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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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CMS Announces $284 Million Saved in Pioneer ACO Program After Two Years

CMS Announces $284 Million Saved in Pioneer ACO Program After Two Years | EHR and Health IT Consulting | Scoop.it

After two years in existence, the Pioneer Accountable Care Organization (ACO) program has saved the Medicare program $384 million in total, or $300 per Medicare beneficiary per year. Participating providers saved Medicare $279.7 million in 2012 and $104.5 million in 2013. That amount of savings was announced on the website of the Department of Health and Human Services (HHS), and came via an independent evaluation report released May 4 by HHS. What’s more, as the announcement noted, the independent Office of the Actuary in the Centers for Medicare and Medicaid Services (CMS) has certified that the Pioneer ACO program is model “is the first to meet expansion to a larger population of Medicare beneficiaries.”


According to the announcement, “The independent evaluation report for CMS found that the Pioneer Accountable Care Organization (ACO) Model generated over $384 million in savings to Medicare over its first two years – an average of approximately $300 per participating beneficiary per year – while continuing to deliver high-quality patient care. The Actuary’s certification that expansion of Pioneer ACOs would reduce net Medicare spending, coupled with Secretary Sylvia Mathews Burwell’s determination that expansion would maintain or improve patient care without limiting coverage or benefits, means that HHS will consider ways to scale the Pioneer ACO Model into other Medicare programs.”


Reacting to the development, HHS Secretary Sylvia Mathews Burwell was quoted in the online announcement as saying, “This is a crucial milestone in our efforts to build a health care system that delivers better care, spends our health care dollars more wisely, and results in healthier people. The Affordable Care Act gave us powerful new tools to test better ways to improve patient care and keep communities healthier. The Pioneer ACO Model has demonstrated that patients can get high quality and coordinated care at the right time, and we can generate savings for Medicare and the health care system at large.”

The Pioneer ACO Model, one of the first payment models launched by CMS, gives experienced health care organizations accountability for quality and cost outcomes for their Medicare patients. Doctors and hospitals who form Pioneer ACOs can share in savings generated for Medicare if they work to coordinate patient care, keep patients healthy and meet certain quality performance standards, or they may be required to pay a share of any losses generated.


Currently, more than 600,000 Medicare beneficiaries are assigned to Pioneer ACO organizations.


The announcement touted the fact that Medicare beneficiaries enrolled in Pioneer ACOs, on average, “report more timely care and better communication with their providers; use inpatient hospital services less and have fewer tests and procedures;  have more follow-up visits from their providers after hospital discharge.” The announcement also noted that the Pioneer ACO program’s evolution harmonizes with broader federal efforts, including with Secretary Burwell’s goal of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016 and 50 percent to such models by 2018.

Reacting to Monday’s news, the Charlotte-based Premier Inc. released a statement, attributed to Blair Childs, senior vice president for public policy for the nationwide health alliance. “Today’s announcement proves that innovative care delivery models such as the Pioneer ACO  program are effective at generating cost savings, while simultaneously improving quality and beneficiary satisfaction with care,” Childs said. “For more than a decade, members of the Premier alliance have been national leaders implementing payment and delivery reforms that improve quality while safely reducing costs.”


Still, Premier’s Childs said in the statement that, “While we support the desire to expand the Pioneer ACO program through track 3, as described in the Medicare Shared Savings Program (MSSP) proposed rule, we believe important changes need to be made, including:

  • Strengthen the assignment process by allowing Medicare beneficiaries to attest to participation in ACOs;
  • Establish a more appropriate balance between risk and reward, including higher shared savings for high-quality providers and a period where risk can be phased in over time;
  • Modify the current benchmark methodology to mitigate the impact on ACOs that lower expenses and achieve savings, and to allow ACOs to decide how to best account for regional and local cost trends;
  • Employ a risk-adjustment methodology that truly takes into account  an individual beneficiary’s acuity;
  • Adopt payment waivers to eliminate barriers to care coordination; and
  •  Provide more comprehensive and timelier data on ACOs’ patients.”


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AAFP Calls MU Audits Into Question

AAFP Calls MU Audits Into Question | EHR and Health IT Consulting | Scoop.it

The American Academy of Family Physicians (AAFP) has sent a letter to Centers for Medicare & Medicaid Services (CMS) acting administrator Andy Slavitt, expressing concerns with meaningful use audits.


