How we navigated ‘meaningful use’

Slow adoption, clear goals and staff involvement put this practice on the road to maximizing CMS incentives.

By Linda Bossler

	About the Author
	Linda Bossler is electronic health information director at Illinois Eye Surgeons, Swansea, III.

Change is never easy, especially when it leads to something much larger than spare change.

That was certainly the case during our effort at Illinois Eye Surgeons to obtain EHR Incentive Program funds from Medicare. That “spare change” came out to the tune of $18,000 per doctor in federal “meaningfuluse” incentive payments, with the hope of an additional $26,000 per doctor spread over the next four years.

As electronic health information director at the practice, where I have worked for the past decade, it was my responsibility to head the drive for EHR adoption for our 13 offices. Combined, 13 ophthalmologists and nine optometrists treat 500 to 600 clinic patients each day. To accomplish this and achieve the incentive payment for our first 90 days, that meant meeting “meaningful use” requirements immediately.

Our practice could not have met this standard had it not been for the skills and dedication of our medical and support staffs, the clarity of Medicare’s instructions, my background in data-base operations, and the guiding hands of the support team at our EHR vendor, Management Plus, of Salt Lake City, who were with us every step (and click) of the way since we began the process five years ago.

GAUNTLET OF REGULATIONS

What CMS expects of EHR

The effort to demonstrate meaningful use must deal with a gauntlet of regulations. The Centers for Medicare and Medicaid Services (CMS), seeking such meaningful-use objectives as complete and accurate patient records and claims, better access to information and patient empowerment, provides the financial incentives through the American Recovery and Reinvestment Act of 2009, and not the Affordable Care Act, as many physicians have come to believe.

Since 2009, CMS says it has paid out more than $6 billion in incentives to 312,074 doctors and other eligible professionals through July 2013.

For physicians who have not adopted EHR, CMS will implement payment adjustments starting in 2015. The penalty will be 1% of Medicare reimbursements a year beginning in 2015, with a ceiling of 3% by 2017, according to CMS. For the most part – though in some instances, doctors nearing retirement may be excluded – physicians will need to be on board with electronic records within the next two years.

Meeting CMS time line

To qualify for the incentive payments, providers must demonstrate meaningful use every year. Medicare established three stages for demonstrating meaningful use of EHR:

• 2011-12, data capture and sharing.

• 2014, advance clinical processes.

• 2016, improved outcomes.

Under CMS regulations, providers must purchase a comprehensive package from a single vendor or buy certified components from different vendors. The box on page 50 outlines the specific professional core objectives and menu objectives EHR must demonstrate to qualify for meaningful use.

OUR EHR IMPLEMENTATION PLAN

Taking our time

The keys to running this regulatory gauntlet are acquiring knowledge and doing homework. For our practice, that called for plenty of preparation – not only on my part, but from team leaders and so-called “super users” (employees first trained on electronic record software) among staff – and a series of planning meetings.

We worked with our EHR software for three years before going live with it in August 2012; the delay worked to our advantage. Even then, we moved one doctor at a time onto the system before we were 100% on-board in October 2012. From there, we spent 90 staffing days, to the end of 2012, before we could qualify for the incentive based on a three-month period during which we reported to CMS on our system use.

Vendor is a team member

Besides meeting with our employees (support staff tended to jump more quickly on board than medical professionals, who at first expressed skepticism on how this would improve our bottom line), we also had frequent meetings with Management Plus, with access all the way up to the company’s CEO, Christine Archibald. We were fortunate that we got in on the ground floor with this vendor when we did, as we paid about one 10th of what we would pay now.

Getting your EHR vendor on board is essential. Having access to our vendor was a key component of working toward our goals of achieving meaningful use. Our software company kept us up to date on Medicare MU updates and correspondence.

Especially helpful, also, were Kerry Lucht, our clinician-support person who served as the liaison to the medical staff and, of course, our IT department for hardware and security compliance. The most important guidance from IT came when we first began the move to EHR and helped guide us to use the same practice-management software as the EHR to eliminate any integration problems.

