D.

Who's who in eye care EHRs?

The federal government has recently made available for download a complete list of "CMS Medicare and Medicaid EHR Incentive Program, electronic health record products used for attestation". Bear in mind that these data are up to February 29, 2012 only. This was the date by which everyone who had attested for 2011 had to have completed their attestation. This means, therefore, that anyone who attested for a 90-day MU period in 2012 is not yet included. We know that this is a significant group over and above what's represented in the current report.


After a little data-crunching, here are some comments about the representation in eye care EHRs:

• optometrists are running just over double the numbers of ophthalmologists: 2,621 ODs versus 1,249 MDs
• the vast majority are using Complete EHR solutions versus Modular EHR solutions
• large numbers of both optometrists and ophthalmologists are in the ambulatory care settings of large health systems, as indicated by the software used
• the two dominant players in optometry, Compulink and Eyefinity, used primarily by independent ECPs, account for 66% of the optometry attestations and 11% of the ophthalmology attestations
• the three dominant players in ophthalmology, EpicCare, NextGen and Medflow, used primarily in health system settings, account for 48% of the ophthalmology attestations and 9% of the optometry attestations

Also of interest:

• modular solutions are most often used in hospital or ambulatory health system settings where one solution meets the clinical criteria and another serves for non-clinical or demographic criteria
• some modular solutions offered by e-prescribing vendors, such as Rcopia MU by DrFirst, are intended only as an interim step for Stage 1 MU and do not pretend to meet the long term clinical needs, for example, of eye care providers
• if we use 36,000 and 18,000 as approximate numbers for optometrists and ophthalmologists respectively, we can deduce that roughly 7.2% and 6.9% attested in 2011.

Takeaways:

• knowing that the train has well and truly left the station, as they say, we would expect the percentage of attestations for each group to rise to an estimated 20% in 2012
• knowing that most ophthalmologists are in health system settings (both ambulatory and in-patient), independent ECPs must take seriously the threat to their businesses as health system ACOs take more and more control over access to patients
• independent ECPs must now make a high priority of applying to their local ACOs to become part of the medical home chronic care teams.

Alistair Jackson, M.Ed.