Specifically, the letter states that “auditors are causing undue hardship for family physicians with unreasonable and burdensome documentation requests...” This is despite the fact that many family physicians have implemented and use electronic health records (EHRs) in the full spirit of the meaningful use program, the letter attests. “They therefore have a reasonable expectation that the meaningful use financial subsidy would help offset the implementation costs and associated initial decrease in practice productivity.”


The letter, written by AAFP board chair Reid B. Blackwelder, M.D., says that when auditors demand that family physician practices produce documentation years after the fact, unreasonable burden is created. “This is especially burdensome for family physicians who have made changes to their practice or have been acquired by a larger healthcare organization,” the letter says.


Another concern, according to AAFP, stems from employed physician situations, since many employment contracts include a clause stating all Medicare payments are turned over to the practice. “This creates an issue when the practice received the meaningful use subsidy, but years later, the individual physician is held responsible for repaying the payment after a failed audit.”


The letter also calls into question the effectiveness, responsiveness, and expertise of the auditors, as well as saying that the program’s “all or nothing” nature means that missing one document may lead to a failed audit and a repayment of the full subsidy payment. In reality, says AAFP, the audit program does not appear to take into consideration the high likelihood that a failed audit can be caused simply by missing documentation rather than by not achieving the meaningful use requirements.


AAFP calls for increased transparency from the federal government regarding audit statistics including the number of audits and the failure rate. “It would be helpful to have a report on what documentation was missing from failed audits. That would enable eligible professionals to have a better understanding over the type and granularity of documentation required,” the letter says.


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How Does ONC Plan to Expand Health Information Exchange?

How Does ONC Plan to Expand Health Information Exchange? | EHR and Health IT Consulting | Scoop.it

With the vast amounts of data collected in the healthcare industry, providers, vendors, and other stakeholders are putting more focus into developing health information exchange (HIE) and greater EHR interoperability. The Office of the National Coordinator for Health IT (ONC) released a report to Congress – Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information – to offer policy guidance on the best ways for optimizing health IT systems and supporting HIEs.


Ever since the federal government passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, the number of hospitals and physician practices adopting EHR systems has grown substantially. Currently, more than half of hospitals have at least a basic EHR system in place while, in 2013, 48 percent of physicians had EHRs at their practice.


Additionally, eligible professionals and eligible hospitals across the country are participating in the Medicare and Medicaid EHR Incentive Programs. While there has been significant progress in implementing health IT, there are still barriers that are halting widespread health information exchange across healthcare organizations and vendor products.


For example, if an individual from Maine takes a vacation in Florida and experiences a patient encounter, their primary care provider from Maine would likely not be informed nor would be able to access the patient’s emergency care data.


The report states that some of the common barriers to EHR adoption and thereby challenges for expanding health information exchange include the cost of purchasing a system, loss of productivity, training difficulties, the costs of annual maintenance, and obstacles related to finding an EHR system that supports practice needs. Nonetheless, in 2013, eight in ten physicians were using an EHR system or planning to adopt one, according to an ONC data brief.


ONC explains in its report that some of the reasons health information exchange is lacking is due to inconsistent structure, format, and even medical vocabulary used across different EHR systems and vendor products. ONC outlines key actions the Department of Health and Human Services (HHS) will need to take to improve nationwide EHR interoperability. These actions include:


  1. Creating new standards that are integral to the development of a connected healthcare system
  2. Requiring more staff in the health IT workforce to support the implementation of electronic records
  3. Improving the sharing of data among providers and public health agencies
  4. Collaborating, advising, and sharing studies with states, communities, and providers to stimulate IT solutions in the healthcare field
  5. Driving patient engagement with their health information


ONC hopes that Stage 2 Meaningful Use requirements will also catalyze a widespread data exchange network within the healthcare sector. By using these five strategies, HHS plans to further advance health information exchange and invest in health IT usability throughout the nation.


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There Are Some Things You Just Can’t Do Without an EHR

There Are Some Things You Just Can’t Do Without an EHR | EHR and Health IT Consulting | Scoop.it

Over the past two years, there has been a lot of talk about a big EHR switching trend. Some of this has been because of Meaningful Use, and some of it has been because of market changes. There are simply more options today if you are unhappy with your current EHR.

Surveys show that many physicians are frustrated with the cost or functionality in their EHR, which has prompted considering a switch. There is also frustration with too much third party interference and regulation. Despite some of these challenges, one thing is clear. Most physicians believe EHRs improve care, reduces errors, and improve billing.


