Meaningful Use Stage 2: Speak Now or Forever Hold Your Peace

A preliminary set of recommendations for defining Stage 2 meaningful use was released by the Meaningful Use Workgroup of the HIT Policy Committee earlier this month in the form of a Request for Comment—the deadline for comments is February 25. The decision-makers in Washington clearly realize the value of securing buy-in from providers, having received over 2,000 comments to the proposed Stage 1 rule when it was issued last year. As a result of those lobbying efforts, which included the Voice of the Physician Petition that we circulated on EMR Straight Talk, CMS made changes that accommodated the specialists and made participation realistic for them.

This is the opportunity for physicians to have a voice in Stage 2 before the final recommendations are submitted to CMS this summer. This request comes very early in the process of developing and finalizing the requirements—the workgroup will consider the comments and then present its recommendations to the HIT Policy Committee, which will review and revise and then forward them to CMS, which will issue the final rule. So for this stage, providers have the chance to provide input well before recommendations become set in stone.

Since most providers haven’t even embarked on Stage 1, and many are not yet conversant in the rules and requirements for that stage (as evidenced by the results of the Meaningful Use IQ Test), the following are highlights of the proposed recommendations. Note that clinical quality measures are not discussed—they will be the subject of a separate set of recommendations.

  • The proposal does not address the excludability of non-relevant measures. I assume its retention is implied, but it is important to comment on the need to keep these options in place. This was a very valuable modification added to Stage 1, particularly for specialists.
  • Disappointingly, Stage 2 still does not define meaningful use in a way that adds value for many specialists, and a way that will keep them engaged once the significant portion of the incentives have been collected.
  • Menu measures will become core measures, so the measures physicians choose to defer in Stage 1 will be mandatory in Stage 2. Some of these measures pose challenges for specialists, e.g. sending reminders to 20% of patients may not be reasonable for certain specialists such as orthopaedists or ENT physicians, because they provide episodic care.
  • Most of the changes involve increased thresholds for satisfying the measures, e.g., CPOE increases from 30% to 60%, ePrescribing from 40% to 60%, etc. These changes should not present a challenge since the software and relevant workflows will already be in place from Stage 1.
  • There are several new measures, such as adding lab or radiology to CPOE and including online secure patient messaging.

To voice your thoughts on this initial set of recommendations, go to www.regulations.gov and click “Submit a Comment”. Don’t say they didn’t ask!

Meaningful Use IQ Test Results

The response to last week’s Meaningful Use IQ Test revealed a tremendous thirst for information and a fair amount of confusion about the facts and realities of meaningful use. Neither was terribly surprising, given the recent hype surrounding the program’s launch and the complexity of the regulations.

Since the quiz was posted last week, 534 people have taken the test. The average score was 56% (see chart below and the breakdown of responses at the bottom of the page). These results mean that physicians will need a great deal of assistance from consultants, Regional Extension Centers, and vendors to succeed in their pursuit of the EHR incentives. If that aid is not forthcoming, there could be a large number of very disappointed providers when the incentives are distributed.

Meaningful Use IQ Test Results

The following are some observations:

  • Only a small minority of our test-takers (9%) appear to truly understand the regulations and the requirements in their entirety. (Inga, from HIStalkPractice.com is one of the few who just might—based on her perfect score!)
  • Many people find the intricacies of the regulations baffling—as indicated by more than half of the respondents (300 of 534) knowing half or less of the information.
  • The fact that over one-third of the respondents did not know that providers cannot collect Medicare EHR incentives and Medicare ePrescribing incentives in the same year—no “double dipping” allowed—means that they have likely not analyzed their options to maximize the total revenue from the two incentive programs.
  • I thought it was interesting that nearly half of the respondents thought that the program requires reporting on only Medicare and Medicaid patients, when, in reality, the government is requiring providers to submit data on all patients.
  • Clearly, the message has come through that the program has been made more specialist-friendly, as physicians will be able to exclude measures that are not relevant to their practices. However, many do not understand how these exclusions factor into the demonstration of meaningful use.

