Christopher Notte, MD

We routinely respond to readers who question our opinions on the value of electronic health records. Many have suggested that we have become so biased in favor of Health IT that we fail to acknowledge its shortcomings. With those we respectfully disagree. In several previous columns, we have discussed the implementation challenges, legal pitfalls, and productivity losses associated with EHRs (these are indisputable facts of life for so many practitioners). But to satisfy our harshest critics, in this column, we’ll try to count the true financial cost of an EHR and assess the impact of that cost on physicians, while balancing this with the very real promise of improved patient care (a very tall order for one column!).

Cause for doubt?

EHR vendors and Health IT evangelists often cite studies that point to the incredible financial benefits of purchasing and using an electronic record. We, too, have propagated this notion, but acknowledge that the data to support this have been quite meager. In addition to the financial incentive, the advent of the meaningful use program brought an acknowledgement of the very real costs and challenges associated with electronic documentation, and many people – both inside and outside health care – are starting to take notice.

A recent survey analysis by Adler-Milstein, et al., published in the March 2013 issue of Health Affairs, prospectively evaluated the costs associated with EHR implementation and usage in a pilot program known as the Massachusetts eHealth Collaborative. "With more than eighty ambulatory care practices in three diverse communities agreeing to adopt EHR systems simultaneously, the pilot offered a unique opportunity to study the long-term financial impact of adoption on a heterogeneous group of practices," according to the authors. The results challenge the conventional wisdom and certainly warrant close examination (Health Affairs 2013;32:1-9).

As a primary conclusion, the authors note that "current meaningful use incentives alone may not ensure that most practices, particularly smaller ones, achieve a positive return on investment from EHR adoption." To break this down further, their analysis shows that across practices of all sizes and specialty, only 41% would see a positive return on investment – even after factoring in the meaningful use incentive payments of $44,000/provider. Productivity losses, software and equipment costs, and ongoing support and maintenance factored among the financial burdens. In addition, 22% of practices reported that physicians were spending more time at work after implementation. Clearly, these results threaten to tarnish our erudite reasoning on the benefits of EHRs – and might even bring a sense of joy and vindication to our detractors! But the data analysis doesn’t end there.

The devil in the details

In spite of their overall conclusion that electronic records typically lead to a net loss in revenue, the authors discovered several scenarios wherein implementing an EHR actually might make financial sense. A few are particularly worth noting here. First, when factoring in the meaningful use incentive dollars, they predict that 56% of primary care practices would realize a positive 5-year return on investment. Larger practices would also see benefit, with 75% achieving true gains in revenue. The survey team went on to comment that successful practices found ways to use the electronic record to their financial advantage and reaped incredible returns, averaging more than $100,000 in additional revenue per physician over 5 years. This was apparently done through improved efficiency (equating to more patient visits per day), better charge capture, and elimination of ancillary services such as dictation and billing.

Also noteworthy was the observation that smaller practices do not fare well in the financial equation. This, presumably, is in part due to their inability to take advantage of the economies of scale. While the expense of most EHRs is tied directly to the number of providers using it, the amount of equipment and support required is not a linear correlation at all. A solo provider requires almost as much support staff as a group of two or three, and the additional providers greatly offset the productivity loss incurred when switching to an electronic system.

Finally, because the EHR incentive program did not begin reimbursing physicians until 2011, the authors made projections based on the expected payment of $44,000/doctor over 5 years. They did not, however, factor in the penalties involved in not adopting an EHR by 2014. This reduced Medicare reimbursement of 1% per year is potentially significant and should be considered in a total cost/benefit analysis.

We still believe!

In spite of the unforgiving data presented in this survey, we continue to feel positive about the future of connected medicine and see reason to be encouraged by the success of the practices that fully "embraced" their EHR. We also are unwilling to accept that the benefits of EHRs are only financial; there are intangible rewards that cannot be appreciated on a ledger sheet. Even the authors of the survey acknowledge there are advantages that "may accrue to other stakeholders – such as patients – which could be significant." We’ve enumerated these in previous columns, but a few worth highlighting are improved access to patient information, better care coordination, and point-of-care decision support. None of these advantages can be realized if they are not implemented well, but if done right, there is no question that in the future the value of electronic health records will be measured in better outcomes, not lower costs.

 

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

We routinely respond to readers who question our opinions on the value of electronic health records. Many have suggested that we have become so biased in favor of Health IT that we fail to acknowledge its shortcomings. With those we respectfully disagree. In several previous columns, we have discussed the implementation challenges, legal pitfalls, and productivity losses associated with EHRs (these are indisputable facts of life for so many practitioners). But to satisfy our harshest critics, in this column, we’ll try to count the true financial cost of an EHR and assess the impact of that cost on physicians, while balancing this with the very real promise of improved patient care (a very tall order for one column!).

Cause for doubt?

EHR vendors and Health IT evangelists often cite studies that point to the incredible financial benefits of purchasing and using an electronic record. We, too, have propagated this notion, but acknowledge that the data to support this have been quite meager. In addition to the financial incentive, the advent of the meaningful use program brought an acknowledgement of the very real costs and challenges associated with electronic documentation, and many people – both inside and outside health care – are starting to take notice.

A recent survey analysis by Adler-Milstein, et al., published in the March 2013 issue of Health Affairs, prospectively evaluated the costs associated with EHR implementation and usage in a pilot program known as the Massachusetts eHealth Collaborative. "With more than eighty ambulatory care practices in three diverse communities agreeing to adopt EHR systems simultaneously, the pilot offered a unique opportunity to study the long-term financial impact of adoption on a heterogeneous group of practices," according to the authors. The results challenge the conventional wisdom and certainly warrant close examination (Health Affairs 2013;32:1-9).

As a primary conclusion, the authors note that "current meaningful use incentives alone may not ensure that most practices, particularly smaller ones, achieve a positive return on investment from EHR adoption." To break this down further, their analysis shows that across practices of all sizes and specialty, only 41% would see a positive return on investment – even after factoring in the meaningful use incentive payments of $44,000/provider. Productivity losses, software and equipment costs, and ongoing support and maintenance factored among the financial burdens. In addition, 22% of practices reported that physicians were spending more time at work after implementation. Clearly, these results threaten to tarnish our erudite reasoning on the benefits of EHRs – and might even bring a sense of joy and vindication to our detractors! But the data analysis doesn’t end there.

The devil in the details

In spite of their overall conclusion that electronic records typically lead to a net loss in revenue, the authors discovered several scenarios wherein implementing an EHR actually might make financial sense. A few are particularly worth noting here. First, when factoring in the meaningful use incentive dollars, they predict that 56% of primary care practices would realize a positive 5-year return on investment. Larger practices would also see benefit, with 75% achieving true gains in revenue. The survey team went on to comment that successful practices found ways to use the electronic record to their financial advantage and reaped incredible returns, averaging more than $100,000 in additional revenue per physician over 5 years. This was apparently done through improved efficiency (equating to more patient visits per day), better charge capture, and elimination of ancillary services such as dictation and billing.

