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Meaningful Use: An Update for Physiatry Practices Q4
Mark Huang, MD INTRODUCTION The American Recovery and Reinvestment Act of 2009 incorporates the Health Information Technology for Economic and Clinical Health Act, which includes provisions that define the process of “meaningful use” (MU) that relates to electronic health records (EHR). The Health Information Technology for Economic and Clinical Health Act uses incentives and penalties for hospitals and professionals to encourage adoption of EHRs [1]. Although the MU incentive program has brought about increased adoption of EHRs by physicians [2], there have been many challenges that practitioners have faced as they have implemented MU [3]. Some physiatric practices have already begun to adopt MU as a means of receiving incentive funds to help offset the costs of implementing EHRs. However, because impending penalties are looming, other physiatrists, especially those in smaller practices, are now beginning to consider whether or not to adopt MU. This article will help address common questions with regard to MU implementation and whether or not it should be considered for your practice.
WHAT IS MU? MU has been defined as the use of certified EHRs in a meaningful manner, such as for electronic prescribing, electronic exchange of health information, and electronic submission of quality measures. There are 3 progressively more comprehensive stages of MU, each with a specific set of compliance measures. There currently are 2 ways to attest for MU, through either the Medicare program or the Medicaid program, depending on the population of patients seen by the provider (Table 1). The Medicare program is more relevant for most adult-care providers, whereas Medicaid may be more relevant for pediatric-care providers who see a higher volume of patients with Medicaid.
WHO IS ELIGIBLE? Eligibility depends on which program you wish to attest. Typically, physicians are eligible for both the Medicare and Medicaid programs regardless of specialty. Mid-level providers, such as nurse practitioners and physician assistants, qualify for the Medicaid program only under certain conditions. Attestation is done at the individual provider level; one cannot attest as a group. MU enrollment for rehabilitation hospitals does not exist as all; postacute care facilities have been excluded from the incentive program.
WHAT ARE THE INCENTIVES? The incentives depend on which program you wish to participate with and in which year you begin your attestation (Table 2). Those who had not enrolled in MU by 2013 have already missed the larger maximum incentive payments of $44,000. The last year to attest for MU and receive incentive payments for Medicare is 2014, and the maximum total incentive has been reduced to $24,000. The amount of incentive received is equal to 75% of allowable Part B Medicare charges for covered professional services up to the maximum amount listed in Table 2 (ie, to achieve the full $12,000 incentive for 2014, the provider would need to have $16,000 of allowable Medicare charges for that calendar year). You have until 2016 to enroll in the Medicaid program to receive incentive PM&R 1934-1482/14/$36.00 Printed in U.S.A.
M.H. Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago, Chicago, IL. Address correspondence to: M.H.; e-mail: [email protected] Disclosure: nothing to disclose Submitted for publication March 27, 2014; accepted March 27, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. -, 1-5, --- 2014 http://dx.doi.org/10.1016/j.pmrj.2014.03.011
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Huang
AN UPDATE FOR PHYSIATRY PRACTICES
Table 1. Comparison of Medicare and Medicaid Incentive Programs Medicare
Medicaid
Provider types
MD, DO, and chiropractors
Eligibility
Must have 10% or more Medicare charges performed in an outpatient setting 2014 is the last year to enroll; maximum incentive is $24,000; payments are over 5 consecutive years Beginning 2015, 1% reduction in reimbursement to maximum of 5% by 2019 For stage 1, must meet all core measures and 5 of 10 menu items; also need to report on quality measures Providers must demonstrate meaningful use every year to receive incentive payments
Incentives
Penalties Requirements
Compliance
payments. To qualify for MU, you only need to report any 90-day period for your first year of reporting. Thus, if you choose to begin attestation for 2014, you can report on dates as late as between October 1 and December 31 and still receive credit for MU in 2014. However, in the second year of MU, you would need to report on the full calendar year.
WHAT ARE THE MEASURES? The specific measures for MU are summarized on the Centers for Medicare and Medicaid Services (CMS) Web site (Table 3 provides a list of CMS links) [4,5]. Measures are based on the stage of MU being implemented. For the first 2 years of attestation, clinicians need to meet stage I requirements. In brief, there are 15 core items and 10 menu items from which the provider must choose 5 to implement. The critical point to understand is that to meet MU, each individual provider must meet all the measures. The biggest concern among providers who implement MU is the amount of extra tasks or duties placed on providers and their clinical staff to meet the specific measures of MU. Key element stage 1 measures that have impact on physiatric
MD, DO; nurse practitioners; physician assistants if practicing Federally Qualified Health Center of Rural Health Clinic Patient volume of 30% or more Medicaid patients (20% if a pediatrician) 2016 is the last year to enroll; maximum incentive is $63,750; payments are over 6 years, does not have to be consecutive years None for Medicaid charges
In the first year, providers can receive an incentive payment for adopting, implementing, or upgrading electronic health record technology; providers must demonstrate meaningful use in the remaining years to receive incentive payments; does not have to be consecutive years
practices include core measure items and menu measure items.
