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“Physician Office Issues: Why and How to Implement HIT in Physician Offices”
Dr. James S. McIlwain
Identify “Meaningful USE” and incentives to EHR implementation
Discuss the current Mississippi Health Information Exchange (HIE) demonstration project and other state initiatives
Describe why and how to implement an EHR in your practice
Objectives
Highest per capita health
care spending Ranked 37th of 191 in
quality* Threatens affordable care
– 46 million currently uninsured
– 71% of uninsured adults
are employed full-time $2T (2005) $4T (2015)
– Increasing % of GDP
U.S. Healthcare Problems:Drivers of Change
* World Health Organization Data, 2000 (http://www.who.int/whr)Figure from: www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthcareSlides.pdf
Health Information Technology/Health Information Exchange
Computers and other devices used to create a communications network for moving health information Exchange-connection of HIT
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What Is HIT/HIE?
Comprehensive, timely management of medical information at the point of care
Secure exchange of medical information between health care consumers and providers
Disease registries/reporting and analysis capabilities
Public Health alerts - rapid detection and notification of disease outbreaks
Benefits of Health Information Technology (HIT)
Creation of a better work environment
Decreased :◦Paper work ◦Costs◦Errors◦Duplicate tests and procedures
Benefits of Health Information Technology (HIT)
$1.2 billion for loans, grants & technical assistance for:
Regional Extension Centers ($640M)
Workforce Training ($80M)
Research and Demonstrations
EHR State Loan Fund
New Medicare & Medicaid paymentincentives for HIT adoption
$23 billion in expected payments from Medicare to hospitals & practitioners thru 2016
$21 billion in expected payments from Medicaid through 2021
~$44 billion expected outlays
$564 M for Statewide HIE Development
States receive between $4 and $40 million
$220 M for “Beacon” Community Program
15 HIEs to receive between $10 million and $20 million
$4.3 billion for broadband & $2.5 billionfor distance learning/ telehealth grants
$1.5 billion in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems
New Incentives for Adoption Funding for Health IT
Funding for HIE
Broadband and Telehealth
Community Health Centers
HITECH Funding for HIT & HIE Infrastructure
$120 million from the ONC for health IT Minimally functional EHR: 20% physicians; 10% hospitals Shortfall of 51,000 qualified HIT workers over the next five years
ONC, in collaboration with the NSF, DOE, and Department of Labor have developed HIT workforce programs to reduce the shortfall by 85%
Programs focus on training HIT professionals, HIT research, & expanding adoption and use of EHRs
Health Information TechnologyWorkforce Development
Rationale - States as Fulcrum to Harmonize Local and National Efforts
StatewideHealth
InformationExchangeNationwide
HealthInformationExchange
Regionaland Local
HealthInformationExchange
Address statewide barriers to HIE
Balance the rights and needs of all residents
Act as a bridge between nationwide, regional, & local HIEs
Serve as a conduit for consensus on and adoption of standards Serve statewide goals for health care quality and cost-effectiveness Provide sufficient level of data and transactional data aggregation to
leverage public/private investments
ONC’s State HIE Program
Required Plans “Domains” to Address
-Strategic Plan: State’s vision, goals, objectives and strategies for statewide HIE; including plans to support provider adoption
-Operational Plan: Detailed explanation, targets, dates for execution of strategic plan
-Governance-Finance-Technical infrastructure-Business & Technical Ops-Legal and Policy
Goal: Plan and develop the HIE infrastructure to ensure:• Widespread interoperability across entire state• Providers and hospitals can achieve meaningful use
Types of Exchange
– Eligibility & claims transactions– eRx & refill requests– Lab ordering & results delivery– Public health reporting– Quality reporting– Rx fill status and/or med fill history– Clinical summary for care coordination
& patient engagement
Status – Estimates of Statewide HIE Efforts
Planning efforts launched
Planning efforts underway, strategic plan in developmentStrategic plan completed, progressing to implementationFramework for statewide HIE completed, operations begun
MSCHIE
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2 1
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2
2
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2
4
7
65
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9
813
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9 1
1
11
412
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1210
Project Implementation
Governor’s Task Force Created:Proof of concept project serving as the core foundation for
statewide implementationGrant received for pilot project on the Mississippi coast
that was affected by hurricane Katrina Grant Administration and Contracting:
Information & Quality Healthcare (IQH)—the Medicare Quality Improvement Organization for Mississippi
RFP Procurement Process IQH/ITSAwarded to Medicity of Salt Lake City, Utah
MSCHIE IS THE HUB
Hospitals Labs Radiology Other Senders
Auto Fax or Printer
PaperRecords
PaperRecords
ElectronicInbox via Portal
Practice EMRVendor 1
Practice EMRVendor 2, etc.