Also noteworthy was the observation that smaller practices do not fare well in the financial equation. This, presumably, is in part due to their inability to take advantage of the economies of scale. While the expense of most EHRs is tied directly to the number of providers using it, the amount of equipment and support required is not a linear correlation at all. A solo provider requires almost as much support staff as a group of two or three, and the additional providers greatly offset the productivity loss incurred when switching to an electronic system.

Finally, because the EHR incentive program did not begin reimbursing physicians until 2011, the authors made projections based on the expected payment of $44,000/doctor over 5 years. They did not, however, factor in the penalties involved in not adopting an EHR by 2014. This reduced Medicare reimbursement of 1% per year is potentially significant and should be considered in a total cost/benefit analysis.

We still believe!

In spite of the unforgiving data presented in this survey, we continue to feel positive about the future of connected medicine and see reason to be encouraged by the success of the practices that fully "embraced" their EHR. We also are unwilling to accept that the benefits of EHRs are only financial; there are intangible rewards that cannot be appreciated on a ledger sheet. Even the authors of the survey acknowledge there are advantages that "may accrue to other stakeholders – such as patients – which could be significant." We’ve enumerated these in previous columns, but a few worth highlighting are improved access to patient information, better care coordination, and point-of-care decision support. None of these advantages can be realized if they are not implemented well, but if done right, there is no question that in the future the value of electronic health records will be measured in better outcomes, not lower costs.

 

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

We routinely respond to readers who question our opinions on the value of electronic health records. Many have suggested that we have become so biased in favor of Health IT that we fail to acknowledge its shortcomings. With those we respectfully disagree. In several previous columns, we have discussed the implementation challenges, legal pitfalls, and productivity losses associated with EHRs (these are indisputable facts of life for so many practitioners). But to satisfy our harshest critics, in this column, we’ll try to count the true financial cost of an EHR and assess the impact of that cost on physicians, while balancing this with the very real promise of improved patient care (a very tall order for one column!).

Cause for doubt?

EHR vendors and Health IT evangelists often cite studies that point to the incredible financial benefits of purchasing and using an electronic record. We, too, have propagated this notion, but acknowledge that the data to support this have been quite meager. In addition to the financial incentive, the advent of the meaningful use program brought an acknowledgement of the very real costs and challenges associated with electronic documentation, and many people – both inside and outside health care – are starting to take notice.

A recent survey analysis by Adler-Milstein, et al., published in the March 2013 issue of Health Affairs, prospectively evaluated the costs associated with EHR implementation and usage in a pilot program known as the Massachusetts eHealth Collaborative. "With more than eighty ambulatory care practices in three diverse communities agreeing to adopt EHR systems simultaneously, the pilot offered a unique opportunity to study the long-term financial impact of adoption on a heterogeneous group of practices," according to the authors. The results challenge the conventional wisdom and certainly warrant close examination (Health Affairs 2013;32:1-9).

As a primary conclusion, the authors note that "current meaningful use incentives alone may not ensure that most practices, particularly smaller ones, achieve a positive return on investment from EHR adoption." To break this down further, their analysis shows that across practices of all sizes and specialty, only 41% would see a positive return on investment – even after factoring in the meaningful use incentive payments of $44,000/provider. Productivity losses, software and equipment costs, and ongoing support and maintenance factored among the financial burdens. In addition, 22% of practices reported that physicians were spending more time at work after implementation. Clearly, these results threaten to tarnish our erudite reasoning on the benefits of EHRs – and might even bring a sense of joy and vindication to our detractors! But the data analysis doesn’t end there.

The devil in the details

In spite of their overall conclusion that electronic records typically lead to a net loss in revenue, the authors discovered several scenarios wherein implementing an EHR actually might make financial sense. A few are particularly worth noting here. First, when factoring in the meaningful use incentive dollars, they predict that 56% of primary care practices would realize a positive 5-year return on investment. Larger practices would also see benefit, with 75% achieving true gains in revenue. The survey team went on to comment that successful practices found ways to use the electronic record to their financial advantage and reaped incredible returns, averaging more than $100,000 in additional revenue per physician over 5 years. This was apparently done through improved efficiency (equating to more patient visits per day), better charge capture, and elimination of ancillary services such as dictation and billing.

Also noteworthy was the observation that smaller practices do not fare well in the financial equation. This, presumably, is in part due to their inability to take advantage of the economies of scale. While the expense of most EHRs is tied directly to the number of providers using it, the amount of equipment and support required is not a linear correlation at all. A solo provider requires almost as much support staff as a group of two or three, and the additional providers greatly offset the productivity loss incurred when switching to an electronic system.

Finally, because the EHR incentive program did not begin reimbursing physicians until 2011, the authors made projections based on the expected payment of $44,000/doctor over 5 years. They did not, however, factor in the penalties involved in not adopting an EHR by 2014. This reduced Medicare reimbursement of 1% per year is potentially significant and should be considered in a total cost/benefit analysis.

We still believe!

In spite of the unforgiving data presented in this survey, we continue to feel positive about the future of connected medicine and see reason to be encouraged by the success of the practices that fully "embraced" their EHR. We also are unwilling to accept that the benefits of EHRs are only financial; there are intangible rewards that cannot be appreciated on a ledger sheet. Even the authors of the survey acknowledge there are advantages that "may accrue to other stakeholders – such as patients – which could be significant." We’ve enumerated these in previous columns, but a few worth highlighting are improved access to patient information, better care coordination, and point-of-care decision support. None of these advantages can be realized if they are not implemented well, but if done right, there is no question that in the future the value of electronic health records will be measured in better outcomes, not lower costs.

 

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

We have written routinely about the positive impact of implementing an electronic health record, citing potential improvements in areas such as charge capture, data sharing, and population management. In an attempt to be balanced, we’ve also discussed the financial implications and the risks of decreased productivity and provider frustration, among others. One area that we have not focused on – but which has been attracting increasingly more attention – is that of the advantages and limitations of Clinical Decision Support Systems (CDSSs).

CDSSs are tools that add evidence-based clinical intelligence to patient care, providing assistance to the provider as he or she treats patients and makes decisions about their management. A simple example of this would be an alert, reminding a physician to provide an immunization to age-appropriate patients while seeing them in the office. Some EHRs ship with this capability built-in and ready for deployment "right out of the box," while others completely lack real-decision support. Most commonly, however, an EHR will have the capability to provide support but rely heavily on end-user customization prior to implementation. The question that many are beginning to ask is how using a clinical decision support system will ultimately affect patient outcomes.

