At the EHR Starting Line
The federal incentive program begins this year. If you haven't already begun, it's off to the races. Here's how certification can help you hit the ground running.
By René Luthe, Senior Associate Editor
The early deadline to qualify as a “meaningful user” for Stage 1 of electronic health records, and thus receive the government reimbursement from CMS's incentive program, is drawing closer—well, the absolute latest date to be eligible for the full incentive is Jan. 1, 2012, but practices can begin in 2011 by demonstrating 90 consecutive days of meaningful use this year. If you want to start early, the latest you need to start demonstrating the 90 days in 2011 is Q4 2011. With up to $44,000 per physician in reimbursement from the federal government available to practices that qualify, one might think ophthalmologists would have already chosen an EHR system and been preparing to dive in to prove meaningful use ASAP. Yet adoption remains low.
So why aren't more practices gearing up to collect their share of the money? According to the American Academy of Ophthalmology and some leading vendors, confusion—more than garden-variety procrastination—may be at work. The commonly misunderstood role of certification in the EHR process often befuddles physicians. Here, the AAO and industry executives share what they think practices most need to know about why and when you should implement a certified EHR system.
Separating Fact From Fiction
First and foremost: Yes, you do need a certified EHR system in order to demonstrate meaningful use! According to Flora Lum, MD, the AAO's policy director for Quality of Care and Knowledge Base Development, that is still a common question from members, despite the Academy's efforts to get the message out.
“Certification is a threshold requirement to participating in the EHR incentive,” affirms Julie Lee, the American Academy of Ophthalmic Executives' EHR Subcommittee Chair. And that system must be certified from Day 1 of a practice's reporting period. “There's going to be an ID number that you plug into the portal when you do your reporting, which identifies you as having a certified EHR product,” Ms. Lee explains.
Currently, there are three authorized testing and certification bodies (ATCBs): CCHIT, the Drummond Group and InfoGuard Laboratories—with more expected to be designated in the future by the Office of the National Coordinator for Health Information Technology, the federal agency that carries out the EHR policy of the recent HITECH act. The list of systems that have been certified can be found online at http://onc-chpl.force.com/ehrcert.
Defining “Meaningful”
Obtaining those reimbursement payments is actually dependent upon two things, says Ian Lane, executive vice president of technology at Kowa Optimed: buying a certified EHR system and demonstrating meaningful use. “The latter step is probably the one that a lot of the later adopters are not yet fully aware of, in my experience,” he says.
Not that demonstrating meaningful use should be seen as an onerous prospect, Mr. Lane adds. “From the government's standpoint, it's not enough just to go buy software and put it in a drawer someplace and then ask for money. You have to show that you are utilizing this in a meaningful way in order to become eligible for the incentive payment.”
To do that, of course, practices must demonstrate:
► Use of certified EHR technology with e-prescribing capability.
► Connectivity (interoperability) for the exchange of patient's health information.
► Compliance with clinical quality measure reporting (the Physician Quality Reporting Initiative).
The Final Rule has 25 criteria that may apply, with the option to defer up to five of the criteria with certain restrictions. You can go to the CMS Web site for specific thresholds on Core Set and Menu Set objectives for your specialty.
CCHIT Then vs CCHIT Now
One of the three ATCBs, CCHIT (the Certification Commission on Health Information Technology) has long certified electronic health records. The commission had its own criteria and testing process, and some EHR vendors had their systems certified by it—making for some confusion now, according to Dr. Lum. “That CCHIT certification does not equate to certification for meaningful use,” she cautions. The qualifications for meaningful use are different, and while programs that obtained the “old” CCHIT certification might find it easier to qualify for meaningful use now, those systems must still go through another certification process to meet the HITECH meaningful use requirements.
Compulink's Vice President of Product Development, Darla Shewmaker, notes that CCHIT's Ambulatory Certification tests more than 300 unique pieces of functionality. “ONC certification represents 34 unique scripts; some of these scripts have multiple components, but do not come close in number to 300.”
For example, she says that in the category of Managing Clinical Documents and Notes, the non-ONC CCHIT certification required the system to have the ability to:
► Filter, search or order notes by the provider who finalized the note.
► Filter, search or order notes by associated diagnosis within a patient record.
► Offer capability of recording comments by the patient or the patient's representative regarding the accuracy or veracity of information in the patient record.
► Display patient annotations in a manner which distinguishes them from other content in the system.
None of these are required of the system under ONC certification.
Some vendors will continue to refer to CCHIT certification, but will mean CCHIT in its prior role as a private, voluntary certification program, not its current role as an ATCB, warns Ms. Lee. “It is extremely confusing for end-users now, because CCHIT is also an ATCB, so you have to seek clarification. Are they ONC certified, or CCHIT in its current role as an ONC-ATCB? That is the certification practices want.”