Interface Interface
DHIN Utility
Secure Results / Reports Delivery
- in preferred format
Patient Record Inquiry / Viewing
-patient centric-remote access-multiple data sources
System-wide Referrals & Consults
-can be done electronically
Common Data Exchange-data feeds direct to EMRs
Functions
Radiology Reports Lab Results Surgical Reports Discharge Summaries Admission Face Sheet Demographic Data ER Reports Transcribed Reports Referrals / Consults Medication History CCR Documentation
Practices and Clinics
Information
DataContributors
MSCHIE
“This should be called an ‘HealthImprovement Exchange’ instead of Health Information Exchange!
WOW!
• There is an evidence base showing that theright combination of HIT and institutionalculture can lead to important gains in qualityand value = Health Care Delivery Reform• The U.S. needs these gains so desperately it iswilling to bet on EHRs• Used appropriately, health IT seems so likelyto improve quality that we should use it now
The Push to Meaningful HIT Use
VisionEnable significant and measurable improvements in population health through a transformed health care delivery system.
Goals1. Improve quality, safety, efficiency and reduce health disparities.
2. Engage patients and families.
3. Improve care coordination.
4. Ensure adequate privacy and security protections for personal health information.
5. Improve population and public health.
Broad Goals for Meaningful Use
The HITECH Act’s Framework for Meaningful Useof Electronic Health Records (EHRs)
Programs - Build, Expand, Demonstrate MUState & Regional Efforts will Lead the WayITEM AGENCY STATUS
State Health Information Exchange Grants
State or state designated entity
•Program launching in Q1 2010•Every state is eligible ($4-$40 million per state)•Over $500 million in funding
Beacon Community Program
State agencies, non-profit IDNs, Health Information Organizations, Regional Extension Centers
•Applications due Feb 1•Competitive process ($10-$20 million per award)•Applicants must have existing HIE capabilities and high rate HIT adoption to demonstrate advanced uses of technology to advance quality, efficiency.
Regional Extension Centers
Non-for-profit entity covering a region that includes 1,000 primary care docs
•Two rounds of funding. Up to 70 RECs across the country covering non-overlapping geographic areas.•Initial focus on supporting primary care practices.•Over $640 million in funding
Administration of Medicaid Incentives
State Medicaid Agency •States are eligible for federal match of 90% of administrative costs. •States will draft their own definition of meaningful use for the Medicaid Incentives.
Statutory Framework:
In HITECH Act, Congress established three fundamental criteriaof requirements for meaningful use:
1. Use of certified EHR technology in a meaningful manner.
2. Certified EHR technology is connected in a manner thatprovides for the electronic exchange of health informationto improve the quality and coordination of care.
3. In using certified EHR technology, the provider submitsclinical quality measures and other measures by thesecretary.
Meaningful Use Overview
Medicare
Medicaid
Incentive Payments
Who is eligible?