The promise and liability of clinical intelligence

There is no question that the medical community has accepted the concept of guideline-based workflows and the importance of evidence-based medicine at the point of care. More recently, though, several studies have begun to look at how CDSS tools that are packaged into EHRs have affected care delivery. Surprisingly, the results are inconsistent; while many studies have demonstrated the benefits of decision support, others have not shown impressive changes in patient outcomes.

Findings from a review of 100 studies comparing the outcomes in care provided with and without a CDSS showed that 64% of the studies demonstrated improvements in practitioner performance when using a Clinical Decision Support System. While the specific systems varied in type and purpose, improvements in performance were "associated with CDSSs that automatically prompted users," compared with those "requiring users to activate the system," (JAMA 2005;293:1223-38).

Similar results were found in a multidisciplinary randomized trial pin which investigators analyzed data from 21 centers and demonstrated that "computerized decision support increased concordance with guideline-recommended therapeutic decisions" for numerous treatment options and "reduced cases of both overtreatment and undertreatment" (BMJ 2009;338:b1440 [doi:10.1136/bmj.b1440]).

But not all of the studies have been so optimistic. Findings from a more recent study showed that there is little benefit to having a CDSS in place. Using survey data collected from over 250,000 ambulatory patient visits (sourced from the National Ambulatory Medical Care Survey), they discovered that only 1 of 20 quality indicators proved better in the group of patients treated using EHRs with a CDSS in place, compared with those treated without decision support. The investigators offered little explanation for these unexpected results, but they did cite some limitations in their methods and theorized that the value of current support systems may be minimal in the absence of standardization and better quality control (Arch. Intern. Med. 2011;171:897-903).

Searching for help

To meet certification for meaningful use, electronic records are required to have some minimal CDSS functionality available from Day 1. But in our experience with most products, the depth and breadth of this built-in support is sorely lacking. For some practitioners who simply view the EMR as a more complicated way of documenting progress notes and telephone calls, this might not seem like a big deal. After all, the world of paper offered no clinical intelligence to speak of. But for others hoping to realize the true promises of health information technology, high-quality decision support may be essential.

It is again important to point out that the usefulness of clinical decision support systems is typically limited by the EHR itself, so it’s critical to start investigating CDSS capability when first selecting an EHR. We would encourage everyone to request to see a demonstration of what – if any – decision support is present in the EHRs they are considering, and ask a lot of questions about how the information is accessed and kept current. Does the product have a standard toolset based on outdated practice suggestions or is it updated as new guidelines are published and research is released? Is the information customizable to meet the needs of the implementation, or is it a "one-size-fits-all" solution? Finally, is the information passive or active? In other words, does the provider need to go searching for the support, or is the software smart enough to offer support when appropriate in the form of an "alert" or "pop-up"?

 

A tale of art and science

When chess champion Gary Kasparov defeated IBM’s Deep Blue Supercomputer back in 1996, people around the globe shared in a warm feeling of vindication. More than a simple win, Kasparov’s victory proved that humans still had the advantage over machines. In the same way, it is possible to find the data questioning the value of CDSSs oddly reassuring. But the irony of history reminds us not to get comfortable in our assertions; just 1 year later, after extensive enhancements, Deep Blue returned to defeat Kasparov in a devastating rematch. We suggest viewing this irony as instructive; if one accepts – as we do unequivocally – the value of evidence-based medicine, one must also accept that the right decision support delivered in a timely fashion will ultimately lead to better care and improved clinical outcomes.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

We have written routinely about the positive impact of implementing an electronic health record, citing potential improvements in areas such as charge capture, data sharing, and population management. In an attempt to be balanced, we’ve also discussed the financial implications and the risks of decreased productivity and provider frustration, among others. One area that we have not focused on – but which has been attracting increasingly more attention – is that of the advantages and limitations of Clinical Decision Support Systems (CDSSs).

CDSSs are tools that add evidence-based clinical intelligence to patient care, providing assistance to the provider as he or she treats patients and makes decisions about their management. A simple example of this would be an alert, reminding a physician to provide an immunization to age-appropriate patients while seeing them in the office. Some EHRs ship with this capability built-in and ready for deployment "right out of the box," while others completely lack real-decision support. Most commonly, however, an EHR will have the capability to provide support but rely heavily on end-user customization prior to implementation. The question that many are beginning to ask is how using a clinical decision support system will ultimately affect patient outcomes.

The promise and liability of clinical intelligence

There is no question that the medical community has accepted the concept of guideline-based workflows and the importance of evidence-based medicine at the point of care. More recently, though, several studies have begun to look at how CDSS tools that are packaged into EHRs have affected care delivery. Surprisingly, the results are inconsistent; while many studies have demonstrated the benefits of decision support, others have not shown impressive changes in patient outcomes.

Findings from a review of 100 studies comparing the outcomes in care provided with and without a CDSS showed that 64% of the studies demonstrated improvements in practitioner performance when using a Clinical Decision Support System. While the specific systems varied in type and purpose, improvements in performance were "associated with CDSSs that automatically prompted users," compared with those "requiring users to activate the system," (JAMA 2005;293:1223-38).

Similar results were found in a multidisciplinary randomized trial pin which investigators analyzed data from 21 centers and demonstrated that "computerized decision support increased concordance with guideline-recommended therapeutic decisions" for numerous treatment options and "reduced cases of both overtreatment and undertreatment" (BMJ 2009;338:b1440 [doi:10.1136/bmj.b1440]).

But not all of the studies have been so optimistic. Findings from a more recent study showed that there is little benefit to having a CDSS in place. Using survey data collected from over 250,000 ambulatory patient visits (sourced from the National Ambulatory Medical Care Survey), they discovered that only 1 of 20 quality indicators proved better in the group of patients treated using EHRs with a CDSS in place, compared with those treated without decision support. The investigators offered little explanation for these unexpected results, but they did cite some limitations in their methods and theorized that the value of current support systems may be minimal in the absence of standardization and better quality control (Arch. Intern. Med. 2011;171:897-903).

Searching for help

To meet certification for meaningful use, electronic records are required to have some minimal CDSS functionality available from Day 1. But in our experience with most products, the depth and breadth of this built-in support is sorely lacking. For some practitioners who simply view the EMR as a more complicated way of documenting progress notes and telephone calls, this might not seem like a big deal. After all, the world of paper offered no clinical intelligence to speak of. But for others hoping to realize the true promises of health information technology, high-quality decision support may be essential.

It is again important to point out that the usefulness of clinical decision support systems is typically limited by the EHR itself, so it’s critical to start investigating CDSS capability when first selecting an EHR. We would encourage everyone to request to see a demonstration of what – if any – decision support is present in the EHRs they are considering, and ask a lot of questions about how the information is accessed and kept current. Does the product have a standard toolset based on outdated practice suggestions or is it updated as new guidelines are published and research is released? Is the information customizable to meet the needs of the implementation, or is it a "one-size-fits-all" solution? Finally, is the information passive or active? In other words, does the provider need to go searching for the support, or is the software smart enough to offer support when appropriate in the form of an "alert" or "pop-up"?

