The End of the Consult Letter as We Know It

The End of the Consult Letter as We Know ItThe end is in sight for the consult letter as we know it today. This has the potential to be a significant benefit delivered by meaningful use standards—physicians will get the clinical information they want and need from other physicians, and they will get it faster and more efficiently. Gone will be the days of lengthy, unstructured notes sent by fax or mail from one provider to another.

In today’s world, specialists report to referring physicians (i.e., primary-care providers) via a dictated consult letter or transcribed exam notes. These tend to be text heavy and contain no discrete or importable data. Others send EHR-generated narratives—lengthy notes that most physicians find difficult to read, if not useless. Finding the impression and care plan buried in massive amounts of verbiage is frequently a frustrating and time-consuming process. Meaningful use addresses this challenge by requiring a discrete data-rich summary of care for transitions from provider to provider. A menu measure in Stage 1, these summaries become a core measure in Stage 2, with more robust and structured content and the requirement that at least some of them be transmitted electronically.

The required Summary of Care provides better-quality information to the receiving provider and is created with less manual effort by the sending physician. The receiving EHR assimilates all of the data, presenting it in a cogent manner. The Summary of Care will contain structured data and a concise, accessible impression and care plan that tells the referring physician exactly what he/she needs to know. The receiving physician will filter the data as desired and the data can then be incorporated into the patient’s chart in his/her EHR, since all certified EHRs will use standard vocabularies.

Ease and speed of communication, along with cost reduction, are significant benefits, too. The Summary of Care can be transmitted as quickly as the data is entered into the patient’s chart. An automated batch process sends the summaries from the specialist’s EHR directly to the PCP’s, eliminating the cost of printing, faxing, or mailing letters. Meaningful use Stage 2 provides for the exchange either directly from provider to provider via secure e-mail (the “Direct” messaging protocol) or through Health Information Exchanges (HIEs).

Meaningful use will mark an end to the transmission of consult letters devoid of discrete data and to the exchange of hard to read exam notes. The impact on physician and practice productivity is undeniable.

Physicians Benefit from CMS’ Harmonization of Program Rules

Physicians Benefit from CMS’ Harmonization of Program Rules width=Kudos to CMS for making good on its promise to align quality measure reporting and incentives across the various government programs with which physicians must contend. With the publication last week of the 2013 Medicare Professional Fee Schedule final rule, CMS delivered on the harmonization promised in the Meaningful Use Stage 2 final rule in August.

This is very good news for physicians. Without the compromises that CMS made in both rules, physicians would be confronted with the challenge of trying to participate in a minimum of 3 government programs that involve quality measure reporting—ePrescribing under MIPPA, meaningful use under ARRA, and PQRS—each with its own set of intricate requirements, timetables, populations on which to report, reporting mechanisms, and incentive/penalty schedules. Not only would this be incredibly complicated, but it could give rise to incongruous situations in which a physician might, for example, successfully ePrescribe as part of demonstrating meaningful use, and yet still be subject to a penalty for inadequately ePrescribing under MIPPA.

Among the key areas of alignment are the following:

  • Reporting for PQRS using the EHR reporting option (as opposed to claims or registry reporting) will satisfy the clinical-quality-measure-reporting component of meaningful use. PQRS EHR-based measures will be aligned with the measures available for reporting under the EHR incentive program.
  • Meaningful use clinical-quality-measure reporting via PQRS will only be on Medicare patients, while all other meaningful use measures will continue to apply to all patients, regardless of payer.
  • PQRS reporting will be done using the CEHRT (Certified EHR Technology) that is required for meaningful use, eliminating the current requirement to use a separately certified “PQRS-Qualified” system.
  • Successful ePrescribing under meaningful use will protect physicians from ePrescribing penalties under MIPPA.

The government programs remain complex—but there is no question that aligning them as the recent rules do will decrease the reporting burden on physicians, spare related administrative costs, and eliminate the costs associated with duplicate EHR certification requirements. Valuable physician resources will be better allocated to providing the quality of care these programs seek to measure.

Audit Risk: EHR Coding, Cloning, and Templated Notes

Audit Risk: EHR Coding, Cloning, and Templated NotesPhysicians beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, templated notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to truly meaningful documentation.

In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits.

This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, physicians have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those physicians who bill higher-level codes.

One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.