Core Measure Items 1. Electronic Prescribing, Drug-Drug, and Drug-Allergy Checking These measures have been found to be quite useful by many clinicians. The ability to electronically prescribe medications as well as to perform automatic allergy checking is helpful. In addition, many EHRs allow for importation of external medication histories electronically so that a provider can view and import medications that a patient has filled at outside pharmacies. There are still some limitations to electronic prescribing for controlled substances for many states and EHRs; therefore, controlled substance prescriptions are excluded from MU and require a paper-generated prescription. Many EHRs can generate paper-based prescriptions. However, maintenance of electronic lists of medications can be time consuming. Obtaining the initial list of medications and entering them into the EHR or importing them from the external pharmacy,
Table 2. Meaningful use incentive payments (U.S. dollars) 2014 Calendar Year 2014 2015 2016 2017 2018 2019 2020 2021
2015
Medicare
Medicaid
12,000 8000 4000
21,250 8500 8500 8500 8500 8500
24,000
63,750
Medicare
2016 Medicaid
Medicare
Medicaid
0
21,250 8500 8500 8500 8500 8500 63,750
21,250 8500 8500 8500 8500 8500 0
63,750
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166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220
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221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
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Table 3. Centers for Medicare and Medicaid Services Web site links* Meaningful use overview page Stage 1 measures Stage 2 measures Stage 1 vs stage 2 comparison 2014 Clinical quality measures
276
277 http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ 278 EP-MU-TOC.pdf 279 http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ 280 Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 281 http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ 282 Stage1vsStage2CompTablesforEP.pdf http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ Q3 283 Stage1vsStage2CompTablesforEP.pdf 284
*All Web sites were accessed April 7, 2014.
updating any changes at each office visit, and collecting the pharmacy information are needed to leverage effective electronic prescribing and drug-interaction checking. 2. Maintain Problem List This is new to the workflow of many clinicians because problem lists typically were used by primary care physicians. Creating and updating the problems list will be an extra task for clinicians to remember to perform. Some EHRs will have problems and diagnosis lists in common, which will allow a diagnosis or problem to be migrated from one list to another. 3. Record Smoking Status Recording of smoking status is not commonly done by physiatrists and will need to be added to the clinic workflow. 4. Record Clinical Quality Measures A key component of MU is the reporting of quality measures [6]. For 2014, clinicians will now have to report on 9 of 64 potential quality measures. Furthermore, the selected quality measures must cover 3 of the 6 quality domains (Patient and Family Engagement, Patient Safety, Care Coordination, Population/Public Health, Efficient Use of Healthcare Resources, Clinical Process/Effectiveness). Each practice will need to carefully review the list of measures to determine ones that are most appropriate. However, few of the measures have significant relevance to physiatry. Even some of the measures that assess functional status of patients use tools not commonly used in physiatric practices. Fortunately, there are no thresholds to meet when reporting on these measures. One simply has to report data on the measures. However, at some point in the future, data reported may be used to compare providers with regard to specific quality measures and be used for eventual value-based purchase modifiers. 5. Provide Clinical Summaries for Patients at Each Office Visit Providing patients with a summary of their visit can be useful for patients, although this is an extra step for the provider. The base requirement is that the patients
receive their medication list, medication allergy list, problem list, and diagnostic laboratory test results. These basic fields are typically not really that “meaningful” to patients unless you provide them with additional information, such as patient instructions, orders, and follow-up appointments. Ensuring that your EHR can easily generate this document is critical to your outpatient workflow. This has been found to be one of the larger hurdles to overcome for providers [3], given the extra steps required to create this summary document. 6. Providing Patients With an Electronic Copy of Records Upon Request With this measure, the EHR should be able to provide an electronic copy of select health record information to the patient. Typically, this should be part of the base functionality of the EHR. Practices need to identify office staff who would be responsible for managing these requests. This information could be downloaded onto a compact disc or USB drive for the patient. Having an associated secure patient portal where patients can view their records online is another method of providing an electronic copy. 7. Conducting a Security Audit For this measure, you would need to work with your vendor to perform a risk assessment on your system or obtain a recommendation about a third party to assist with this assessment.