 

A tale of art and science

When chess champion Gary Kasparov defeated IBM’s Deep Blue Supercomputer back in 1996, people around the globe shared in a warm feeling of vindication. More than a simple win, Kasparov’s victory proved that humans still had the advantage over machines. In the same way, it is possible to find the data questioning the value of CDSSs oddly reassuring. But the irony of history reminds us not to get comfortable in our assertions; just 1 year later, after extensive enhancements, Deep Blue returned to defeat Kasparov in a devastating rematch. We suggest viewing this irony as instructive; if one accepts – as we do unequivocally – the value of evidence-based medicine, one must also accept that the right decision support delivered in a timely fashion will ultimately lead to better care and improved clinical outcomes.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

We have written routinely about the positive impact of implementing an electronic health record, citing potential improvements in areas such as charge capture, data sharing, and population management. In an attempt to be balanced, we’ve also discussed the financial implications and the risks of decreased productivity and provider frustration, among others. One area that we have not focused on – but which has been attracting increasingly more attention – is that of the advantages and limitations of Clinical Decision Support Systems (CDSSs).

CDSSs are tools that add evidence-based clinical intelligence to patient care, providing assistance to the provider as he or she treats patients and makes decisions about their management. A simple example of this would be an alert, reminding a physician to provide an immunization to age-appropriate patients while seeing them in the office. Some EHRs ship with this capability built-in and ready for deployment "right out of the box," while others completely lack real-decision support. Most commonly, however, an EHR will have the capability to provide support but rely heavily on end-user customization prior to implementation. The question that many are beginning to ask is how using a clinical decision support system will ultimately affect patient outcomes.

The promise and liability of clinical intelligence

There is no question that the medical community has accepted the concept of guideline-based workflows and the importance of evidence-based medicine at the point of care. More recently, though, several studies have begun to look at how CDSS tools that are packaged into EHRs have affected care delivery. Surprisingly, the results are inconsistent; while many studies have demonstrated the benefits of decision support, others have not shown impressive changes in patient outcomes.

Findings from a review of 100 studies comparing the outcomes in care provided with and without a CDSS showed that 64% of the studies demonstrated improvements in practitioner performance when using a Clinical Decision Support System. While the specific systems varied in type and purpose, improvements in performance were "associated with CDSSs that automatically prompted users," compared with those "requiring users to activate the system," (JAMA 2005;293:1223-38).

Similar results were found in a multidisciplinary randomized trial pin which investigators analyzed data from 21 centers and demonstrated that "computerized decision support increased concordance with guideline-recommended therapeutic decisions" for numerous treatment options and "reduced cases of both overtreatment and undertreatment" (BMJ 2009;338:b1440 [doi:10.1136/bmj.b1440]).

But not all of the studies have been so optimistic. Findings from a more recent study showed that there is little benefit to having a CDSS in place. Using survey data collected from over 250,000 ambulatory patient visits (sourced from the National Ambulatory Medical Care Survey), they discovered that only 1 of 20 quality indicators proved better in the group of patients treated using EHRs with a CDSS in place, compared with those treated without decision support. The investigators offered little explanation for these unexpected results, but they did cite some limitations in their methods and theorized that the value of current support systems may be minimal in the absence of standardization and better quality control (Arch. Intern. Med. 2011;171:897-903).

Searching for help

To meet certification for meaningful use, electronic records are required to have some minimal CDSS functionality available from Day 1. But in our experience with most products, the depth and breadth of this built-in support is sorely lacking. For some practitioners who simply view the EMR as a more complicated way of documenting progress notes and telephone calls, this might not seem like a big deal. After all, the world of paper offered no clinical intelligence to speak of. But for others hoping to realize the true promises of health information technology, high-quality decision support may be essential.

It is again important to point out that the usefulness of clinical decision support systems is typically limited by the EHR itself, so it’s critical to start investigating CDSS capability when first selecting an EHR. We would encourage everyone to request to see a demonstration of what – if any – decision support is present in the EHRs they are considering, and ask a lot of questions about how the information is accessed and kept current. Does the product have a standard toolset based on outdated practice suggestions or is it updated as new guidelines are published and research is released? Is the information customizable to meet the needs of the implementation, or is it a "one-size-fits-all" solution? Finally, is the information passive or active? In other words, does the provider need to go searching for the support, or is the software smart enough to offer support when appropriate in the form of an "alert" or "pop-up"?

 

A tale of art and science

When chess champion Gary Kasparov defeated IBM’s Deep Blue Supercomputer back in 1996, people around the globe shared in a warm feeling of vindication. More than a simple win, Kasparov’s victory proved that humans still had the advantage over machines. In the same way, it is possible to find the data questioning the value of CDSSs oddly reassuring. But the irony of history reminds us not to get comfortable in our assertions; just 1 year later, after extensive enhancements, Deep Blue returned to defeat Kasparov in a devastating rematch. We suggest viewing this irony as instructive; if one accepts – as we do unequivocally – the value of evidence-based medicine, one must also accept that the right decision support delivered in a timely fashion will ultimately lead to better care and improved clinical outcomes.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.

Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."

It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?

While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.

This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.

Unsealing the Sacred Book

There are a number of issues raised anytime a practice or health system decides to install a patient portal.

First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.

It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.

We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.

Why More Is (Usually) Better

Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).

In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."

The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."

This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.

In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.

Managing Liabilities

As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.

 

As we noted above, when patients feel more ownership of their health care, they perceive they are being better cared for, and fewer important details get overlooked. Abnormal lab values that may slip by a physician in the deluge of the daily mail are easily caught by a patient who is anxiously anticipating them.

But what about patients who will trouble their doctor over less than concerning results? While the cost might be a panicked phone call from someone with a slightly elevated BUN or low MCH, the reward could be a providential request to reevaluate the results of a CT scan showing a mass the primary care physician somehow missed.

We are hopeful that in the end, EHR technology will fulfill its touted promises, and that the downpour of new challenges will actually make the landscape more fertile to the growth of better patient care.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.

Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."

It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?

While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.

This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.

Unsealing the Sacred Book

There are a number of issues raised anytime a practice or health system decides to install a patient portal.

First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.

It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.

We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.

Why More Is (Usually) Better

Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).

In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."

The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."

This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.

In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.

Managing Liabilities

As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.

 

As we noted above, when patients feel more ownership of their health care, they perceive they are being better cared for, and fewer important details get overlooked. Abnormal lab values that may slip by a physician in the deluge of the daily mail are easily caught by a patient who is anxiously anticipating them.

But what about patients who will trouble their doctor over less than concerning results? While the cost might be a panicked phone call from someone with a slightly elevated BUN or low MCH, the reward could be a providential request to reevaluate the results of a CT scan showing a mass the primary care physician somehow missed.

