Getting your system to deliver information in a way that ensures you’re meeting the requirements
By Morris W. Stemp, CPA, MBA, CPHIMS, February 01, 2013
By now almost every physician is aware of the federal government’s financial incentives to providers who implement a certified electronic health record (EHR) system and use the EHR in a “meaningful way.” As described on the Health Resources and Services Administration’s website, the concept behind encouraging the meaningful use of an EHR is to enhance health care in five key areas:
- Improve the quality, safety, and efficiency of care while reducing disparities;
- Engage patients and families in their care;
- Promote public and population health;
- Improve care coordination; and
- Promote the privacy and security of patient information.
The government knew, however, that changing the way physicians practice medicine was not going to be easy or quick and thus phased in the adoption of new meaningful use workflows to achieve these goals over a period of years spanning three stages. Stage 1 started in 2011. Stage 2 was supposed to start in January 2013 but has been postponed until January 2014. Stage 3 is expected to begin in 2016 but is as likely to be delayed as the other two stages. Each stage both expands the thresholds of the prior stage and adds new measurement criteria. For example, in Stage 1, providers must collect demographics on 50 percent of unique patients while in Stage 2, this percentage has increased to 80 percent. In Stage 2, a totally new requirement is to use secure electronic messaging to communicate with more than 5 percent of unique patients. [pagebreak]
A number of new measures and increased thresholds are already being proposed for Stage 3. These include the following updates from the Stage 2 requirements:
- Allow patients to request amendments to their medical record;
- Send automatic electronic alerts to the care teams of 10 percent of patients when a significant health care event for a specific patient occurs;
- Send electronic summary of care documents to 30 percent of patients (up from 10 percent); and
- Use of computerized order entry by providers for 60 percent of all labs and radiological orders (up from 30 percent).
(For more information on the Stage 2 criteria, see a sidebar to this month’s article on smartphones) Some of the more mundane measures are being considered for removal, including collection of demographic data and recording of vital signs and smoking status.
The most fundamental requirement of meaningful use (MU) is the implementation of a certified EHR system. The certification process, created by the National Institute of Standards and Testing, is designed to certify an EHR’s ability to collect and report on data required to comply with meaningful use. For example, one requirement of Stage 1 is to maintain an active medication allergy list. An EHR, before it can be certified, must demonstrate that the software has the functions and screens to collect and retrieve this information. [pagebreak]
As the requirements of MU change from stage to stage, it makes sense that the EHR software requirements must also change. Thus, all EHR systems must be recertified under the new 2014 certification guidelines and all practices will be required to use a 2014-certified EHR to qualify for MU bonuses and avoid Medicare penalties. For most practices that have an EHR system, this will not be a problem, as most EHR companies will achieve their 2014 certification during 2013 and work to upgrade their customer base upon final release of their 2014-certified version.
In the first year of Stage 2 compliance, providers must only demonstrate MU in accordance with Stage 2 for a period of three consecutive months. This will give providers who upgrade to 2014-certified EHR technology time to implement the new systems.
Use it or lose it
The certification process is designed to make sure that all providers use an EHR system with the functionality to at least enable the provider to enter the data required to be a meaningful user. It’s up to the provider, however, to modify his/her patient visit workflows and to properly use the functionality of the certified EHR system to achieve MU. A certified EHR does not necessarily mean an easy-to-use EHR. Thus selecting an EHR designed to make MU compliance easy is critical. An EHR system can do this through the use of simple end-user data entry screens and effective warnings when required data is omitted. [pagebreak]
For example, as noted above, providers must record demographics for 50 percent of patients, going up to 80 percent in Stage 2. According to the rule, this specifically includes preferred language, sex, race, ethnicity, and date of birth. Race, ethnicity, and language are three new fields that generally were not collected before Stage 1. I have seen EHRs handle the addition of these three fields in different ways, from hiding them in “additional patient info” screens to placing them right up front and setting them as required fields.
This variability may explain the statistics I read recently suggesting that almost 50 percent of medical practices will replace their originally selected EHR system. Ease of use (sometimes euphemistically referred to as a “[mouse] click count”) is most certainly a contributing factor in this figure. But so is the accessibility and ease of use of the MU compliance data-entry screens and functionality. If a practice has to dramatically and unexpectedly change its workflows to conform to some programmer’s idea of MU data-entry, it may be more effective, even if painful and costly, to switch EHR systems, perhaps during the 2014 certification upgrade cycle.