Menu Measure Items 1. Incorporating Clinical Laboratory Tests Incorporating clinical laboratory tests is challenging to meet because many providers rarely order laboratory tests for their outpatients. Furthermore, this would need to be imported into the provider’s EHR via an interface. This is a large hurdle for practices because it can entail significant additional costs and typically requires outside expertise to successfully implement. 2. Sending Patient Reminders Sending patients reminders is based on the EHR being able to generate reminders pertinent to a patient’s
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AN UPDATE FOR PHYSIATRY PRACTICES
condition, orders, or medications. However, many systems do not have reminders that are relevant to rehabilitation-related diagnoses, and thus the patient may receive more generic reminders based on chronic conditions (eg, diabetes or hypertension) and health maintenance issues (eg, vaccinations). 3. Using EHR Technology to Identify Patient-specific Educational Resources Use of EHR technology to identify patient-specific educational resources would rely on the EHR being able to suggest educational content based on diagnoses, orders, or medications. Again, it is important to evaluate the content provided by the EHR system to determine if the educational materials are relevant to your patient population. Most of the base educational materials are generic and do not suit the specific needs of physiatrists. One needs to check with the vendor to see if custom educational materials can be added and mapped to diagnoses or medications. 4. Provide Patients With Timely Electronic Access to Health Care Information Providing patients with timely electronic access to health care information differs from the prior core measure of providing electronic copies of their health record. This measure focuses on granting patients timely access to their health information online. This would require use of a patient portal, which is a secure Web site that patients can access and which would contain elements of their health record. Having patients enroll in a patient portal to view their data is new to many clinicians; this typically requires greater thought in execution to encourage patients to enroll. In addition, one needs to work with the EHR vendor to ensure that this is a capability of the system. Often this requires additional licensing costs. Many of the measures described above can be offloaded to clinical and nonclinical office staff; however, this would require additional resources as well as reallocation of current duties. Stage 2 has more stringent criteria with higher thresholds and the introduction of several additional items related to interoperability and patient communication. The differences are highlighted on the CMS Web site with a stage 1 versus stage 2 comparison (Table 3 provides a list of CMS links) [7]. For most measures, there are expectations for higher percentage compliance to meet the respective measure. There also are increased expectations to have information transmitted electronically to other providers and the need to report information to patient registries, which currently have little relevance to physiatric practices. A secure patient portal also is essentially required because there is an expectation for patients to actually send a secure message to their provider as one of the measures.
386 387 388 Beginning in 2015, penalties will apply to Medicare allow- 389 able charges for eligible providers who do not participate in 390 MU. Penalties start with a 1% adjustment. For each subse- 391 quent year, the adjustment increases by 1%, and the total 392 reaches a 5% reduction by 2019. Currently, there are no 393 penalties for Medicaid reimbursement. 394 395 396 WHAT ARE THE EXCEPTIONS? 397 There are several exceptions to MU for which you can apply 398 for a hardship exemption. 399 1. New eligible professionals. Newly practicing physicians 400 may apply for a 2-year limited exception to payment 401 Q2 402 adjustments to allow time to become an MUr. 2. Infrastructure. Providers who practice in an area with- 403 out sufficient Internet access or who face insurmount- 404 able barriers to obtaining infrastructure (eg, lack of 405 406 broadband). 3. Practice at multiple locations. A lack of control over 407 availability of certified EHR technology for more than 408 50% of patient encounters. This typically applies to 409 practitioners who practice from multiple offices in 410 411 different health systems. 412 413 414 CAN I PURCHASE ANY EHR SOFTWARE? 415 To be eligible for MU, the EHR solution you use must be 416 certified for MU. All vendors must submit their product for 417 approval by a CMS certification agency to show that they 418 meet requirements for MU. The vendor should be assigned a 419 specific EHR certification number. If you already use soft- 420 ware, it is best to check with your vendor as to what steps 421 422 you need to take to attest for MU. There are many factors in selecting and implementing an 423 EHR that are beyond the scope of this article. There are 424 several resources online to get started with EHR selection 425 [8,9]. However, the most important component of imple- 426 mentation is analyzing current workflow and tasks among 427 office staff and mapping those to anticipated workflows and 428 procedures once the EHR is implemented. Furthermore, 429 adequate training and support are vital for proper use of the 430 EHR. EHR usability to the clinician and office staff is vital. 431 Many systems still present challenges with usability and 432 workflow, which can contribute to further inefficiencies. 433 One should ask for references of practices that have gone live 434 with the product to see how it works for them. For MU, the 435 EHR needs to have robust reporting tools that allow you to 436 track your attestation for each measure. Make sure that you 437 check with your vendor about the reporting tools. These are 438 essential to understanding your compliance with each indi- 439 440 vidual measure.
WHAT ARE THE PENALTIES IF I DO NOT PARTICIPATE?