We are hopeful that in the end, EHR technology will fulfill its touted promises, and that the downpour of new challenges will actually make the landscape more fertile to the growth of better patient care.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.

Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."

It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?

While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.

This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.

Unsealing the Sacred Book

There are a number of issues raised anytime a practice or health system decides to install a patient portal.

First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.

It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.

We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.

Why More Is (Usually) Better

Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).

In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."

The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."

This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.

In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.

Managing Liabilities

As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.

 

As we noted above, when patients feel more ownership of their health care, they perceive they are being better cared for, and fewer important details get overlooked. Abnormal lab values that may slip by a physician in the deluge of the daily mail are easily caught by a patient who is anxiously anticipating them.

But what about patients who will trouble their doctor over less than concerning results? While the cost might be a panicked phone call from someone with a slightly elevated BUN or low MCH, the reward could be a providential request to reevaluate the results of a CT scan showing a mass the primary care physician somehow missed.

We are hopeful that in the end, EHR technology will fulfill its touted promises, and that the downpour of new challenges will actually make the landscape more fertile to the growth of better patient care.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

While we often mention the government incentives offered for meaningful use compliance, we frequently get questions about the specifics of each program, who is eligible for which incentives, and when the actual checks will arrive in the mail. Admittedly, it can be somewhat mystifying, so here we will help to lay out what to expect.

Let’s start with the basics:

– Which program do I qualify for?

By now, you likely know that the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Reinvestment and Recovery Act of 2009, promises financial incentives for hospitals and clinicians who meet the requirements for meaningful use. There are two separate programs under which institutions and "eligible providers" (EPs) can qualify for a payout: Medicare and Medicaid. We won’t cover the hospital programs here, but will focus just on the incentives for EPs.

First, under the Medicare Program, any doctor (which includes any MD or DO, dentist, podiatrist, optometrist, or chiropractor) who treats Medicare patients can qualify as an eligible provider. EPs who adopt a certified electronic health record and comply with an extensive set of rules defining how they use it will receive up to $44,000 in increased Medicare payments over a 5-year period.

Below, we will discuss in detail how the money is allocated, but it is worth noting here that EPs who do not charge a defined minimum annual dollar amount to Medicare will not receive the full incentive. Instead, they will receive a percentage of their total billing.

Also worth noting is the absence of care extenders such as nurse practitioners (NPs) and physician assistants (PAs) from the list of eligible providers under the Medicare program. The Medicaid program is quite different.

Fewer providers will qualify for the Medicaid incentive, but there is greater financial benefit and flexibility for those who do fall under this program. To be eligible, any physician (MD or DO), nurse practitioner, certified nurse-midwife, or dentist must have a minimum of 30% Medicaid patient volume (or 20% if the provider is a pediatrician). Physician assistants can also be eligible if he or she provides care in a federally qualified health center or rural health clinic that is led by a physician assistant.

The maximum financial incentive is raised to $63,750; but unfortunately, the Medicaid incentive program is not available in every state. Currently absent from the list of participating states are Hawaii, Minnesota, Nevada, New Hampshire, and Virginia. One additional note: A provider eligible under both Medicare and Medicaid will need to choose just one program in which to participate, but may switch once during the total duration of the incentive initiative.

– How does the money get paid out?

As mentioned above, the Medicare incentive program pays out a maximum of $44,000 over a 5-year period. It is not divided equally over each year, and several factors may affect the total amount.

First, only providers who adopt a certified EHR and begin attesting by the 2012 incentive year can receive the maximum benefit. To receive any benefit at all, an EP must begin attesting by 2014. To give a more tangible example, if one were to successfully attest starting in 2012 and continue to successfully attest every year, he or she would receive the following annual payments: $18,000 in 2012, $12,000 in 2013, $8,000 in 2014, $4,000 in 2015, and $2,000 in 2016, for a total of $44,000.

If he or she were to delay attesting by just 1 year, the maximal payout amount would decrease to $39,000, as the first payment drops to $15,000 and final year incentive is lost.

As mentioned earlier, any EP not meeting a minimum threshold in Medicare charges will not be eligible for the full incentive, but instead will receive a percentage of their billing. For example, in year 1, any EP not submitting at least $24,000 in Medicare charges will receive 75% of their billing as their incentive.

Thankfully, a provider need not wait to attest until that $24,000 is reached. Medicare will hold the payment until the threshold is met or until the end of the calendar year, whichever is first. At that point, an EP can expect to see the incentive check within 4-8 weeks, according to CMS statements.

The Medicaid program works a bit differently. First, the EP may receive an incentive payment in year 1 of the 6-year attestation period for simply adopting, implementing, or upgrading to a certified electronic health record. (Following the initial year, that provider will need to follow the same guidelines outlined under the Medicare program).

 

Second, delaying implementation does not limit the amount of incentive money available to the EP – so a provider who waits to begin the process in 2016 can receive the same $63,750 incentive as one who begins in 2012.

Finally, the CMS requires that states disburse the payments within 45 days of attestation, and there are no billing thresholds to meet.

– What about the penalties?

Providers who are eligible under the Medicare program will begin to see "payment adjustments" if they fail to comply with meaningful use by 2015. This amounts to a 1% penalty per year, and will max out at 5%. Under the Medicaid program, there is no penalty for not adopting an EHR.

Either way, the timeline should provide plenty of time for anyone who is serious about switching to electronic health records. Those who eschew technology and refuse to make the jump can decide on their own if the outlined penalties are a reasonable price to pay.

This column, EHR Report, appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

While we often mention the government incentives offered for meaningful use compliance, we frequently get questions about the specifics of each program, who is eligible for which incentives, and when the actual checks will arrive in the mail. Admittedly, it can be somewhat mystifying, so here we will help to lay out what to expect.

Let’s start with the basics:

– Which program do I qualify for?

By now, you likely know that the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Reinvestment and Recovery Act of 2009, promises financial incentives for hospitals and clinicians who meet the requirements for meaningful use. There are two separate programs under which institutions and "eligible providers" (EPs) can qualify for a payout: Medicare and Medicaid. We won’t cover the hospital programs here, but will focus just on the incentives for EPs.

First, under the Medicare Program, any doctor (which includes any MD or DO, dentist, podiatrist, optometrist, or chiropractor) who treats Medicare patients can qualify as an eligible provider. EPs who adopt a certified electronic health record and comply with an extensive set of rules defining how they use it will receive up to $44,000 in increased Medicare payments over a 5-year period.

Below, we will discuss in detail how the money is allocated, but it is worth noting here that EPs who do not charge a defined minimum annual dollar amount to Medicare will not receive the full incentive. Instead, they will receive a percentage of their total billing.

Also worth noting is the absence of care extenders such as nurse practitioners (NPs) and physician assistants (PAs) from the list of eligible providers under the Medicare program. The Medicaid program is quite different.