The Case for Centralized Quality Reporting: A Perfect Example

The Case for Centralized Quality Reporting: A Perfect Example’ TimeQuality measure reporting is one of the 3 basic tenets of the EHR Incentive Program—the other 2 being ePrescribing and data sharing (interoperability)—as identified in ARRA, the program’s defining legislation. It is a key component to improving the quality of patient care. In a recent EMR Straight Talk post—“A Waste of Physicians’ Money and Vendors’ Time”—I proposed a more cost-effective method of analyzing clinical quality measure (CQM) data that would deliver more useful information for quality improvement than the approach currently in place for meaningful use. I suggested that rather than requiring each of the 472 vendors of certified EHRs to program the same CQMs (no longer 125 as initially proposed, but still a burdensome 64), EHRs should simply collect and report the data, and CMS or its designate should provide the analytics. Such a centralized approach would not only be more efficient, but it would produce more consistent and reliable data. Most importantly, it would allow for the immediate implementation of any changes to measure specifications as necessitated by the availability of new medical information.

Recently, I confronted a perfect example of the ineffectiveness of the current system and the opportunities that a centralized approach would afford. A physician informed me that a new CVX (immunization) code was created for the influenza vaccine—CVX code 144. While I told this client that we could easily add this code to the EHR for his use in documenting vaccinations (which we did), these vaccinations would unfortunately still not be reflected in the numerator for NQF 0041 (Preventive Care and Screening: Influenza Immunization for Patients over Age 50)—a fact validated by CMS. New electronic specifications for CQMs will not be implemented until 2014, and the current specifications remain in force for 2012 and 2013.

As an EHR vendor, I certainly appreciate the fact that we are not subject to the expectation that we will reprogram measures off-cycle. That would wreak havoc with our development roadmap and resource planning. Furthermore, changing the calculations to accommodate the new codes would compromise data comparability. So now we have comparable—but incorrect—data that does not reflect actual vaccination status. Under this system, how will we ever stay current as medicine constantly evolves?

Just imagine if everyone could begin using the new CVX codes immediately because the electronic specifications were updated in one centralized location with one effort. This is just one example from a potential 64 CQMs. How much more value would we derive from all the work that we demand of physicians in capturing the CQM data? How can we accelerate healthcare improvement if we are always 2–3 years behind?

Meaningful Use Stage 2: Did CMS Hear the Physicians? (Part 2)

Meaningful Use Stage 2: Did CMS Hear the Physicians? (Part 2)’ TimeIn my last post, I commended CMS for responding positively to many of the comments that were submitted regarding the Proposed Rule for Stage 2 of meaningful use. However, there were also troublesome areas that were acknowledged in the Final Rule, but addressed in a way that remains problematic for physicians. This post will review some of those issues.

Most notable are the two measures that make physicians’ incentives dependent on actions by patients—actions over which the physician does not have control. The Final Rule requires that:

  • More than 5% of all patients seen by the physician during the reporting period actually view, download, or transmit their available health information, and
  • More than 5% of patients seen send a secure message to the physician (containing health information, not just a request for an appointment).

The proposed rule had set the threshold at 10% for each of these measures. The response from the provider community was almost universal, arguing that no matter how much education, encouragement, and cajoling the practice provides to encourage this form of patient engagement, the physicians could not guarantee patient compliance. Alternatives were offered—my company suggested having the physician be the source of the messages, or holding him/her responsible for responding to a minimum percent of the messages received from patients. However, CMS held firm in its belief that it is incumbent upon the physician to encourage patients by offering an attractive, patient-friendly portal. By way of compromise, the Final Rule reduced the threshold from 10% to 5%, but this solution does not address the principle involved—i.e., the inequity of making the physician’s incentive dependent on the actions of patients. Just imagine if after successfully meeting all of the Stage 2 requirements for the 1,000 patients a physician saw during the reporting period, only 49 of the patients (instead of 50) actually viewed their information on the portal that the physician installed—his entire year’s incentive payment would be lost.

The menu set of measures is intended to afford physicians some flexibility—there are 6 measures from which they must select 3. Part of the rationale for this structure is to make meaningful use more meaningful for specialists. Yet in Stage 2, the menu measures that a physician is eligible to exclude will no longer count as being met, so many specialists will be left with no real choices at all—the menu measures become de facto core measures. Many specialists will find 3, or even 4, of the menu measures to be in that category—CMS acknowledges that syndromic surveillance is still premature, cancer registry reporting is likely irrelevant to most physicians, diagnostic images are only relevant to a few specialties, and many others will find no viable specialty registry to which to report so CMS “does not expect every EP to select this measure.” An ophthalmologist, for example, will have to report on the family history measure and the electronic progress note—not a measure they would choose if the menu were truly a menu.