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HOW DO I ATTEST FOR MU? It is best to first go to the CMS Web site to register when you have made the decision to implement MU. You then need to implement your EHR and collect data for required measures for stage 1 of MU. Once you have the necessary data from your reporting period, the eligible professional would “attest” to MU through an online application process. In this attestation, the provider submits data on each measure that is necessary to achieve MU. This information can be completed by the end of February of the subsequent year of reporting. Once all necessary information has been entered and the provider is deemed eligible, a confirmation statement will be generated by stating that attestation has been accepted. For each subsequent year, providers will need to attest that they have met the MU measures. In the third year of MU, you would need to advance to meeting stage 2 requirements. When advancing from stage 1 to 2, the reporting period is reduced to 90 days, but this needs to fall in the quarter of a calendar year (eg, Jan-March or April-June). You will then have 3 years in stage 2 before moving on to stage 3. You need to keep careful records because most likely you will get audited for your attestation. CMS has stated that providers need to keep records for 10 years.
IS IT WORTH IT? The first consideration is the number of Medicare and Medicaid patients seen in your practice. If it is not significant, then you would not receive the full incentive and your practice may have minimal impact from the reimbursement penalties proposed. If one has significant Medicare or Medicaid patient populations, then the threat of increasing penalties may be cause for future concern. There are several concerns to the physiatrist with respect to MU. Many challenges have been cited in adoption of MU [3]. Clearly, the biggest concern is the extra time and resources spent on meeting measures that may not seem so “meaningful“ to clinicians. When taken in total, this may add a substantial burden to the clinician and office staff. Some of this can be offset by incentive funds; however, 2014 is the last year to be eligible for incentive payments for the Medicare program. One needs to keep in mind that each subsequent stage of MU brings larger hurdles to overcome in terms of the measures.
CONCLUSION The MU incentive program is well under way, and many physicians have elected to take advantage of incentive
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payments to offset costs of EHR implementation. Yet, attesting for MU creates an increased burden for providers to maintain their attestation and continued incentive payments. If you have not yet started to attest, time is rapidly ending to receive any substantial incentive payments. Furthermore, beginning in 2015, penalties will be assessed and will continue to increase. Clinicians who see a significant number of patients with Medicare and Medicaid should consider implementation while there is still time to avoid the penalties and receive what incentive payments are still available. However, practitioners may decide that it is not worth attesting to MU given the added costs and expense but at the same time have to accept reduced reimbursement in the years forthcoming. Unfortunately, this may drive more practitioners to choose to not provide care for Medicare and Medicaid patients, which may reduce access to physiatrists for the populations that may need them the most.
REFERENCES 1. CMS.gov. Centers for Medicare & Medicaid Services. EHR Incentive Programs. Available at http://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/index.html. Accessed March 24, 2014. 2. Boland MV, Chiang MF, Lim MC, et al. Adoption of electronic health records and preparations for demonstrating meaningful use: An American Academy of Ophthalmology survey. Ophthalmology 2013;120: 1702-1710. 3. Heisey-Grove D, Danehy LN, Consolazio M, Lynch K, Mostashari F. A national study of challenges to electronic health record adoption and meaningful use. Med Care 2014;52:144-148. 4. EHR Incentive Program. Eligible Professional Meaningful Use Table of Contents Core and Menu Set Objectives. Stage 1. Available at http://www .cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Downloads/EP-MU-TOC.pdf. Accessed March 24, 2014. 5. Stage 2 Eligible Professional (EP) Meaningful Use Core and Menu Measures Table of Contents. Date issued: October, 2012. Eligible Professional Core Objectives. Available at http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_Mean ingfulUseSpecSheet_TableContents_EPs.pdf. Accessed March 24, 2014. 6. Additional Information Regarding EP Clinical Quality Measures for 2014 EHR Incentive Programs. Clinical Quality Measures for 2014 CMS EHR Incentive Programs for Eligible Professionals 2014 Clinical Quality Measures. Available at http://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_ CQMs.pdf. Accessed March 24, 2014. 7. Stage 1 vs Stage 2 Comparison Table for Eligible Professionals. Last Updated: August, 2012. Available at http://www.cms.gov/Regulationsand-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vs Stage2CompTablesforEP.pdf. Accessed March 24, 2014. 8. AMA. American Medical Association. Medicare/Medicaid EHR Incentive Program. Available at http://www.ama-assn.org/ama/pub/advocacy/ topics/health-information-technology/medicare-medicaid-incentive-pro grams.page? Accessed March 24, 2014. 9. American EHR. Beta. Available at http://www.americanehr.com/Home .aspx. http://www.americanehr.com/Home.aspx.
