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.

Just What the Doctor Ordered

The government is hearing the voice of the specialists.

Since the inception of the EHR incentive program in February 2009, specialists have been concerned about their role in a program that is clearly focused on primary care. As I have pointed out before, the legislation’s primary-care focus is borne out by the composition of the decision-making committees, the allocation of funding for associated programs, and the fact that specialists were not even a topic of conversation in the deliberations until late in the game.

I have tried to advocate for the physicians—specialists, in particular—by representing their special issues via the Voice of the Physician Petition, blog postings, letters to Dr. Blumenthal and Secretary Sebelius, and by sending staff to Washington to speak on their behalf. In the last few months, specialists, their medical societies, and industry pundits such as David Kibbe and Vince Kuraitis have speculated that many specialists will not participate in the program.

Apparently, the government is worried and is taking steps to reach out to specialists to assuage their concerns. Last week, David Blumenthal confirmed publicly that specialists will not be expected to add primary-care clinical workflows to their practices to satisfactorily demonstrate meaningful use, and that they can exclude select measures that don’t apply to their practices. (See my HIStalk Practice post for more information.) While nothing in the regulations has changed since the release of the final rule in July, Dr. Blumenthal’s recent statements should dispel physicians’ initial skepticism about the potential exclusions—skepticism that had roots in disappointing PQRI experiences.

Having heard Dr. Blumenthal speak before an audience of ophthalmologists at the recent AAO meeting, I find it refreshing to see a move to a more inclusive program.

The Paper Chase: A Behind-the-Scenes Look at a Non-Digital Medical Practice

With all the talk about meaningful use, it’s easy to forget what used to—and still should—motivate practices to become digital in the first place: the overwhelming problems created by paper.

Paper has an enormous impact on practices, and on patients, too. I know most EMR Straight Talk readers are medical professionals, but regardless of our professions, all of us are patients, and we know how it feels to call our doctor with an important question—maybe regarding a recent test—and then have to wait a day or more to get an answer.

Why does it take so long? To respond appropriately to your call, your physician must first review key chart information before the call, and then document the conversation after the call. If your doctor works in a non-digital practice—or worse, in a satellite office of a non-digital practice—here’s what typically happens:

Your call comes in and a staff member writes your message on a piece of paper and gives it to the Medical Records staff so they can pull your chart. Of course, since you were just in yesterday, the chart has not yet been re-filed and could be in any number of places. And so the chart hunt begins, starting with the “to-be-filed” pile and continuing throughout the office, from the physician’s desk, chair, or floor to the nurse’s inbox, from the billing department through the “waiting-for-transcription” pile to pre-certification or procedure scheduling. If the chart is not found—for example, it could be in the trunk of your physician’s car—your call either has to wait for another day, or be answered without the benefit of complete medical information. If your chart finally is located, Medical Records has to note where it was found (so it can be returned later), clip the message to it, and put it in the “to-be-faxed” pile. When a staff member has time, he or she has to disassemble the chart, remove the pages that will give the doctor enough information to answer your question (hopefully!), and head for the fax machine. With luck, the fax is not in use on either end, and the message can be sent to the satellite office. (Otherwise, your call has to wait again.) The staff member then reassembles the chart and returns it to where it belongs.

In the satellite office, a staff member retrieves the fax and gives it to the physician’s nurse or secretary, who in turn gives it to the physician. When the physician has the time, he or she goes through the pile of messages and charts on the desk and tries to contact you, hoping that you are still available. If you are, then you finally get the answer you need, but the practice still has a lot of work to do. The physician has to document the discussion—if he or she does so on paper, this must be faxed back to the main office; your chart has to be located again; the note has to be inserted, and the chart has to be returned to wherever it was when your call was first received. If the physician dictates a summary of the call, an even-more-complex transcription-management process ensues.

On the other hand, consider the simplified workflow in a digital office. Your call is received, and then transferred to your physician, who brings up your chart within a few seconds. Because this is such a quick process, there’s a good chance your call can be answered right away or within a few minutes, in between patients. Afterwards, he or she can summarize the conversation by typing or using Dragon to immediately enter the note into your chart. And it’s done.

When you multiply the impact of this process by the number of patient calls received, and then extend it to the myriad of other routine workflow tasks repeated over and over on a daily basis, it is clear that the built-in inefficiencies of a paper-based office are overwhelming—especially in large, multi-office group practices. No practice can afford to maintain the paper chart status quo.

EMR Ratings: A KLAS Act (Part 2)

Last week, I discussed the merits of the new KLAS Performance Report that categorizes EMR ratings based upon practice specialty. The industry has responded very positively to this major step forward, and I suspect that KLAS has received many requests for access to the publication.

One of the obstacles that KLAS faced in reporting by specialty was a lack of sufficient data in many of the categories and for many of the vendors. This data limitation leads me to several initial observations and raises important questions:

  • While there are 27 vendors rated in the primary-care section and 20 in family practice, there are only 2 vendors in ophthalmology, 3 in orthopaedics, and 5 in cardiology with sufficient volume to merit inclusion. Why is that? EMR vendors have been marketing to the specialty physicians for well over a decade. Does this confirm that traditional EMRs have only had real traction in primary care after all these years?
  • A disclaimer by KLAS says that vendors may be excluded from a category due to insufficient data points, yet I know from my own company’s sales experience that there are vendors who claim a large number of installs in specialty practices. Why are these practices not included in the survey results? Did they de-install their EMR? Did the implementation fail, or are the providers not really using the EMR so they chose not to respond to KLAS? Did vendors not supply KLAS with a sufficient number of specialists due to such problems? Whatever the reasons, the lack of responses from specialists is not surprising, given the dearth of specialists’ testimonials or EMR success stories on vendor websites and on industry and government blogs.
  • Some of the vendors that are not rated highly by clients in the specialty categories received significantly better KLAS ratings from their primary-care clients. This data validates the tremendous difference between the EMR needs of specialists and those of primary-care physicians, as I have discussed in numerous posts. The fact that traditional EMRs are designed to meet the needs of primary-care physicians was a concern echoed by the American Academy of Orthopaedic Surgeons in its EMR Position Statement, which said that the primary-care focus “can limit the utility of EHRs for specialty surgical practice.” Force-fitting an EMR designed for primary care into a specialty practice is what has resulted in the historically high failure rate of EMRs among specialists.

Limitations of the data notwithstanding, one conclusion is inescapable: The KLAS report is a great first step in providing specialists with considerably more information than they had prior to its publication, but the burden still remains on the specialists to do their due diligence to identify an EMR with proven success in their specialty.