ARRA
The American Recovery and Reinvestment Act (ARRA), commonly known as the stimulus bill, includes incentive payments (“the carrot”) to most practices of up to $44,000, per physician, for those who implement electronic health records (EHR). Further, the bill includes a “stick” — reductions in Medicare payments that could grow to as much as 5% for physicians who do not use this technology. Taken together, these two factors have changed the game so that many now view selecting an EHR as a “must do” for practices.
This new imperative to implement electronic records leaves many physicians feeling daunted. With hundreds of vendors touting their wares, health reform and uncertain change on the horizon, and colleagues’ stories of EHR disasters, the task can seem frightening and overwhelming. Here is a roadmap for moving forward.
ROADMAP
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Know the government rules. Government money is a big part of the new financial equation. Most physicians who treat Medicare patients will be eligible for up to $44,000, paid out over 5 years, beginning in 2011. A different formula applies to physicians who treat a high percentage of Medicaid patients. Here is what we know at this writing:
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To get paid, physicians must demonstrate “meaningful use” of their system. The government hopes to officially define “meaningful use” by late 2009. You can see a draft definition — go to https://healthit.hhs.gov, click on “Health IT/Recovery” and then “Meaningful Use”. This preliminary definition calls on physicians to perform 28 specific functions with their EHR software and to submit 29 quality measures to CMS to qualify for the first of 5 annual payments. The bar will be raised in 2013 and again in 2015 — to keep getting paid, physicians must improve clinical performance on key health outcomes.
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Physicians must buy a “certified” software package. The Bush administration set up the Certification Commission for Health Information Technology, or CCHIT, to certify EHR software. You can get the list of current CCHIT-certified software packages at www.cchit.org. However, ARRA does not specifically name CCHIT, and CCHIT has its detractors. The Secretary of Health and Human Services will decide whether to bless CCHIT or to come up with some other certification.
- E-prescribing bonus. This is a separate program that gives physicians a bonus equal to 2% of Medicare payments for 2010. The guidelines are available now.
Reading materials from resources already available to you can help you select the right EHR.
This formula puts a big responsibility on physicians – you must successfully implement the system in order to get the government payments. So point #1 – get the rules when they come out so that you know what you need to accomplish in order to earn the government payments.
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Get organized and get educated. Get the right people from the practice on-board at the beginning. Then, get educated. Two good places to start are on the web, The Center for Health IT (www.centerforHIT.org) and Health Information Management Systems Society (www.himss.org). These sites contain references to numerous other resources that will get you up to speed. Your professional society may provide educational programs. A number of good books are available. Learn from others who have gone before you.
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Consider getting help. Since the road to electronic record success is littered with failed projects, cost overruns and disappointments, consider hiring a reputable consultant to lead you through the process. Another source of help will be the “Regional Extension Centers”, educational and technical assistance agencies that will be government-funded through ARRA. Extension Centers are tasked with helping physicians with selection, implementation and achieving meaningful use of their EHRs. Extension Centers as a priority will help:
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Primary care physicians in small groups
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Physicians in rural areas, and physicians who serve large numbers of uninsured and underinsured patients (such as poor urban areas)
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Physicians practicing in FQHCs
For prioritized physicians, help may include a government-funded consultant who will come on-site. Some help will be provided to all providers. Watch for news of this resource.
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Know yourself and where you are going. Preparation and self-assessment is the foundation for EHR selection and implementation success. Before getting buried in the morass of technical details of EHR features and functions, here are some key areas to consider:
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Alignment. For many reasons, more and more physicians are aligning in large groups, IPAs and/or with hospital systems. In some cases, independent physicians sell their practices to the hospital system and become employees. In other cases, the practice remains independent while establishing common treatment protocols, referral networks, and other “clinical integration” functions with a health system partner. In still other cases, a practice may be strong enough to remain independent and interact with multiple hospital systems. Consider your future – what your alignment will be over the next few years. Tight alignment might necessitate that you use the same EHR. If you think that you will be casting your lot with a big partner, strongly consider using the EHR they are promoting.