MedicareDoctor of medicine orosteopathy
Doctor of dental surgery ormedicine
Doctor of podiatricmedicine
Doctor of optometry
Chiropractor
› MedicaidPhysiciansDentistsCertified nurse-midwives
Nurse practitioners
Physician assistantspracticing in an FQHC orRHC that is so led by a
physician assistant
Calendar Year First CY in which the EP Receives an Incentive Payment
2011 2012 2013 2014 2015 andsubsequen
t years
2011 $18,000
2012 $12,000 $18,000
2013 $8,000 $12,000 $15,000
2014 $4,000 $8,000 $12,000 $12,000
2015 $2,000 $4,000 $8,000 $8,000 $0
2016 $2,000 $4,000 $4,000 $0
TOTAL $44,000 $44,000 $39,000 $24,000 $0
Medicare Incentive Payments
Medicaid Incentives to EHR implementation
As noted, EHR-related incentives reflect 85 percent of the net average allowable costs for certified EHR technology. The maximum payment schedule for office-based physicians or practices that have at least 30 percent Medicaid volume is as follows:
• Year 1: $21,250• Year 2: $8,500• Year 3: $8,500• Year 4: $8,500• Year 5: $8,500• Year 6: $8,500
Total= $63,750
Entity Minimum Medicaid patient volume thresholdPhysicians 30%Pediatricians 20%Dentists 30%CNMs 30%PAs 30%NPs 30%
Acute care hospitals 10%Children’s hospitals No requirement
Needy individual patient volume thresholdEP practices in an FQHC or RHC 30%
Medicaid Incentive EP’s
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Medicare Medicaid
› $44,000
› HPSA 10% bonus
› No minimum # of patients› No mid-levels
› Calculation: 75% of submittedallowable charges by doc, up to cap for the year
› First year of program is 2011
› Penalties for non-compliance
› All external funds okay
› $63,750
30% threshold; 20% for peds› NPs, NMWs; Pas if lead
provider in a rural health clinic
› No calculation based on fees – flatpayment intended to offsetpurchase of the EHR and can collect in 2010 if State is ready
›
No penalties (yet!)
› Stark $$ or Fed grants may lower payment
Welcome to 2010 . . .THE YEAR OF THE EHR
Electronic Health Record Implementation
1.The study identified 285 practices where EHR implementation is in process or is fully implemented. Over 76% of the adopters report that they are satisfied or extremely satisfied with their EHR system and over 66% report that they are satisfied or extremely satisfied with their EHR vendor support. This indicates that adopters are more satisfied with their actual systems than with their vendor support of those systems.
Results of MGMA Study
2. Much hard work and planning is required to enhance the probability of a successful EHR implementation.
3. Most practices should expect increased operating costs, reduced productivity, and other assorted surprises and challenges during the first 6 to 24 months of the implementation.
4. After the first 6 to 24 months, the benefits of EHR adoption should increasingly exceed the costs, and most practices will wonder how they ever conducted business without an EHR.
3. Increased practice productivitya. Automatic generation of prescriptions, lab reports, and lettersb. More efficient phone triage due to immediate access to patient recordc. Critical review and revision of work flow leads to increased efficiency.d. Increased provider productivity due to increased staff productivity
4. Elimination of paper files frees up space for other usesa. Space can be used for new examination rooms, improving patient flowb. Space can be used for new revenue generating ancillary services
5. Increased practice revenuea. Better E and M documentation enhances provider confidence to code and bill appropriately for services renderedb. Improved charge capturec. Reduction in delays in billing activitiesd. Reduction in payer denials
Potential EHR Benefits (continued)
6. Increased quality of patient carea. Improved continuity of care and preventive careb. Improved chronic disease management
7. Increased patient safetya. Patient record available 24/7 in order to respond to emergenciesb. Ease of accessing patient prescription information in case of drug
recallc. Increased safety in prescribing due to drug interaction and allergy
alerts8. Increased patient satisfaction
a. More rapid processing of prescription orders and refillsb. More rapid reporting of lab results to patientsc. More rapid response to patient phone calls and questionsd. Reduction in cost to patient by reducing need for duplicating radiology and lab tests
9. Increased staff job satisfactiona. Reduced staff stress related to failed searches for paper recordsb. Process of EHR implementation creates
Potential EHR Benefits (continued)
Potential EHR Benefits (continued)
10. Increased physician satisfaction and quality of lifea. Ability to complete charts before going home or in comfort of homeb. Reduced need to do dictation after seeing a patientc. EHR can be a benefit in recruiting new physicians
11. Increased referring and consulting physician satisfactiona. Enhanced ability to quickly generate letters to physiciansb. Enhanced ability to share radiology and lab results with physicians
12. Increased quality of the health recorda. Record is legible and timelyb. Record is more consistent across different providersc. Record is more defensible from billing perspective
13. Integration with other systems and facilitiesa. Interfaces with lab and imaging equipment automatically incorporate data into the health recordb. Interfaces with hospitals and surgery centers enable health record data to be shared by authorized providers
Potential EHR Benefits (continued)
14. Increased ability to query the data base and conduct data mining activitiesa. Ability to track outcomes and participate in pay for performance programsb. Ability to monitor and benchmark quality of carec. Government and public health reporting is easierd. Diagnosis registries easier to maintain.