Patient reminders is another measure that may be problematic for specialists who provide episodic care. Stage 2 requires the physician to send an appropriate reminder for follow-up or preventive care to 10% of the patients seen during the prior 24 months. No exclusion is available for physicians who see patients two or three times to treat a particular problem, but have no reason to ever recall the patient.

The above are examples of where CMS may have listened to the physicians, but didn’t really hear them. I hope that some further guidance related to these issues will be forthcoming to ensure that physicians are able to successfully demonstrate meaningful use in Stage 2.

Meaningful Use Stage 2: Did CMS Hear the Physicians?

Meaningful Use Stage 2: Did CMS Hear the Physicians?’ TimeKudos to CMS for responding positively and reasonably to many of the comments submitted by physicians and/or their professional organizations regarding the Proposed Rule for Stage 2 meaningful use. Of course, there were also a number of issues that could have been addressed more favorably from the providers’ perspective—and I will address those in my next EMR Straight Talk post—but I was pleasantly surprised to see the changes and the compromises that CMS did make that will benefit physicians.

The most significant concession was related to timing: in 2014, physicians will only report for a 90-day calendar quarter—rather than a full year, as originally intended. This should result in higher-quality, more-usable EHRs as vendors will have more time to develop, test, and certify their new versions. It also eliminates the fiasco that surely would have ensued for providers were they all to require upgrading by their vendors within a very small window of time. This new schedule also ensures that physicians will have the time they need to implement, and sufficiently train on, the new versions of their software, enhancing the likelihood that they will be able to successfully demonstrate meaningful use. The 90-day reporting period also provides some flexibility for those unfortunate physicians who hastily purchased an EHR in a rush to meet meaningful use and now find themselves dissatisfied with their decision—they will have down time that will make the replacement process easier.

I was also pleased to see several changes that address the reporting burden for physicians. Stage 2 offers a batch-reporting option—however, providers must still individually meet all of the meaningful use requirements—and it attempts to harmonize clinical quality measure reporting across the various government programs. These were two proposed concepts that physicians strongly endorsed in their comments.

Specialists particularly appreciate the Final Rule’s successful resolution to the challenges posed by the vital-signs measure currently in force—the new requirement unlinks the reporting of height and weight from the reporting of blood pressure. Beginning in 2013 (i.e., a year before Stage 2 even takes effect), physicians who find height and weight relevant to their practices (but not blood pressure) will be able to report the former while attesting to an exclusion for the latter. This will remove an irrelevant step in the workflow for many specialists.

While CMS did hear the physicians on these important issues, there are other areas that the Final Rule did not sufficiently address. I will discuss these in my next post.

A Waste of Physicians’ Money and Vendors’ Time

A Waste of Physicians’ Money and Vendors’ TimeEHR vendors are facing the arduous task of programming as many as 125 clinical quality measures (CQMs)—in addition to the development challenges presented by all the other new meaningful use requirements for Stage 2—and to do this in a relatively short period of time. To compound matters, the calendar is rapidly advancing and the specifications for these quality measures are not even available yet.

Is there a better way to approach quality measure reporting? I think so—and it seems so obvious to me! EHRs should not be doing all of the analysis—they should simply collect and report the data, and CMS or its designate should provide the analytics. A centralized approach would be much more efficient and would produce more consistent and reliable data.

Think of the time and resources being wasted. Why should each of the 472 vendors offering certified EHRs have to program the same 125 clinical quality measures—that’s the programming of a total of 59,000 measures—when they should not have to program any at all? This unnecessary cost will ultimately be passed on to physicians. And what about the effect on standardization and comparability of the data produced? Despite the certification requirements for each of the quality measures, minor variances in calculations are inevitable, and this compromises the value of the data for comparative purposes. Centralization would also allow changes to be implemented in a nimble and timely manner. With a centralized registry, new measures could be introduced, and changes to measure specifications that result from new research could be programmed and released immediately, without having to wait what could be years for each of the 472 vendors to develop, upgrade, and deploy the changes to the hundreds of thousands of physician-EHR users.

A model already exists for such an approach, and the infrastructure for data exchange is in place using one or more of the standards that are accepted in the industry today. Registries are already analyzing clinical data and identifying areas for quality improvement. It is critical that we think outside of the box to find opportunities like the above that eliminate unnecessary duplication of effort and free vendors to focus on areas of keen interest—like EHR usability and physician productivity.