Fewer providers will qualify for the Medicaid incentive, but there is greater financial benefit and flexibility for those who do fall under this program. To be eligible, any physician (MD or DO), nurse practitioner, certified nurse-midwife, or dentist must have a minimum of 30% Medicaid patient volume (or 20% if the provider is a pediatrician). Physician assistants can also be eligible if he or she provides care in a federally qualified health center or rural health clinic that is led by a physician assistant.

The maximum financial incentive is raised to $63,750; but unfortunately, the Medicaid incentive program is not available in every state. Currently absent from the list of participating states are Hawaii, Minnesota, Nevada, New Hampshire, and Virginia. One additional note: A provider eligible under both Medicare and Medicaid will need to choose just one program in which to participate, but may switch once during the total duration of the incentive initiative.

– How does the money get paid out?

As mentioned above, the Medicare incentive program pays out a maximum of $44,000 over a 5-year period. It is not divided equally over each year, and several factors may affect the total amount.

First, only providers who adopt a certified EHR and begin attesting by the 2012 incentive year can receive the maximum benefit. To receive any benefit at all, an EP must begin attesting by 2014. To give a more tangible example, if one were to successfully attest starting in 2012 and continue to successfully attest every year, he or she would receive the following annual payments: $18,000 in 2012, $12,000 in 2013, $8,000 in 2014, $4,000 in 2015, and $2,000 in 2016, for a total of $44,000.

If he or she were to delay attesting by just 1 year, the maximal payout amount would decrease to $39,000, as the first payment drops to $15,000 and final year incentive is lost.

As mentioned earlier, any EP not meeting a minimum threshold in Medicare charges will not be eligible for the full incentive, but instead will receive a percentage of their billing. For example, in year 1, any EP not submitting at least $24,000 in Medicare charges will receive 75% of their billing as their incentive.

Thankfully, a provider need not wait to attest until that $24,000 is reached. Medicare will hold the payment until the threshold is met or until the end of the calendar year, whichever is first. At that point, an EP can expect to see the incentive check within 4-8 weeks, according to CMS statements.

The Medicaid program works a bit differently. First, the EP may receive an incentive payment in year 1 of the 6-year attestation period for simply adopting, implementing, or upgrading to a certified electronic health record. (Following the initial year, that provider will need to follow the same guidelines outlined under the Medicare program).

 

Second, delaying implementation does not limit the amount of incentive money available to the EP – so a provider who waits to begin the process in 2016 can receive the same $63,750 incentive as one who begins in 2012.

Finally, the CMS requires that states disburse the payments within 45 days of attestation, and there are no billing thresholds to meet.

– What about the penalties?

Providers who are eligible under the Medicare program will begin to see "payment adjustments" if they fail to comply with meaningful use by 2015. This amounts to a 1% penalty per year, and will max out at 5%. Under the Medicaid program, there is no penalty for not adopting an EHR.

Either way, the timeline should provide plenty of time for anyone who is serious about switching to electronic health records. Those who eschew technology and refuse to make the jump can decide on their own if the outlined penalties are a reasonable price to pay.

This column, EHR Report, appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

While we often mention the government incentives offered for meaningful use compliance, we frequently get questions about the specifics of each program, who is eligible for which incentives, and when the actual checks will arrive in the mail. Admittedly, it can be somewhat mystifying, so here we will help to lay out what to expect.

Let’s start with the basics:

– Which program do I qualify for?

By now, you likely know that the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Reinvestment and Recovery Act of 2009, promises financial incentives for hospitals and clinicians who meet the requirements for meaningful use. There are two separate programs under which institutions and "eligible providers" (EPs) can qualify for a payout: Medicare and Medicaid. We won’t cover the hospital programs here, but will focus just on the incentives for EPs.

First, under the Medicare Program, any doctor (which includes any MD or DO, dentist, podiatrist, optometrist, or chiropractor) who treats Medicare patients can qualify as an eligible provider. EPs who adopt a certified electronic health record and comply with an extensive set of rules defining how they use it will receive up to $44,000 in increased Medicare payments over a 5-year period.

Below, we will discuss in detail how the money is allocated, but it is worth noting here that EPs who do not charge a defined minimum annual dollar amount to Medicare will not receive the full incentive. Instead, they will receive a percentage of their total billing.

Also worth noting is the absence of care extenders such as nurse practitioners (NPs) and physician assistants (PAs) from the list of eligible providers under the Medicare program. The Medicaid program is quite different.

Fewer providers will qualify for the Medicaid incentive, but there is greater financial benefit and flexibility for those who do fall under this program. To be eligible, any physician (MD or DO), nurse practitioner, certified nurse-midwife, or dentist must have a minimum of 30% Medicaid patient volume (or 20% if the provider is a pediatrician). Physician assistants can also be eligible if he or she provides care in a federally qualified health center or rural health clinic that is led by a physician assistant.

The maximum financial incentive is raised to $63,750; but unfortunately, the Medicaid incentive program is not available in every state. Currently absent from the list of participating states are Hawaii, Minnesota, Nevada, New Hampshire, and Virginia. One additional note: A provider eligible under both Medicare and Medicaid will need to choose just one program in which to participate, but may switch once during the total duration of the incentive initiative.

– How does the money get paid out?

As mentioned above, the Medicare incentive program pays out a maximum of $44,000 over a 5-year period. It is not divided equally over each year, and several factors may affect the total amount.

First, only providers who adopt a certified EHR and begin attesting by the 2012 incentive year can receive the maximum benefit. To receive any benefit at all, an EP must begin attesting by 2014. To give a more tangible example, if one were to successfully attest starting in 2012 and continue to successfully attest every year, he or she would receive the following annual payments: $18,000 in 2012, $12,000 in 2013, $8,000 in 2014, $4,000 in 2015, and $2,000 in 2016, for a total of $44,000.

If he or she were to delay attesting by just 1 year, the maximal payout amount would decrease to $39,000, as the first payment drops to $15,000 and final year incentive is lost.

As mentioned earlier, any EP not meeting a minimum threshold in Medicare charges will not be eligible for the full incentive, but instead will receive a percentage of their billing. For example, in year 1, any EP not submitting at least $24,000 in Medicare charges will receive 75% of their billing as their incentive.

Thankfully, a provider need not wait to attest until that $24,000 is reached. Medicare will hold the payment until the threshold is met or until the end of the calendar year, whichever is first. At that point, an EP can expect to see the incentive check within 4-8 weeks, according to CMS statements.

The Medicaid program works a bit differently. First, the EP may receive an incentive payment in year 1 of the 6-year attestation period for simply adopting, implementing, or upgrading to a certified electronic health record. (Following the initial year, that provider will need to follow the same guidelines outlined under the Medicare program).

 

Second, delaying implementation does not limit the amount of incentive money available to the EP – so a provider who waits to begin the process in 2016 can receive the same $63,750 incentive as one who begins in 2012.