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Meaningful Use: An Update for Physiatry Practices Q4
Mark Huang, MD INTRODUCTION The American Recovery and Reinvestment Act of 2009 incorporates the Health Information Technology for Economic and Clinical Health Act, which includes provisions that define the process of “meaningful use” (MU) that relates to electronic health records (EHR). The Health Information Technology for Economic and Clinical Health Act uses incentives and penalties for hospitals and professionals to encourage adoption of EHRs [1]. Although the MU incentive program has brought about increased adoption of EHRs by physicians [2], there have been many challenges that practitioners have faced as they have implemented MU [3]. Some physiatric practices have already begun to adopt MU as a means of receiving incentive funds to help offset the costs of implementing EHRs. However, because impending penalties are looming, other physiatrists, especially those in smaller practices, are now beginning to consider whether or not to adopt MU. This article will help address common questions with regard to MU implementation and whether or not it should be considered for your practice.
WHAT IS MU? MU has been defined as the use of certified EHRs in a meaningful manner, such as for electronic prescribing, electronic exchange of health information, and electronic submission of quality measures. There are 3 progressively more comprehensive stages of MU, each with a specific set of compliance measures. There currently are 2 ways to attest for MU, through either the Medicare program or the Medicaid program, depending on the population of patients seen by the provider (Table 1). The Medicare program is more relevant for most adult-care providers, whereas Medicaid may be more relevant for pediatric-care providers who see a higher volume of patients with Medicaid.
WHO IS ELIGIBLE? Eligibility depends on which program you wish to attest. Typically, physicians are eligible for both the Medicare and Medicaid programs regardless of specialty. Mid-level providers, such as nurse practitioners and physician assistants, qualify for the Medicaid program only under certain conditions. Attestation is done at the individual provider level; one cannot attest as a group. MU enrollment for rehabilitation hospitals does not exist as all; postacute care facilities have been excluded from the incentive program.
WHAT ARE THE INCENTIVES? The incentives depend on which program you wish to participate with and in which year you begin your attestation (Table 2). Those who had not enrolled in MU by 2013 have already missed the larger maximum incentive payments of $44,000. The last year to attest for MU and receive incentive payments for Medicare is 2014, and the maximum total incentive has been reduced to $24,000. The amount of incentive received is equal to 75% of allowable Part B Medicare charges for covered professional services up to the maximum amount listed in Table 2 (ie, to achieve the full $12,000 incentive for 2014, the provider would need to have $16,000 of allowable Medicare charges for that calendar year). You have until 2016 to enroll in the Medicaid program to receive incentive PM&R 1934-1482/14/$36.00 Printed in U.S.A.
M.H. Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago, Chicago, IL. Address correspondence to: M.H.; e-mail: [email protected] Disclosure: nothing to disclose Submitted for publication March 27, 2014; accepted March 27, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. -, 1-5, --- 2014 http://dx.doi.org/10.1016/j.pmrj.2014.03.011
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Huang
AN UPDATE FOR PHYSIATRY PRACTICES
Table 1. Comparison of Medicare and Medicaid Incentive Programs Medicare
Medicaid
Provider types
MD, DO, and chiropractors
Eligibility
Must have 10% or more Medicare charges performed in an outpatient setting 2014 is the last year to enroll; maximum incentive is $24,000; payments are over 5 consecutive years Beginning 2015, 1% reduction in reimbursement to maximum of 5% by 2019 For stage 1, must meet all core measures and 5 of 10 menu items; also need to report on quality measures Providers must demonstrate meaningful use every year to receive incentive payments
Incentives
Penalties Requirements
Compliance
payments. To qualify for MU, you only need to report any 90-day period for your first year of reporting. Thus, if you choose to begin attestation for 2014, you can report on dates as late as between October 1 and December 31 and still receive credit for MU in 2014. However, in the second year of MU, you would need to report on the full calendar year.
WHAT ARE THE MEASURES? The specific measures for MU are summarized on the Centers for Medicare and Medicaid Services (CMS) Web site (Table 3 provides a list of CMS links) [4,5]. Measures are based on the stage of MU being implemented. For the first 2 years of attestation, clinicians need to meet stage I requirements. In brief, there are 15 core items and 10 menu items from which the provider must choose 5 to implement. The critical point to understand is that to meet MU, each individual provider must meet all the measures. The biggest concern among providers who implement MU is the amount of extra tasks or duties placed on providers and their clinical staff to meet the specific measures of MU. Key element stage 1 measures that have impact on physiatric
MD, DO; nurse practitioners; physician assistants if practicing Federally Qualified Health Center of Rural Health Clinic Patient volume of 30% or more Medicaid patients (20% if a pediatrician) 2016 is the last year to enroll; maximum incentive is $63,750; payments are over 6 years, does not have to be consecutive years None for Medicaid charges
In the first year, providers can receive an incentive payment for adopting, implementing, or upgrading electronic health record technology; providers must demonstrate meaningful use in the remaining years to receive incentive payments; does not have to be consecutive years
practices include core measure items and menu measure items.