Potential Unsatisfactory Outcomes from EHR Adoption
“A general theme from the adopters is that it simply takes a year or two to learn how to rectify the adverse outcomes, particularly in practices that did not conduct critical work flow analysis prior to implementation.”
1. The EHR does not live up to the practice's expectations.a. Practice has difficulty in setting up the EHR system, data capture
methods, and data input templates to fit the needs of different provider and specialty work styles and patient conditions. This leads to inconsistent use of the system and inconsistent data in the EHR.
b. Specialists in multispecialty settings often want features that are not available.
c. Practice does not recognize need for certain features until after implementation begins.
d. EHR creates new work flows that are hard to implement.
2. Practice staff and physicians experience increased frustration and stress.a. Some physicians (often older physicians) have difficulty in learning how to use the system.b. Some physicians and staff are intransigent and refuse to use the system.c. EHR use has adverse impact on staff interaction and communication.d. Physician satisfaction decreases due to extra time spent learning and using the EHR.
Potential Unsatisfactory Outcomes from EHR Adoption (continued)
(1.) e. Practice is unable to eliminate paper records.f. Long time period is required to get up to speed.g. Expectations were that EHR would be easier to use.h. Physicians are unable to reduce dictation and use features of the EHR.i. The EHR software has an unacceptable level of flaws and bugs.
3. Practice productivity decreases.a. Physicians devote more time to using the EHR system after the patient visit.b. Additional workload and documentation is shifted to physicians.c. Too many template screens are required to document a visit.d. Software updates require new things to learn on continual basis.e. Unanticipated time and cost are required to scan old medical records.f. Too much time is devoted to abstracting old records to the new database when a scanned image will suffice.g. Staff is unable to effectively search for scanned information.h. Practice sees fewer patients during initial implementation.i. Productivity drops when system goes down.j. Practice unable to find temps and subs who know how to use the EHR.
4. Practice costs increase.a. Information technology staffing, salaries, and oversight costs increase.b. Staff overtime costs increase.c. Practice adopted too early, before some hardware costs had decreased.d. Practice underestimated costs of continual software and hardware
upgrades, malware protection, and security protocols.
Potential Unsatisfactory Outcomes from EHR Adoption (continued)
http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=21086
Provides education, outreach and technical assistance to select, successfully implement, and meaningfully use certified EHR technology
Regional Extension Centers (REC)
Grant applications for the REC will be awarded in two cycles:
◦Cycle one announced February 12, 2010 (32 awardees)
◦Cycle two (MS) should be awarded at the end of March 2010
Regional Extension Center (MS)
Target settings:◦Individual and small group primary care practices (10 or less providers)
◦Public and Critical Access Hospitals
◦Community and Rural Health Centers
◦Other settings that predominately serve uninsured, underinsured, and medically underserved populations
Regional Extension Center
Project Goal:
◦1000 of the 2,253 Mississippi priority primary care providers located in the state will be recruited to adopt, implement, and meaningfully use HIT within the first two years of the four year project
Regional Extension Centers (MS)
•Provide Education and Outreach to Providers:
The Regional Center will provide for dissemination of knowledge about the effective strategies and practices to select, implement, and meaningfully use EHRs
The Regional Center will become, upon award, a member of a consortium that will be facilitated by the HITRC.
•Provide on-site technical assistance as a key service offered by the Regional Center to priority primary-care providers, who are:
Physicians and/or other health care professionals with prescriptive privileges, such as physician assistants and nurse practitioners
Individual and small group practices primarily focused on primary care; Community Health Centers and Rural Health Clinics; and other settings that predominantly serve uninsured, underinsured, and medically underserved.
Functions of the Regional Extension Center
• Provide comprehensive support for providers to achieve meaningful use.
• Help providers achieve, through appropriate infrastructure, exchange of health information in compliance with applicable statutory and regulatory requirements, and patient preferences.
• Participate in local workforce development projects and with community colleges to provide expanded career pathways in information management and technology in health care.
• Provide knowledge of privacy and security best practices for dissemination of personal health information.
• Construct a collaboration to obtain vendor evaluations and arrange optimal group purchasing offers.
Functions (continued)
What You Need to Do
Contract with the Mississippi Regional Extension Center– 90% of the expenses for these services will be paid for using this resource for 2010-2012 if you are a priority primary care physician in Mississippi!
Electronic Health Record Implementation