Be Careful of Fine Distinctions
“Vendors will typically certify their latest and greatest version,” Ms. Lee says. At the practice where she works, the EHR vendor has a certified system, but it is not yet in general release. Once it is, the practice already has arrangements in place with the vendor to upgrade. Active communication with the vendor in such cases is crucial, Ms. Lee says.
Don't get too anxious if your system is not listed as certified on the ONC Web site at this very moment. Systems are being added to the list continually, Dr. Lum says. “But as we've told our members, definitely get a guarantee, if they aren't on the list now, that they are definitely going to be.”
Modular vs. Complete
Another issue generating considerable confusion among practices is certification for modules of an EHR system vs. certification of a complete system. Certification for a complete system means that the product has met all of the certifying criteria elements, says Ms. Lee. EHR modules, in contrast, have met at least one criterion. To qualify for the incentive payments, a practice must have enough certified modules to add up to a complete certified system.
“You would have to fill the holes yourself, if you have a system where only some modules are certified,” Dr. Lum explains. Be sure to ask any vendor with modular certification which pieces must be added by the user to qualify, she advises. Vendors should be able to tell which criteria they've met, and which they haven't. The end user would have to find another vendor who could provide those missing pieces. And, critically, “you would have to do that by Day 1 of your participation in the program,” Ms. Lee says.
Compulink's Ms. Shewmaker points out that the modular approach has its own potential headaches. “The most tenuous part of the modular-certification route is going to be the reporting. That encompasses every aspect of what's important for meaningful use, and systems are really going to have to be able to communicate with each other for that reporting to be automatically pulled for the physician. Inability to accomplish this may result in additional staff expenses related to manual tracking.”
Their tracking and reporting may suffer with a modular approach, she believes. An example, Ms. Shewmaker notes, is criteria 170.304(j)–Calculate and submit clinical quality measures. “A system that captures all of your key information, like Problem List, Medication List and Medication Allergies but that can't report on that information won't be a practical option,” she explains.
Another example she cites is 170.304(f)–Electronic copy of health information. “If your system has a series of modular certifications that let you do most everything but can't create an electronic copy for your patient, then how will you find another module that can read the data from that system and do it for you?”
The risk in choosing a “modular” approach, warns Ms. Shewmaker, is that as a provider, you take responsibility for combining a group of products that can achieve all of the required elements.
About half the systems currently approved are modular systems, she says, while the rest are complete EHRs.
On the bright side, IO Practiceware's Mr. Leopold does not foresee many ophthalmology practices having to track down missing pieces to come up with a certified whole system. “Hospitals and other large entities might have bits and pieces, but that is not going to be the normal case,” he says. “The normal case is that Somewhere Eye Associates is going to buy an EMR from a vendor that is certified.”
Temporary vs Permanent
Practices may also be confused after hearing about “temporary certification” for Stage 1 of meaningful use. Because of the tight timeframe to get the EHR incentive program underway for 2011, the ONC implemented a program of temporary certification for 2011.
A program for permanent certification is “coming down the pike,” Ms. Lee says.
Fortunately, those systems certified under the temporary program will maintain their certification status even after the permanent program is in place, at least for Stage 1 criteria. Physicians who enroll in the incentive program must demonstrate meaningful use during Stage 1 in their first two years before the more demanding criteria for Stage 2 are implemented in 2013, and for Stage 3 in 2015. And while it is known that the criteria for the latter two stages will be more rigorous, no one yet knows exactly what they will be.
“There's a gradual escalation towards full interoperability and decision support,” says Kowa's Mr. Lane.
| You can see the list of EHR vendors who have passed ONC certification at: http://ONC-CHPL.force.com/ehrcert |
Fees and the Future
As the criteria for Stages 2 and 3 are implemented, vendors will have to pay new testing fees. Purchasers of EHR systems, however, will have access to the new levels of certification through upgrades and support fees.
“For us at Kowa, when we certify levels 2 and 3, we will bear the testing charges,” Mr. Lane explains. “For our customers, that will be part of a normal upgrade by the annual licensing upgrade. So there won't be any surprises coming down the road for them.”
Medflow says it will offer upgraded certification to its clients in a similar fashion. The end user will not have to repurchase licenses, but will have received upgrades under support fees. “Typically, our history has been that we push an update out about every three months,” says Jim Messier, vice president of sales and marketing at Medflow. “So long as a client pays the support fees, they get that software and obsolescence won't be an issue.”