Core Measure Items 1. Electronic Prescribing, Drug-Drug, and Drug-Allergy Checking These measures have been found to be quite useful by many clinicians. The ability to electronically prescribe medications as well as to perform automatic allergy checking is helpful. In addition, many EHRs allow for importation of external medication histories electronically so that a provider can view and import medications that a patient has filled at outside pharmacies. There are still some limitations to electronic prescribing for controlled substances for many states and EHRs; therefore, controlled substance prescriptions are excluded from MU and require a paper-generated prescription. Many EHRs can generate paper-based prescriptions. However, maintenance of electronic lists of medications can be time consuming. Obtaining the initial list of medications and entering them into the EHR or importing them from the external pharmacy,
Table 2. Meaningful use incentive payments (U.S. dollars) 2014 Calendar Year 2014 2015 2016 2017 2018 2019 2020 2021
2015
Medicare
Medicaid
12,000 8000 4000
21,250 8500 8500 8500 8500 8500
24,000
63,750
Medicare
2016 Medicaid
Medicare
Medicaid
0
21,250 8500 8500 8500 8500 8500 63,750
21,250 8500 8500 8500 8500 8500 0
63,750
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221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
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Table 3. Centers for Medicare and Medicaid Services Web site links* Meaningful use overview page Stage 1 measures Stage 2 measures Stage 1 vs stage 2 comparison 2014 Clinical quality measures
276
277 http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ 278 EP-MU-TOC.pdf 279 http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ 280 Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 281 http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ 282 Stage1vsStage2CompTablesforEP.pdf http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ Q3 283 Stage1vsStage2CompTablesforEP.pdf 284
*All Web sites were accessed April 7, 2014.
updating any changes at each office visit, and collecting the pharmacy information are needed to leverage effective electronic prescribing and drug-interaction checking. 2. Maintain Problem List This is new to the workflow of many clinicians because problem lists typically were used by primary care physicians. Creating and updating the problems list will be an extra task for clinicians to remember to perform. Some EHRs will have problems and diagnosis lists in common, which will allow a diagnosis or problem to be migrated from one list to another. 3. Record Smoking Status Recording of smoking status is not commonly done by physiatrists and will need to be added to the clinic workflow. 4. Record Clinical Quality Measures A key component of MU is the reporting of quality measures [6]. For 2014, clinicians will now have to report on 9 of 64 potential quality measures. Furthermore, the selected quality measures must cover 3 of the 6 quality domains (Patient and Family Engagement, Patient Safety, Care Coordination, Population/Public Health, Efficient Use of Healthcare Resources, Clinical Process/Effectiveness). Each practice will need to carefully review the list of measures to determine ones that are most appropriate. However, few of the measures have significant relevance to physiatry. Even some of the measures that assess functional status of patients use tools not commonly used in physiatric practices. Fortunately, there are no thresholds to meet when reporting on these measures. One simply has to report data on the measures. However, at some point in the future, data reported may be used to compare providers with regard to specific quality measures and be used for eventual value-based purchase modifiers. 5. Provide Clinical Summaries for Patients at Each Office Visit Providing patients with a summary of their visit can be useful for patients, although this is an extra step for the provider. The base requirement is that the patients
receive their medication list, medication allergy list, problem list, and diagnostic laboratory test results. These basic fields are typically not really that “meaningful” to patients unless you provide them with additional information, such as patient instructions, orders, and follow-up appointments. Ensuring that your EHR can easily generate this document is critical to your outpatient workflow. This has been found to be one of the larger hurdles to overcome for providers [3], given the extra steps required to create this summary document. 6. Providing Patients With an Electronic Copy of Records Upon Request With this measure, the EHR should be able to provide an electronic copy of select health record information to the patient. Typically, this should be part of the base functionality of the EHR. Practices need to identify office staff who would be responsible for managing these requests. This information could be downloaded onto a compact disc or USB drive for the patient. Having an associated secure patient portal where patients can view their records online is another method of providing an electronic copy. 7. Conducting a Security Audit For this measure, you would need to work with your vendor to perform a risk assessment on your system or obtain a recommendation about a third party to assist with this assessment.