Finally, the CMS requires that states disburse the payments within 45 days of attestation, and there are no billing thresholds to meet.

– What about the penalties?

Providers who are eligible under the Medicare program will begin to see "payment adjustments" if they fail to comply with meaningful use by 2015. This amounts to a 1% penalty per year, and will max out at 5%. Under the Medicaid program, there is no penalty for not adopting an EHR.

Either way, the timeline should provide plenty of time for anyone who is serious about switching to electronic health records. Those who eschew technology and refuse to make the jump can decide on their own if the outlined penalties are a reasonable price to pay.

This column, EHR Report, appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

Okay, we admit it – even we are becoming a bit jaded with all of the attention being paid to meaningful use. So we thought we’d give ourselves and our readers a break this month and instead write about a topic that gets far too little attention: optimization.

This is the concept of using electronic health records in ways that actually fulfill their intended promises of increased efficiency and improved patient care.

Often, the mere mention of optimization is met with looks of speculation and incredulity. This is followed with a question like, "Have you ever actually tried to use this thing?" or a definitive statement such as, "Impossible!"

We would argue, however, that if a practice has done its homework and invested in a high-quality, well-regarded EHR, there is no reason to doubt that real advantages eventually can be realized. In fact, if priority is given to optimal use early on in the implementation of an electronic record, government incentive and quality initiatives (such as meaningful use, PQRS/PQRI, etc.), can be far less painful to manage.

Here we focus on a few simple tools providers can use to increase – or at least maintain – their productivity.

Start With the Right Information

The most valuable step in ensuring optimal use of an EHR is timely and relevant education. Unfortunately, this is where many vendors fall short, as most training is done by individuals who do not actually care for patients. As a result, a great deal of emphasis is placed on what each button or checkbox does instead of how to make it through the day as efficiently as possible.

Instead, we encourage all providers to view the use of an electronic record through the lens of a workflow process. From beginning to end, interacting with the EHR should follow a logical progression and make sense to the user. If there is functionality that is unnecessary and only slows the provider down, it should be avoided in favor of elements that streamline the documentation process.

To put it another way, when learning the software, we should always be looking to the goal of an efficiently completed visit.

Preplan Your Visits

A great advantage of an electronic health record can be the ability to look into the future and "preplan" visits. It may be a novel concept to most, but adjusting to this model can greatly increase efficiency in the long run.

As an example, providers might look ahead at which patients will be coming in for a visit and preorder lab tests, in-office diagnostic studies, or routine health maintenance items. This way, the staff can properly prepare in advance and increase the speed of patient flow through the office. This also will reduce the amount of "clicking" and documentation the provider will need to do while the patient is in the exam room.

Avoid Duplicate Work

Most electronic health records include the ability to create timesaving templates or macros that can dramatically increase documentation efficiency. Templates created for common encounters (such as sinusitis, headache, or hypertension follow-up) allow providers to call up a mostly completed note and simply fill in the blanks to make it accurate and specific to an individual patient.

Templates also can be created for unique patients. For example, if Mrs. Jones comes in regularly for a diabetic check but her care plan always remains the same, a template specific to her will greatly decrease the documentation burden each time she visits. Likewise, macros that contain commonly used language can be created.

To illustrate, instructions for a hypertensive patient to avoid salt intake and increase exercise are typically provided. This text can be saved as a macro, and then, with a few keystrokes, can be inserted whenever deemed appropriate.

These invaluable tools are always helpful and well received, though it’s surprising how few physicians actually take advantage of them.

Think Like a Coder

Before taking offense to this section’s heading, consider this: Most of us are paid based on our documentation and coding. While far from a perfect – or even fair – system, it is the current reality. As a result, the way we create our notes should be informed by this fact.

It is important, therefore, to include documentation to support the way you are billing, and an EHR makes this a much easier thing to do.

Once they’re comfortable with the workflow, it is common for physicians to develop a sort of muscle memory – a pattern of documenting that insures all of the required elements for better evaluation and management coding are being hit. It is essential, however, not to fall into the trap of overdocumentation – including history points or exam elements in a note out of habit when they were not actually obtained. This is fraudulent and becomes obvious through repeated abuse.

 

Bottom line: Be sure to get paid for the work you are already doing through robust, but honest and accurate, documentation.

Summing Up

Unfortunately, it often seems that the government’s EHR incentive program has completely backfired. Instead of making our use of health information technology more meaningful, it has instead only resulted in additional mouse clicks and less efficient workflow. It is possible, though, to optimize the way we use health information technology and increase our efficiency with it.

Who knows? This might even make using it more meaningful at the same time!

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

Okay, we admit it – even we are becoming a bit jaded with all of the attention being paid to meaningful use. So we thought we’d give ourselves and our readers a break this month and instead write about a topic that gets far too little attention: optimization.

This is the concept of using electronic health records in ways that actually fulfill their intended promises of increased efficiency and improved patient care.

Often, the mere mention of optimization is met with looks of speculation and incredulity. This is followed with a question like, "Have you ever actually tried to use this thing?" or a definitive statement such as, "Impossible!"

We would argue, however, that if a practice has done its homework and invested in a high-quality, well-regarded EHR, there is no reason to doubt that real advantages eventually can be realized. In fact, if priority is given to optimal use early on in the implementation of an electronic record, government incentive and quality initiatives (such as meaningful use, PQRS/PQRI, etc.), can be far less painful to manage.

Here we focus on a few simple tools providers can use to increase – or at least maintain – their productivity.

Start With the Right Information

The most valuable step in ensuring optimal use of an EHR is timely and relevant education. Unfortunately, this is where many vendors fall short, as most training is done by individuals who do not actually care for patients. As a result, a great deal of emphasis is placed on what each button or checkbox does instead of how to make it through the day as efficiently as possible.

Instead, we encourage all providers to view the use of an electronic record through the lens of a workflow process. From beginning to end, interacting with the EHR should follow a logical progression and make sense to the user. If there is functionality that is unnecessary and only slows the provider down, it should be avoided in favor of elements that streamline the documentation process.

To put it another way, when learning the software, we should always be looking to the goal of an efficiently completed visit.

Preplan Your Visits

A great advantage of an electronic health record can be the ability to look into the future and "preplan" visits. It may be a novel concept to most, but adjusting to this model can greatly increase efficiency in the long run.

As an example, providers might look ahead at which patients will be coming in for a visit and preorder lab tests, in-office diagnostic studies, or routine health maintenance items. This way, the staff can properly prepare in advance and increase the speed of patient flow through the office. This also will reduce the amount of "clicking" and documentation the provider will need to do while the patient is in the exam room.

Avoid Duplicate Work

Most electronic health records include the ability to create timesaving templates or macros that can dramatically increase documentation efficiency. Templates created for common encounters (such as sinusitis, headache, or hypertension follow-up) allow providers to call up a mostly completed note and simply fill in the blanks to make it accurate and specific to an individual patient.