What sometimes gets left out are the other opportunities created by using an EHR. Some of these are new revenue sources that might be impossible or very hard to access without one. Here are a few examples, but certainly not the only ones.


Medicare Programs


There are some new codes that have come out in the last two years for services that are revenue generators, but you really do need an EHR to manage them. The first is transitional care management (TCM). While TCM doesn’t require you to use an EHR, the complexity of it makes it hard to do without one. The ability to easily put in your notes and set reminders for needed follow up makes managing TCM much easier. With reimbursement ranging anywhere from about $100 to over $200 per patient, this can be a great opportunity for providers who see many patients who need post hospitalization follow ups.


The other Medicare program is newer and does require the use of a certified EHR. It is the Chronic Care Management (CCM) code that came out this year. The reimbursement is about $42 per patient and can be billed once a month. The requirement is that the patient has two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. Clinical staff must spend at least 20 minutes performing CCM services for the patient each month that the code it billed. The services are non-face-to-face and direct supervision is not required, which means that nursing staff or non-physician practitioners can render CCM even if the physician is not in the office. Again, if your practice sees a lot of patients with chronic health problems, this can be a great way to add revenue by using nursing or mid-level staff.


Affordable Care Act Opportunities


By now I hope everyone knows that preventive care services are covered with no copays or deductibles. What many providers still aren’t very aware of are the other types of programs that are now covered by insurance that can be great revenue generators. While they don’t require an EHR, this is another area where using an EHR makes running these programs much easier. The two programs that make a lot of sense for primary care providers and specialists who see patients with certain types of qualifying conditions are group visits and weight loss programs.


With group visits, the practice identifies a group of patients who have a similar, chronic condition that requires frequent visits. You can do this using your EHR (it would be tough using paper charts). Some examples include HIV, chronic pain, COPD, and hypertension. Vitals are done individually as patients arrive and then the whole group spends the rest of the 1.5 – 2 hour visit together with the provider. Once a group visit is completed, each patient’s insurance is billed for the appropriate E&M code for their individual situation. The ability to use templates and copy note features in the EHR can make documenting after the group visit much faster and easier than it would be if done by hand.


For patients with certain conditions, a weight loss program may be mostly or fully covered by insurance like preventive care. The great thing about this is that it can be as simple or complex as you are willing to manage. You can do simple nutritional counseling and weigh-ins or go for a fully formed program through a third party that includes food and supplements. Again, using an EHR makes it much easier and faster to manage and track multiple follow up appointments, set reminders, and copy notes and simply update them each time. You can even have a group visit component!


The key to all of these opportunities is that an EHR helps reduce the complexity of managing the requirements and helps insure that you can quickly and easily show accurate, thorough documentation to payers. Without an EHR, these revenue generating programs would simply seem too difficult to manage. In a time when every penny counts, you can’t ignore opportunities like these.


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Modifications to Meaningful Use for 2015 through 2017

Modifications to Meaningful Use for 2015 through 2017 | EHR and Health IT Consulting | Scoop.it

On April 10, 2015, the Centers for Medicare & Medicaid Services issued a new proposed rule for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs to align Stage 1 and Stage 2 objectives and measures with the long-term proposals for Stage 3, to build progress toward program milestones, to reduce complexity, and to simplify providers’ reporting. These modifications would allow providers to focus more closely on the advanced use of certified EHR technology to support health information exchange and quality improvement.

Better Care, Smarter Spending and Healthier People
The proposed rule is just one part of a larger effort across HHS to deliver better care, spend health dollars more wisely, and have healthier people and communities by working in three core areas: improving the way providers are paid, improving the way care is delivered, and improving the way information is shared to support transparency for consumers, health care providers, and researchers and to strengthen decision-making.


Vision for the Future


The proposed rule issued today is a critical step forward in helping to support the long-term goals of delivery system reform; especially those goals of a nationwide interoperable learning health system and patient-centered care. CMS is also simplifying the structure and reducing the reporting requirements for providers participating in the program by removing measures which have become duplicative, redundant, and reached wide-spread adoption (i.e., are “topped out”). This will allow providers to refocus on the advanced use objectives and measures. These advanced measures are at the core of health IT supported health care which drives toward improving the way electronic health information is shared among providers and with their patients, enhancing the ability to measure quality and set improvement goals, and ultimately improving the way health care is delivered and experienced.