In terms of communicating with Medicare, we never spoke to anyone directly: Communication occurred via Web sites and webinars, and again, it was our EHR vendor – you have to have yours on board – that smoothed this process for us. They provided a custom, built-in meaningful-use report based on all criteria from Medicare. All we had to do was run the report by the doctor and attest the data.

Maintaining scheduled

From the beginning of the EHR adoption process, we were determined to maintain our clinic’s schedules. We did not reduce the schedules by one slot. We took time to slowly integrate EHR into the routine so the patient flow would not be affected.

Through training, we spotted some potential pitfalls of electronic records, such as the possible downside of using drop-down menus. We learned that, with more self-typing, we were better able to avoid relying too heavily on boilerplate narratives for the patient record.

THE PHYSICIAN FACTOR

Doctors need to tune in

With the meaningful-use attestation process, Medicare receives our report electronically, including all MU criteria. As with all attestations and reporting, we clearly understand that these reports are subject to audits.

But while the support staff was easy to motivate and were involved in talks with us for years, I’d have to admit that, with the 20/20 benefit of hindsight, if I had it to do over again, I would have gotten the doctors more involved from the start.

Early on, there was some feeling from the doctors, who are directly affected by all these changes, of reluctance. “We’ve always done it this way,” was their common reply. They were in agreement, however, that it had to be done to avoid upcoming penalties, so they assigned the “project” and said “make it happen.”

With the patient load our practice carries, no way could a doctor could step aside to lead such a project. When we got to the point to present the forms for capturing data, the doctors offered suggestions. The process involved a lot of going back to the drawing board. Each time our vendor would guide us through, making sure MU was being reported with each revision.

Physicians warmed to the idea

Once we revised forms and were able to show the physicians actual records in testing, they slowly became open to the change, and they were particularly pleased with the suggestion that they use scribes. Initially our scribes start training with data entry outside the clinic, taking the handwritten exams and loading them into an EHR visit. Then they move to the live setting with the doctor. They follow the doctor from room to room, taking down all clinical information and entering it into the EHR with the physician’s review and sign-off.

"I’d have to admit that if I had to it to do over again, I would have gotten the doctors more involved from the start.”

In this process, the physician conducts the examination, and the scribe takes down information so the physician can continue to communicate face-to-face with the patient. The scribe soon becomes more than just a scribe; she or he becomes a key part of the patient encounter.

Any lab results or communications for the doctor are sent electronically and the scribe is the first to get it for her or his doctor. The scribe opens the patient’s electronic record attachments and reveals the document at the same time for the physician’s review. The scribe also learns the doctor’s language and treatment patterns, becoming more of a chair-side assistant. Thus, the scribe is equipped to handle patient questions, frequently freeing the doctor for the next patient.

BENEFITS OF EHR IN FOCUS

Building patient histories

Now that we have been on EHR for more than a year and patient histories are building in the EHR, physicians and staff are becoming more confident with it as they see the benefits unfold – which, when it comes to eye care, can be immense.

Electronic records ease the process for tracking medication use, to transfer information on patients among our many practices and to track day-to-day business as we send records along. Specific to eye care, electronic records are especially helpful for tracking the progression of disease, particularly for building synopsis grids to follow IOP, visual acuities and general disease progression over multiple visits.

Another benefit of EHR is the ability to extract information on all patients with certain conditions. The doctors can readily identify such patients for specific instances, such as being candidates for emerging treatments.

A natural progression

Patients expect more from specialists, so when they come to an ophthalmologist, they anticipate the kind of service that comes from electronic records. Our practice has always been first with technology in surgical treatments for cataracts or LASIK. We were the first in the St. Louis area, and one of the first in the country, to use the femtosecond laser for cataract surgery. It was just a natural transition to become technically advanced in the clinic.

For us, meaningful use took a village, so to speak, to make the change happen. When it did, everyone involved, from our IT, support and medical staffs, to our choice of vendor, and, most important of all, our patients, won. OM