Menu Measure Items 1. Incorporating Clinical Laboratory Tests Incorporating clinical laboratory tests is challenging to meet because many providers rarely order laboratory tests for their outpatients. Furthermore, this would need to be imported into the provider’s EHR via an interface. This is a large hurdle for practices because it can entail significant additional costs and typically requires outside expertise to successfully implement. 2. Sending Patient Reminders Sending patients reminders is based on the EHR being able to generate reminders pertinent to a patient’s
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AN UPDATE FOR PHYSIATRY PRACTICES
condition, orders, or medications. However, many systems do not have reminders that are relevant to rehabilitation-related diagnoses, and thus the patient may receive more generic reminders based on chronic conditions (eg, diabetes or hypertension) and health maintenance issues (eg, vaccinations). 3. Using EHR Technology to Identify Patient-specific Educational Resources Use of EHR technology to identify patient-specific educational resources would rely on the EHR being able to suggest educational content based on diagnoses, orders, or medications. Again, it is important to evaluate the content provided by the EHR system to determine if the educational materials are relevant to your patient population. Most of the base educational materials are generic and do not suit the specific needs of physiatrists. One needs to check with the vendor to see if custom educational materials can be added and mapped to diagnoses or medications. 4. Provide Patients With Timely Electronic Access to Health Care Information Providing patients with timely electronic access to health care information differs from the prior core measure of providing electronic copies of their health record. This measure focuses on granting patients timely access to their health information online. This would require use of a patient portal, which is a secure Web site that patients can access and which would contain elements of their health record. Having patients enroll in a patient portal to view their data is new to many clinicians; this typically requires greater thought in execution to encourage patients to enroll. In addition, one needs to work with the EHR vendor to ensure that this is a capability of the system. Often this requires additional licensing costs. Many of the measures described above can be offloaded to clinical and nonclinical office staff; however, this would require additional resources as well as reallocation of current duties. Stage 2 has more stringent criteria with higher thresholds and the introduction of several additional items related to interoperability and patient communication. The differences are highlighted on the CMS Web site with a stage 1 versus stage 2 comparison (Table 3 provides a list of CMS links) [7]. For most measures, there are expectations for higher percentage compliance to meet the respective measure. There also are increased expectations to have information transmitted electronically to other providers and the need to report information to patient registries, which currently have little relevance to physiatric practices. A secure patient portal also is essentially required because there is an expectation for patients to actually send a secure message to their provider as one of the measures.
386 387 388 Beginning in 2015, penalties will apply to Medicare allow- 389 able charges for eligible providers who do not participate in 390 MU. Penalties start with a 1% adjustment. For each subse- 391 quent year, the adjustment increases by 1%, and the total 392 reaches a 5% reduction by 2019. Currently, there are no 393 penalties for Medicaid reimbursement. 394 395 396 WHAT ARE THE EXCEPTIONS? 397 There are several exceptions to MU for which you can apply 398 for a hardship exemption. 399 1. New eligible professionals. Newly practicing physicians 400 may apply for a 2-year limited exception to payment 401 Q2 402 adjustments to allow time to become an MUr. 2. Infrastructure. Providers who practice in an area with- 403 out sufficient Internet access or who face insurmount- 404 able barriers to obtaining infrastructure (eg, lack of 405 406 broadband). 3. Practice at multiple locations. A lack of control over 407 availability of certified EHR technology for more than 408 50% of patient encounters. This typically applies to 409 practitioners who practice from multiple offices in 410 411 different health systems. 412 413 414 CAN I PURCHASE ANY EHR SOFTWARE? 415 To be eligible for MU, the EHR solution you use must be 416 certified for MU. All vendors must submit their product for 417 approval by a CMS certification agency to show that they 418 meet requirements for MU. The vendor should be assigned a 419 specific EHR certification number. If you already use soft- 420 ware, it is best to check with your vendor as to what steps 421 422 you need to take to attest for MU. There are many factors in selecting and implementing an 423 EHR that are beyond the scope of this article. There are 424 several resources online to get started with EHR selection 425 [8,9]. However, the most important component of imple- 426 mentation is analyzing current workflow and tasks among 427 office staff and mapping those to anticipated workflows and 428 procedures once the EHR is implemented. Furthermore, 429 adequate training and support are vital for proper use of the 430 EHR. EHR usability to the clinician and office staff is vital. 431 Many systems still present challenges with usability and 432 workflow, which can contribute to further inefficiencies. 433 One should ask for references of practices that have gone live 434 with the product to see how it works for them. For MU, the 435 EHR needs to have robust reporting tools that allow you to 436 track your attestation for each measure. Make sure that you 437 check with your vendor about the reporting tools. These are 438 essential to understanding your compliance with each indi- 439 440 vidual measure.
WHAT ARE THE PENALTIES IF I DO NOT PARTICIPATE?