Simplifying and Streamlining


The proposed rule would streamline reporting requirements. To accomplish these goals, the NPRM proposes:

  • Reducing the overall number of objectives to focus on advanced use of EHRs;
  • Removing measures that have become redundant, duplicative or have reached wide-spread adoption;
  • Realigning the reporting period beginning in 2015, so hospitals would participate on the calendar year instead of the fiscal year; and
  • Allowing a 90 day reporting period in 2015 to accommodate the implementation of these proposed changes in 2015.


Supporting Interoperability and the Adoption of Electronic Health Records


The EHR Incentive Programs support the adoption and meaningful use of certified EHR technology to allow providers and patients to exchange and access health information electronically and support interoperability broadly. The program supports interoperability by requiring the capture of data in structured formats as well as the exchange of data in standardized form as well as the sharing of this data electronically with other providers and with patients.

The proposed rule would reduce required reporting, allowing providers to focus on objectives which support advanced use of EHR technology and quality improvement, including health information exchange.


Improving Outcomes for Patients


The rule would support improved outcomes and measurement of those outcomes. By proposing to simplify the reporting requirements, the proposed rule would allow providers to focus on objectives that support advanced use of EHR technology, including quality measurement and quality improvement. The rule supports providers leveraging their resources and health IT to coordinate care for patients, to provide patients with access to their health information, and to support data collection in a format that can be shared across multiple health care organizations.


Program Registration and Participation Milestones


As of March 1, 2015, more than 525,000 providers have registered to participate in the Medicare and Medicaid EHR Incentive Programs. In addition, more than 438, 000 eligible professionals, eligible hospitals, and CAHs have received an EHR incentive payment. As of the end of 2014, 95% of eligible hospitals and CAHs, and more than 62% of eligible professionals have successfully demonstrated meaningful use of certified EHR technology.


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The Dire Need for Healthcare Interoperability

The Dire Need for Healthcare Interoperability | EHR and Health IT Consulting | Scoop.it

In a recently published study, "Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging," physician Hemal Kanzaria and co-authors uncovered that 97 percent of the over 700 responding ED physicians admit that nearly one in four advanced diagnostic imaging studies they personally order are "medically unnecessary." Worse yet, most in-hospital diagnostic imaging studies cost about five times more than their independent counterparts for the same work.

"The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation," according to the study abstract. The real contributor is that emergency physicians, and virtually every other consulting physician, is being forced to treat immediate crisis in the blind under looming threat of litigation, a callously perverse system that costs Medicare and Medicaid hundreds of billions of dollars each year, and the overall healthcare system arguably close to a trillion dollars per year in waste.


Emergency physicians, hospitalists, specialists, and even primary-care doctors, which pretty much covers anyone with a prescription pad, order lots of unnecessary or redundant tests not because the vast majority are intentionally wasteful but, because they, with rare exceptions, have no idea of what has or has not been done before them and must treat patients in the moment of crisis, not in the continuum of care.


This does not mean that ED doctors are bad at their jobs. It's just that doctors working in teams are proven to provide better care at lower cost. Much lower cost. As much as 30 percent.


Doctors work best if they can work in teams using the same information. Unfortunately, EHRs do not provide the kind of information that doctors need to be effective. They need information that helps them make informed decisions and they need to be responsible for all care and costs. When this happens, the quality of care improves. People get and stay healthier, and, costs go down.

Interoperability Hurdles


So, has spending $24.6 billion in taxpayer dollars on EHR systems been a bad idea? Not irreversibly. Some conflicts of interest that strongly inhibit the flow of data need to be addressed first:


1. It's good for EHR vendors to make it as hard as possible to move data to a competing system, denying the healthcare system as a whole.


2. It's good business for hospitals and their sub-specialist employees, whose stability relies on a steady stream of people in medical crisis, to keep data within their own walls and away from competitors.


3. It's good business for the industry as a whole because a free-flow of data means price, quality, and effectiveness transparency, forcing healthcare to compete like the rest of the economy.

And, the federal government obliges everyone with a cloak to hide behind: HIPAA.


The public is the only stakeholder in healthcare that restricting access to data is not good for.


The key to saving our healthcare system is to achieve a free flow of data and to convert that data into actionable clinical, price, and quality information for primary-care physicians, called interoperability.

Interoperability is the ability for different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. It solves three of the most vexing problems the healthcare system and its providers face:


1. It unites a fragmented healthcare delivery system;


2. It streamlines and standardizes communication among providers; and,


3. It eliminates duplication of services.


Three Solutions to Move Forward


Karen DeSalvo, a physician and the former national coordinator for health information technology, set a goal to get the basic infrastructure in place by 2017 and to have a fully interoperable national system by 2024. That deadline has since been moved to 2017.


