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.

EMR Ratings: A KLAS Act

This week, KLAS released its first EMR Performance Report that organizes results according to the specialty of the rating provider. Although the publication of “Ambulatory EMR by Specialty” came on the heels of my posts last week—titled “One Size Does Not Fit All” in EMR Straight Talk and HIStalk—the timing was purely coincidental.

I want to commend Mark Wagner and Kent Gale for taking on this new approach to analyzing and reporting the data they collect. I have had numerous conversations with KLAS on this subject over the years, urging them to report by specialty for all the reasons identified in my posts, and they clearly recognize the value of this type of information. This effort by KLAS was a major undertaking, and the result represents a significant breakthrough in the way the EMR industry provides access to information.

For any specialists looking to adopt an EMR, the KLAS report “Ambulatory EMR by Specialty” is a must-read. It contains information that is vitally important to informed EMR decision-making.

The data raises some interesting questions and implications. In next week’s EMR Straight Talk, I will share some initial observations.

Enterprise EMR: One Size Does Not Fit All

In my recent post on the industry-leading EMR blog HIStalk, I discussed the impossibility of one type of EMR ever meeting the needs of all the disparate types of providers. Among the arguments I presented was that it is impossible for the same EMR product to satisfy both hospitals and private-practice physicians. Enterprise EMRs simply do not work in high-volume ambulatory settings, and it is unrealistic to expect that they would.

Apparently, this hit a nerve, given the passion and intensity of the comments, most of which addressed Epic. (You can read the comments by clicking here.) In response to Peppermint Patty’s claim that “tens of thousands of happy specialists use Epic,” Epic Mythology replied, “The idea that all specialists, or users in general, are happy with Epic is a flat-out lie. My own academic specialty clinic rebelled against Epic’s ambulatory interface as long as we could, and we switched only by force. It destroyed my clinic workflow, and I now see fewer patients while spending longer documenting. . . . I have yet to meet any doctor who really likes Epic.”

There you have it—the basic problem in our industry identified very simply by the argument between Peppermint Patty and Epic Mythology. How do we know who is right? These and several of the other comments beg the question of how a specialist—or any physician—can ferret out the truth about the potential of Epic (or any other enterprise EMR) to satisfy his or her practice’s needs? This is becoming an increasingly critical issue, given the growing pressure hospitals are putting on physicians to adopt the enterprise system by subsidizing the cost. Are physicians who succumb to this pressure getting what is right for their practices?

The following is the comment I added to HIStalk following the initial set of responses to my “Reader’s Write” post:

Judging by the comments to my post, the implementation of enterprise EMRs in ambulatory practices is a major issue confronting physicians. Most of the comments focus on Epic, the dominant player in that market. Peppermint Patty and Epic Mythology sum up the two positions—the former claims that there are many happy users of Epic, while the latter argues the exact opposite. Who is right? And how do we find out for sure? My experience speaking with thousands of physicians over the years supports Epic Mythology’s position—like him, I have not met many specialists satisfied with using enterprise EMR systems in their private practices.

Given the revived interest in EMR purchases, it’s critical for the physician community to know the truth.

Please continue the conversation by commenting on EMR Straight Talk (below) or by joining the dialogue on HIStalk.