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PMS/Outside Billing Service. Your EHR shares much data with your Practice Management System (PMS) and/or your outside billing service. Patient Demographic information, scheduling information, and charges are used by both. Does your PMS vendor and/or billing service market an EHR that is already interfaced or integrated with your current PMS? If you like your current PMS/billing service, look carefully at the systems these vendors sell and/or recommend.
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Specialty. Most EHR functions are similar for all specialties – they schedule patients, record your E&M coding, document prescriptions and orders, etc. A few functions may be specific and/or unique to your specialty. For example, a pediatrician needs to display growth charts and an oncologist must manage chemotherapy regimens. Know any unique functions that are important to your specialty.
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Hosting. Consider outsourced vs. in-house hosting of your server:
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ASP Model. With the Application Service Provider, or ASP model, the vendor assumes responsibility for the management of the software and server including maintaining a secure data center, updating the software, and performing daily system backup. Many practices, including both solo physicians and large multi-location practices find this model attractive since small practices lack staff to handle ongoing operational responsibilities, and multi-location practices save telecommunications costs.
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In-house Hosting. The traditional in-house server keeps the programs and data in your office, giving you more control and responsibility for your operations. This technology may offer faster response time, it allows you to keep sensitive data in-house, and frees you from total reliance on your internet connectivity.
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EHR Functions / Your Priority List. Now it is time to dive into EHR details. Develop a list of features/functions that are important to you. One list that can help you get started is the Concise Guide to CCHIT Certification Criteria available on the CCHIT website (www.cchit.org). This 9 page document is a good laundry list of features – check off the functions that are most important to you. Add to this list anything important to you that is not listed, for example, any specialty-specific functions.
Inventory other software and clinical equipment installed in your practice – practice management software, PACS, pharmaceutical dispensing, diagnostic equipment with computer interfaces, or other software. Prioritize which should be interfaced to your EHR.
Achieving “Meaningful use” will include creating working connections with outside parties. Make a list of outside parties and systems your EHR should interact with – labs, hospitals, imaging facilities and others. Your EHR should connect to the outside parties with whom you do the highest volume of activity. Watch the news for a “Health Information Exchange”, or electronic clearinghouse, that will help physicians in this area lower the cost of interconnecting with multiple entities.
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Develop a list of vendors. Consider vendors related to your PMS software or billing service and your major hospital system partner. Your national, state, or local medical society may have preferred vendors you may wish to consider. What about specialty-specific vendors, which serve oncology, orthopedic surgery and many other specialties? Consider systems your colleagues recommend. Consider vendors that emerge from EHR selection tools that you may find on the web. Narrow these candidates down to no more than 3 to 8 vendors for a more in depth review. To narrow the list ask about number of installed clients, the financial strength of the company, references, and client satisfaction survey results. Be aware that many smaller companies will not survive.
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System Demo / Proposals / Financial Analysis / Decision. The physician will be intimately wedded to the EMR, so take the time to view an in-depth demonstration. You may start with a “canned” demo to get to know the “look and feel” of the system. This step may allow you to cut some vendors and proceed with an in-depth, customized demo of 2 or 3 systems. For these demos, use your priority list developed above, and ask the vendor to show you how each of your priority tasks is accomplished. Verify that the vendor has worked with others in your specialty and has templates available. Get a proposal that includes a sufficient quantity of support hours to allow you to achieve “meaningful use”. Get details of costs for 5 years. Check references including visits to users of these systems. Estimate the financial benefits that you will achieve (supply cost reductions, improved reimbursement through better coding, reduced labor) and the other practice costs you will incur (such as reduced billing due to lower productivity while learning, labor costs to convert paper charts, and other costs). Beware of “lowball” estimates of technical support time and costs. If you wish, Eagle Consulting provides EHR selection and implementation services.
Keep things in perspective…
Take a deep breath as you ponder the true dollar cost, the lengthy time frame and significant effort for implementation. Make your decision. The hard work is just starting. Know that the time you spend up-front building support from the key people, assessing your needs, developing realistic expectations of time and cost, and preparing for a new way of practice will pay dividends by improving odds of your ultimate satisfaction and implementation success.
Editor’s Note: Subsequent to the publication of this article, CMS has renamed the “Meaningful Use” programs and MIPS “Advancing Care Information” category to “Promoting Interoperability”.