The Meaningful Use IQ Test is still active, so if you haven’t accepted the challenge yet, you can still do so. I’m glad that it is raising awareness and providing valuable education. That was precisely its purpose!

Meaningful Use IQ Test Results

Test Your Meaningful Use IQ

Meaningful Use IQ TestNow that the EHR incentive program has officially begun, physicians and practice managers are taking a closer look at the meaningful use requirements and the rules for participation. At my company, we have been fielding an increasing number of questions about meaningful use, and it is clear that the complexity of the regulations has created a fair amount of confusion.

See how well you understand meaningful use. Challenge yourself: Check your knowledge by taking this quiz, and learn some important information in the process. Comments are welcome.

EMR Study Shows One Size Does Not Fit All

The results of a recently released UC Davis study on the effect of EMR adoption on physician productivity say a lot about the impracticality of trying to impose one EHR solution on an entire healthcare delivery system. Although this study was limited in its focus—primary-care providers within an academic medical center—its implications are even greater when applied to specialists, and magnified exponentially when extended to community-based, private-practice physicians.

The researchers at UC Davis were not surprised with their findings that the initial implementation of EMR technology resulted in a 25% to 33% decline in physician productivity, but what they did find surprising was that the results varied widely by medical discipline. While internal medicine physicians regained—and slightly increased—their prior productivity over time, pediatricians and family practice physicians did not, “even after they had climbed the learning curve.” The study’s conclusion was that inherent differences in workflows create varied needs for EHR technology and that “One size does not fit all.

If one EHR cannot satisfy the needs of different types of primary-care physicians, clearly that EHR cannot be expected to meet the needs of specialists whose workflow is very different, driven by different types of patients and care. It is foolish to expect that a hospital can impose on its physicians the EHR that meets its needs and expect that it will also meet theirs. This is particularly true with community-based, private-practice physicians, whose incomes are tied to their productivity. Physicians understand the productivity impact of the wrong EHR and will resist.

An anticipated positive outcome of the government’s goal of interoperability, which it is trying to achieve through the establishment of EHR standards, should be that providers will be able to adopt the software that best meets their needs and not have to conform to another provider’s preference. One size will no longer be expected to fit all.

ePrescribing 2011: The Irony and the Ecstasy

The number of different government programs, and the length of the rules that describe how to take advantage of each of them, can be overwhelming. But one thing is eminently clear: the importance of ePrescribing in 2011. There are three compelling reasons to ePrescribe in the coming year:

  1. Physicians can earn a 1% bonus on their 2011 Medicare revenue. Aside from the patient-care and physician-efficiency benefits that ePrescribing offers, ePrescribing on at least 25 unique Medicare encounters in 2011 will qualify a physician for an additional 1% of that year’s Medicare Part B Fee-for-Service revenue under MIPPA (Medicare Improvements for Patients and Providers Act). That money would be received in the fall of the following year.

  2. 2011 ePrescribing activity protects physicians from the Medicare ePrescribing penalties in 2012 and 2013. Odd as it sounds, while bonuses for 2012 and 2013 will be based on successful ePrescribing in each of those years, penalties for those years will be assessed based on 2011 activity. To avoid penalties in 2012, (1% of Medicare revenue), physicians must report ePrescribing on 10 unique Medicare encounters between January and June, 2011. To avoid penalties in 2013 (1.5% of Medicare revenue), physicians must report at least 25 times during the full 2011 year.

  3. ePrescribing is a great way to begin the transition to an EHR, particularly if a physician intends to participate in the EHR incentives program (ARRA). ePrescribing is an integral part of the Meaningful Use requirements and—with the right software—a great way to begin the transition to a digital office.