Considering that literally hundreds of thousands of doctors do not have or cannot afford EHR systems, nor can they afford to jump through the annual labyrinth of regulatory hoops to meet the federal government's definition of "meaningful use," and over 150 EHR manufacturers fighting for the only thing that keeps them in business — proprietary data — this goal is not only unrealistic, it is disingenuous.


But, there are companies already operational and their population health, analytics, and quality measurement systems combined with primary-care practice operational transformation, best practices training, and support that unleashes the power of that information, already generating high quality care and superior clinical outcomes at lower cost.


They do this by cutting waste and managing chronic disease effectively, which keeps patients out of the hospital. As a result, they must be independent of hospitals to avoid the conflict of interest.

Hospitals and their unions, whose lament you are already hearing, realize their vulnerability, and will fight unless you change the system to protect them. Hospitals are necessary to the public welfare and our national security.


Three simple actions can accelerate the process:


1. Funding the expansion of our interoperability capabilities and use of a common population health and analytics system with practice transformation, and requiring EHR companies to format their data in the same way and put it in the same place;


2. Limiting "out-of-network" payments to a reasonable percentage of Medicare to protect both patients and providers to protect patients and shared savings and risk programs from predatory practices; and,


3. Indemnifying doctors that use and document best practices from frivolous lawsuits.


With the kind of savings programs like these can deliver, investing the savings from just four or five Medicare beneficiaries per year for each enabled primary-care practice,  the return on investment generates savings of 100 times or more.


The hardest part is mentally disengaging from the misperception that hospitals are healthcare providers. They are not. Hospitals are medical crisis treatment and rehabilitation facilities. Hospitals cannot so much as dispense an aspirin without a doctor's approval, and doctors need to be clear of conflict of interest.


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Why Providers Seek EHR Flexibility Standards From CMS

Why Providers Seek EHR Flexibility Standards From CMS | EHR and Health IT Consulting | Scoop.it

Over the last several years, a multitude of providers have found meaningful use requirements too complex and advanced to reach as quickly as the Centers for Medicare & Medicaid Services (CMS) mandates. Specifically, the healthcare industry is calling for more EHR flexibility when integrating these systems.


Due to the large volume of concerns from stakeholders and healthcare providers, CMS did move forward with revising some aspects of the meaningful use requirements. For example, instead of reporting on EHR use in a full calendar year, CMS decided to implement a 90-day reporting period instead.


“We continue to support the long-term goals of the meaningful use program and share the Department of Health and Human Services’ commitment to elevating patient-centered care and improving health outcomes, but greater flexibility is needed to support the providers and make participation less daunting,” American Academy of Family Physicians President Dr. Robert Wergin said in a public statement.

Along with concerns over meaningful use requirements, the lack of sharing capabilities among EHR systems is also causing providers to worry. The lack of EHR flexibility and interoperability is a significant concern, which the Office of the National Coordinator for Health IT (ONC) recently addressed by releasing a 10-year roadmap.


While approximately half of providers and 59 percent of hospitals have implemented EHR technology, not nearly as many physicians have the EHR flexibility necessary to communicate with doctors at other establishments. The Department of Health and Human Services (HHS) reported that, in 2013, only 14 percent of physicians electronically shared data with ambulatory care providers or hospitals that were outside of their facility.


Additionally, that same year only 10 percent of hospitals were offering their patients online access to view, download, and distribute their personal health records based on their hospital stay.

On March 18, the American Hospital Association (AHA) advised Congress to allow providers more EHR flexibility when implementing these systems. With the ICD-10 transition taking place on October 1, providers will need more secure and flexible products when adopting the new coding set.


Additionally, the recent release of the Stage 3 Meaningful Use proposed rule sets 2018 as the anticipated year for meeting the requirements. This may be difficult to achieve for providers that are still struggling to attain Stage 2 Meaningful Use regulations.

In a statement by AHA to the Senate Committee on Health, Education, Labor and Pensions, the organization commented on how health IT tools do not support a high level of health information sharing. AHA asks for the development of policy that supports EHR flexibility and the designing of systems to securely adapt to the ICD-10 coding set.

AHA also highlights the importance of delivering health IT products that promote patient safety and quality improvements. The various EHR issues including data exchange concerns will need to be addressed by the federal government over the coming months, as the ICD-10 transition is currently set to take place on October 1, 2015.


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