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HOW DO I ATTEST FOR MU? It is best to first go to the CMS Web site to register when you have made the decision to implement MU. You then need to implement your EHR and collect data for required measures for stage 1 of MU. Once you have the necessary data from your reporting period, the eligible professional would “attest” to MU through an online application process. In this attestation, the provider submits data on each measure that is necessary to achieve MU. This information can be completed by the end of February of the subsequent year of reporting. Once all necessary information has been entered and the provider is deemed eligible, a confirmation statement will be generated by stating that attestation has been accepted. For each subsequent year, providers will need to attest that they have met the MU measures. In the third year of MU, you would need to advance to meeting stage 2 requirements. When advancing from stage 1 to 2, the reporting period is reduced to 90 days, but this needs to fall in the quarter of a calendar year (eg, Jan-March or April-June). You will then have 3 years in stage 2 before moving on to stage 3. You need to keep careful records because most likely you will get audited for your attestation. CMS has stated that providers need to keep records for 10 years.
IS IT WORTH IT? The first consideration is the number of Medicare and Medicaid patients seen in your practice. If it is not significant, then you would not receive the full incentive and your practice may have minimal impact from the reimbursement penalties proposed. If one has significant Medicare or Medicaid patient populations, then the threat of increasing penalties may be cause for future concern. There are several concerns to the physiatrist with respect to MU. Many challenges have been cited in adoption of MU [3]. Clearly, the biggest concern is the extra time and resources spent on meeting measures that may not seem so “meaningful“ to clinicians. When taken in total, this may add a substantial burden to the clinician and office staff. Some of this can be offset by incentive funds; however, 2014 is the last year to be eligible for incentive payments for the Medicare program. One needs to keep in mind that each subsequent stage of MU brings larger hurdles to overcome in terms of the measures.
CONCLUSION The MU incentive program is well under way, and many physicians have elected to take advantage of incentive
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payments to offset costs of EHR implementation. Yet, attesting for MU creates an increased burden for providers to maintain their attestation and continued incentive payments. If you have not yet started to attest, time is rapidly ending to receive any substantial incentive payments. Furthermore, beginning in 2015, penalties will be assessed and will continue to increase. Clinicians who see a significant number of patients with Medicare and Medicaid should consider implementation while there is still time to avoid the penalties and receive what incentive payments are still available. However, practitioners may decide that it is not worth attesting to MU given the added costs and expense but at the same time have to accept reduced reimbursement in the years forthcoming. Unfortunately, this may drive more practitioners to choose to not provide care for Medicare and Medicaid patients, which may reduce access to physiatrists for the populations that may need them the most.
REFERENCES 1. CMS.gov. Centers for Medicare & Medicaid Services. EHR Incentive Programs. Available at http://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/index.html. Accessed March 24, 2014. 2. Boland MV, Chiang MF, Lim MC, et al. Adoption of electronic health records and preparations for demonstrating meaningful use: An American Academy of Ophthalmology survey. Ophthalmology 2013;120: 1702-1710. 3. Heisey-Grove D, Danehy LN, Consolazio M, Lynch K, Mostashari F. A national study of challenges to electronic health record adoption and meaningful use. Med Care 2014;52:144-148. 4. EHR Incentive Program. Eligible Professional Meaningful Use Table of Contents Core and Menu Set Objectives. Stage 1. Available at http://www .cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Downloads/EP-MU-TOC.pdf. Accessed March 24, 2014. 5. Stage 2 Eligible Professional (EP) Meaningful Use Core and Menu Measures Table of Contents. Date issued: October, 2012. Eligible Professional Core Objectives. Available at http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_Mean ingfulUseSpecSheet_TableContents_EPs.pdf. Accessed March 24, 2014. 6. Additional Information Regarding EP Clinical Quality Measures for 2014 EHR Incentive Programs. Clinical Quality Measures for 2014 CMS EHR Incentive Programs for Eligible Professionals 2014 Clinical Quality Measures. Available at http://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_ CQMs.pdf. Accessed March 24, 2014. 7. Stage 1 vs Stage 2 Comparison Table for Eligible Professionals. Last Updated: August, 2012. Available at http://www.cms.gov/Regulationsand-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vs Stage2CompTablesforEP.pdf. Accessed March 24, 2014. 8. AMA. American Medical Association. Medicare/Medicaid EHR Incentive Program. Available at http://www.ama-assn.org/ama/pub/advocacy/ topics/health-information-technology/medicare-medicaid-incentive-pro grams.page? Accessed March 24, 2014. 9. American EHR. Beta. Available at http://www.americanehr.com/Home .aspx. http://www.americanehr.com/Home.aspx.
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