Based on the above, I offer a few strategies for consideration. The rules, and the interplay between them, have created a number of consequences, that intended or not, can be used by physicians to their financial advantage:

  1. It is important to start ePrescribing early in 2011. Ironically, even if a physician meets the 25-prescription minimum and earns the 2011 incentive, he or she would still be subject to a penalty in 2012 if that ePrescribing activity—no matter how extensive—occurs only in the second half of the year. So at a minimum, ePrescribe 10 times in the first half of the year and 15 times in the second half.

  2. Since the rules (MIPPA and ARRA) do not allow collecting under both programs during the same year, physicians can maximize the combined revenue by earning the ePrescribing bonus in 2011, and waiting to begin participation in Meaningful Use until 2012. Beginning in 2012 still allows a physician to qualify for the full 5 years of EHR incentives ($44,000 as a Medicare provider).

  3. Another irony is that, although ePrescribing is integral to ARRA, it is possible to satisfy the measures for one program and not satisfy the requirements of the other in any particular year. The requirements differ, and the onus is on the physicians to meet each set of rules to qualify for the respective incentives.

As confusing as the above appears, it is actually even more so, because there are also some exceptions. Not surprisingly, there are organizations (MGMA and AMA, for example) actively petitioning the government to reconsider the basis for 2012 and 2013 ePrescribing penalties and asking for harmonization of the MIPAA and ARRA regulations. For further information on the implications for your practice, I invite you to take advantage of the educational resources available through SRSsoft by calling our Government Affairs Department: 201-802-1300 X 1229.

Reimbursement Woes: Physicians Can Now Move On

In an unusual display of bipartisanship, Congress made it clear that they have no intentions of cutting physician reimbursement—even in a time when the country is facing severe economic challenges. By unanimous consent, the Senate passed the Medicare and Medicaid Extenders Act of 2010, extending Medicare rates through the end of 2011 and preventing the threatened 25% cut that was to go into effect on January 1. The following day, the House of Representatives passed the payment fix by an overwhelming (nearly unanimous) vote of 409 to 2, and President Obama’s signature is expected imminently.

Physicians should feel reassured that the uncertainty and concern that the SGR formula creates each year—and no doubt will until the calculation is redefined—should be tempered. This year’s resolution, albeit not an increase, can be taken as an indication that the annually feared drastic reductions are not likely. Physicians can now plan accordingly and make business decisions and capital investments that enable practice growth.

Not All Meaningful Use EMRs Are Created Equal

I’ve written before about the economic challenges facing physicians—in particular, the problem of stagnant or declining reimbursement rates. With no permanent fix to the SGR formula in sight, physicians are concerned about overhead, productivity, and patient mix. To maximize the value of their time and to increase—or at least maintain—their income if reimbursement rates fall to an unacceptable level, some physicians are considering dropping out of Medicare or limiting the number of Medicare patients they see.

As another means of increasing their income, many physicians are now also re-evaluating their participation in the EHR incentives program. Specialists, many of whom who had previously dismissed participation because they thought it would require adding primary-care workflows to their practice, are now giving the program a second look—in light of Dr. Blumenthal’s encouraging comments about the applicability and excludability of meaningful use requirements for specialists. (See “Just What the Doctor Ordered.”)

However, demonstrating meaningful use will still demand additional work, and certified—or to-be-certified—EMRs are not alike in how they facilitate doing this. It is critical for physicians to understand and evaluate the differences among EMRs in terms of how they deliver meaningful use capability and the impact on the time it takes to meet the requirements with each. Here are a few suggestions of what to look for in assessing the value of different solutions:

  • How easy is it to enter the required data? (This is particularly important as requirements become more demanding in future stages of the program.)
  • What changes will you have to make to the way you see patients?
  • How will you document the care you provide?
  • Does the system effectively allow delegation of tasks to staff members to minimize the time physicians must spend doing data entry?
  • Does the vendor’s software platform enable keeping up with evolving requirements?

The most valuable resource a physician has is his/her time. The software physicians select will have a significant impact on how they use that time.