Dashboard your way to compliance
Perhaps the most important MU feature of a certified EHR is a feature not even required under the certification rules. This feature is commonly referred to as a MU Compliance Dashboard or MU Wizard and is offered by many, if not all, of the major EHR systems. This dashboard or wizard basically provides a list of all the MU measures along with the compliance status of each measure, so that it is possible to monitor the progress of MU compliance in real time. For those measures based on percentages of patients or visits, the dashboard also presents the number of compliant units (numerator) compared to the total population of units (denominator). [pagebreak]
Who would have thought that the words numerator and denominator, math terms we all learned in elementary school, would become so important?
For example, one of the Stage 1 measures calls for e-prescribing at least 40 percent of permissible prescriptions. An effective dashboard would show the total number of prescriptions which were e-prescribed (numerator) compared to the total number of eligible prescriptions written (denominator). If the percentage is above the MU threshold (in this case 40 percent) a green light or check mark might display next to the measure description. Otherwise, a red light or an “X” would appear. Every dashboard or wizard has a different user interface, but all should at least provide this MU status information.
More importantly, an effective dashboard can assist in holding providers accountable for their actions, leading to MU compliance. The dashboard could allow the practice administrator to click on a specific measure and drill down into more details regarding the population of that measure. In the e-prescribing example above, clicking on the denominator might make the dashboard present a list of all the eligible prescriptions by the provider. This list can then be filtered to just those that were not e-prescribed (and thus not part of the numerator and thus out of compliance). The provider can then be asked why he/she did not e-prescribe in those specific cases. This would also help the practice determine if additional EHR workflow training is needed. [pagebreak]
In the example of e-prescribing, it is obviously too late to remedy the out-of-compliance action; the solution can only come through improved future performance. But with other measures, such as missing demographics, the out-of-compliance condition can be fixed. Assuming the staff can drill into those patient charts with missing demographics, staff with appropriate security and knowledge of the patient’s demographics could open the patient demographic screen and enter the proper values at any time. In other cases, such as MU measures related to visit summaries, only the physician can update any missing information.
Given the effectiveness of this tool as described above, I believe a practice should designate a MU compliance officer (most likely the practice administrator) to regularly monitor the dashboard and take proactive measures to ensure that providers and staff are using the EHR system in a compliant manner. Catching out-of-compliance entries close to the time of the patient encounter allows the doctor to fix the omissions while the encounter is still fresh in his/her mind. [pagebreak]
It’s not just about the software
It’s a common misconception (and one not frequently disclaimed by the EHR vendors) that a practice can be in full compliance with MU simply by diligently using all the MU features of its EHR system. In fact, in the early days of Stage 1, software companies used to “guarantee” MU compliance to any practice using that company’s EHR. The truth is that at least one element of Stage 1 compliance and a number of Stage 2 elements are not software-related at all and thus not under control of the EHR system.
Stage 1 Measure 15 and Stage 2 Measure 9 require that a practice protect electronic health information via the conduct and review of a security risk analysis and by having a risk management process. These requirements are all under the direction of the practice IT and administrative staff. None of these are under the purview of any EHR system. As I described in “Crisis management: Planning for a systems crash,” it is not sufficient to just have a plan. The plan must be documented as a set of written policies and procedures. [pagebreak]
Stage 2 Measure 7 requires a practice to provide more than 50 percent of its patients with online access to their health information. But a second requirement of Measure 7 is that more than 5 percent of patients “view, download, or transmit to a third party their health information.” While the first requirement is easily accomplished via the patient portal offered by most EHRs, the EHR cannot force patients to “view, download, or transmit.” It will be solely up to the practice to educate and induce patients to take these actions. Admittedly, 5 percent is a very small population but as with all measures, you can expect the population requirements to increase in later stages. (Note: Stage 1 only required an “electronic copy,” not “online access,” so a patient portal is a requirement for Stage 2 but not for Stage 1.)
Let’s get serious about compliance, earn incentive payments, and avoid future penalties. Choosing an EHR that makes it easy to complete the required fields, has an engaging patient portal with an easy-to-use interface (for the patient!), and has an informative, navigable MU dashboard, will simplify meeting the majority of the MU requirements. Once you attest that your practice is MU compliant and cash your incentive check, you basically sign off that you allow the government access to your medical records to audit your compliance. (Note: Audits of MU attestation have already started.)
Thus, it is imperative that you are indeed both compliant, and that you can produce the evidence of your compliance. A well-designed EHR system will make it easy to be MU-compliant with small changes to your workflow by providing effective MU dashboards to self-audit and review your level of compliance, and will provide detailed reporting to support your compliance claim that you can submit to the government should your practice be audited.