The Case for Acting Now
The uncertainty related to Stages 2 and 3 of meaningful use are further reason to start implementation of a certified EHR system sooner rather than later, according to Mr. Messier. While he notes that some sources may claim that practices can wait until Oct. 1, 2012 to qualify for Stage 1, he believes that it is both less stressful and more profitable to begin earlier. Waiting until Oct. 1, 2012, he points out, means the user has only 90 days to make a success of Stage 1. “That's basically the last 90 days of your opportunity of filing and submission for Stage 1,” Mr. Messier says. “My approach is a little bit different. I tell people, if you're going to get into this, then do it now, so you've got that first 90 day reporting in 2011, and what that allows you to do is safely secure that first payment doing the minimum amount of work.”
Because the criteria for Stages 2 and 3 are still a mystery, Mr. Messier contends that positioning oneself to submit the necessary reporting for Stage 1 90 days in 2011 will enable the user to potentially receive the first $18,000 incentive check as well as buy some “breathing room” for 2012.
“You still have to do your reporting, but your second reporting period can still be within Stage 1 criteria; meaning you know what you have to do and how to do it, and it's just a longer period of time,” he explains. “So rather than 90 days, it's going to be for the full year of 2012.”
The user can potentially secure 70% of the $44,000 reimbursement doing what is required under Stage 1, which, Mr. Messier notes, is the minimal amount of work. “Come 2013, we go to Stage 2,” he says, and those requirements are as-yet unknown. “We do know that they are going to be more than Stage 1. So the safe bet is, don't procrastinate, don't put it off until 2012.” If you do, he says, “you'll have to report on all new criteria that's yet to be defined for Stage 2 during your second reporting period, which will have to be a full year.”
Another reason to start adoption now is that the speed of the learning curve to demonstrating meaningful use depends on the individual practice. Mr. Lane identifies some significant variables. One is the user, or practice.
“You get those practices where the doctors are really gung-ho but the staffs are not, and sometimes you'll get it the other way around,” he says. “Sometimes in a multi-doctor practice, only a couple of the doctors are more interested in change.”
The second variable Mr. Lane identifies is the ease of operation of the EHR software selected, and the third is the support team from the vendor.“It's really a multifactorial thing, and it's truly a team approach,” Mr. Lane says.
Ms. Shewmaker also urges practices to get busy implementing their EHRs ASAP. They need to do the same due diligence required if they had started a year ago, she notes, which means looking at their processes in their office and figuring out how things are going to change from their paper system to an electronic system, as well as training staff.
Vendor Insights
While vendors naturally appreciate the business that government incentives for EHR use are bringing to them, some worry that the mandate for a certified system has skewed the perspective of potential customers. Before, notes Mr. Messier, EHR vendors had to persuade potential clients of the merits of a given system and the benefits it could bring to a practice. “You had to sell on your case studies of practices that had put the system in and show their improved patient care and other things,” he says. Now, the focus is on the word “certified,” rather than on the merits of the particular system.
“It's unfortunate that this whole thing has kind of overshadowed all those benefits and selling points for an EHR. Everyone is just focusing on what they have to do to get the $44,000 from the federal government,” Mr. Messier says.
Certification is an important piece of the puzzle, but it's not the only piece, Mr. Lane argues. Many of the early adopters of EHR, he says, have realized that although the government reimbursement is attractive, it is far from the only reason to purchase an EHR. “There are a lot of other good reasons to do that.” Earlier adopters tend to understand that “it's really about change,” he says, notably to workflows and patient management.
He urges potential buyers to focus on what the particular EHR can do for the practice. “It's really important to look for that platform for the future as opposed to technology of the past that has certification bolted on.”
His second suggestion is to stick with ophthalmology-only EHRs. “Ophthalmology has special requirements for documentation, and general-purpose EHRs simply do not address those requirements,” Mr. Leopold says.
Going with a vendor who has a long track record of successful implementations, a vendor who has at least approximately 50 installations, he believes, means a higher degree of likelihood that the system will be a success for you.
And Mr. Leopold's last piece of advice: Choosing an EHR is not the time to become unduly tight-fisted. “This is a terrible place to use price as a decision point; all of the good systems cost about the same amount of money.” Buying the wrong system because of a low price tag can turn out to be the most expensive mistake you can make, he believes. “If the system costs you time in the exam room, it will cost you much more than what you ‘saved’ when you bought it. Buy the system you think will be the most efficient system in your exam room. Don't worry about the price or the incentive,” Mr. Leopold says.
No Need to Dread the Future
Despite the tension associated with shopping for and implementing a comprehensive EHR, then learning to comply with government rules for use in a relatively short time frame, vendors recommend concentrating on the many positive things and EHR can do for your practice—in both practice efficiency and patient care. Planning and preparation, they say, are key.
“It's a fun trip if you do it the right way,” Mr. Messier says. OM
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