Templates also can be created for unique patients. For example, if Mrs. Jones comes in regularly for a diabetic check but her care plan always remains the same, a template specific to her will greatly decrease the documentation burden each time she visits. Likewise, macros that contain commonly used language can be created.

To illustrate, instructions for a hypertensive patient to avoid salt intake and increase exercise are typically provided. This text can be saved as a macro, and then, with a few keystrokes, can be inserted whenever deemed appropriate.

These invaluable tools are always helpful and well received, though it’s surprising how few physicians actually take advantage of them.

Think Like a Coder

Before taking offense to this section’s heading, consider this: Most of us are paid based on our documentation and coding. While far from a perfect – or even fair – system, it is the current reality. As a result, the way we create our notes should be informed by this fact.

It is important, therefore, to include documentation to support the way you are billing, and an EHR makes this a much easier thing to do.

Once they’re comfortable with the workflow, it is common for physicians to develop a sort of muscle memory – a pattern of documenting that insures all of the required elements for better evaluation and management coding are being hit. It is essential, however, not to fall into the trap of overdocumentation – including history points or exam elements in a note out of habit when they were not actually obtained. This is fraudulent and becomes obvious through repeated abuse.

 

Bottom line: Be sure to get paid for the work you are already doing through robust, but honest and accurate, documentation.

Summing Up

Unfortunately, it often seems that the government’s EHR incentive program has completely backfired. Instead of making our use of health information technology more meaningful, it has instead only resulted in additional mouse clicks and less efficient workflow. It is possible, though, to optimize the way we use health information technology and increase our efficiency with it.

Who knows? This might even make using it more meaningful at the same time!

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

Okay, we admit it – even we are becoming a bit jaded with all of the attention being paid to meaningful use. So we thought we’d give ourselves and our readers a break this month and instead write about a topic that gets far too little attention: optimization.

This is the concept of using electronic health records in ways that actually fulfill their intended promises of increased efficiency and improved patient care.

Often, the mere mention of optimization is met with looks of speculation and incredulity. This is followed with a question like, "Have you ever actually tried to use this thing?" or a definitive statement such as, "Impossible!"

We would argue, however, that if a practice has done its homework and invested in a high-quality, well-regarded EHR, there is no reason to doubt that real advantages eventually can be realized. In fact, if priority is given to optimal use early on in the implementation of an electronic record, government incentive and quality initiatives (such as meaningful use, PQRS/PQRI, etc.), can be far less painful to manage.

Here we focus on a few simple tools providers can use to increase – or at least maintain – their productivity.

Start With the Right Information

The most valuable step in ensuring optimal use of an EHR is timely and relevant education. Unfortunately, this is where many vendors fall short, as most training is done by individuals who do not actually care for patients. As a result, a great deal of emphasis is placed on what each button or checkbox does instead of how to make it through the day as efficiently as possible.

Instead, we encourage all providers to view the use of an electronic record through the lens of a workflow process. From beginning to end, interacting with the EHR should follow a logical progression and make sense to the user. If there is functionality that is unnecessary and only slows the provider down, it should be avoided in favor of elements that streamline the documentation process.

To put it another way, when learning the software, we should always be looking to the goal of an efficiently completed visit.

Preplan Your Visits

A great advantage of an electronic health record can be the ability to look into the future and "preplan" visits. It may be a novel concept to most, but adjusting to this model can greatly increase efficiency in the long run.

As an example, providers might look ahead at which patients will be coming in for a visit and preorder lab tests, in-office diagnostic studies, or routine health maintenance items. This way, the staff can properly prepare in advance and increase the speed of patient flow through the office. This also will reduce the amount of "clicking" and documentation the provider will need to do while the patient is in the exam room.

Avoid Duplicate Work

Most electronic health records include the ability to create timesaving templates or macros that can dramatically increase documentation efficiency. Templates created for common encounters (such as sinusitis, headache, or hypertension follow-up) allow providers to call up a mostly completed note and simply fill in the blanks to make it accurate and specific to an individual patient.

Templates also can be created for unique patients. For example, if Mrs. Jones comes in regularly for a diabetic check but her care plan always remains the same, a template specific to her will greatly decrease the documentation burden each time she visits. Likewise, macros that contain commonly used language can be created.

To illustrate, instructions for a hypertensive patient to avoid salt intake and increase exercise are typically provided. This text can be saved as a macro, and then, with a few keystrokes, can be inserted whenever deemed appropriate.

These invaluable tools are always helpful and well received, though it’s surprising how few physicians actually take advantage of them.

Think Like a Coder

Before taking offense to this section’s heading, consider this: Most of us are paid based on our documentation and coding. While far from a perfect – or even fair – system, it is the current reality. As a result, the way we create our notes should be informed by this fact.

It is important, therefore, to include documentation to support the way you are billing, and an EHR makes this a much easier thing to do.

Once they’re comfortable with the workflow, it is common for physicians to develop a sort of muscle memory – a pattern of documenting that insures all of the required elements for better evaluation and management coding are being hit. It is essential, however, not to fall into the trap of overdocumentation – including history points or exam elements in a note out of habit when they were not actually obtained. This is fraudulent and becomes obvious through repeated abuse.

 

Bottom line: Be sure to get paid for the work you are already doing through robust, but honest and accurate, documentation.

Summing Up

Unfortunately, it often seems that the government’s EHR incentive program has completely backfired. Instead of making our use of health information technology more meaningful, it has instead only resulted in additional mouse clicks and less efficient workflow. It is possible, though, to optimize the way we use health information technology and increase our efficiency with it.

Who knows? This might even make using it more meaningful at the same time!

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.

Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.

So, What’s the Big Deal?

If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.

You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.

A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.

One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.

Communication Is Key

Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.

For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).

The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.

Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.

One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.

Quality Matters

Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.

Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.

It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.

 

Be Prepared

As stated previously, many of the rules proposed for stage 2 expand upon those already expected in stage 1. If providers choose to be proactive and exceed the stage 1 targets wherever possible in advance of 2014, they’ll likely find the transition a very reasonable undertaking. Those who have done the bare minimum to skate by in stage 1 will be far more challenged.

Either way, we encourage all physicians to continue to investigate the changes and engage their EHR vendor to see how the software may be updated to accommodate the new rules. As with most things, a better understanding of what’s to come will aid in framing the issues constructively and hopefully allay the concerns that many of us have any time the government gets more involved in health care.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.

Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.

So, What’s the Big Deal?

If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.

You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.

A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.

One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.

Communication Is Key

Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.

For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).

The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.

Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.

One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.

Quality Matters

Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.

Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.

It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.

 

Be Prepared

As stated previously, many of the rules proposed for stage 2 expand upon those already expected in stage 1. If providers choose to be proactive and exceed the stage 1 targets wherever possible in advance of 2014, they’ll likely find the transition a very reasonable undertaking. Those who have done the bare minimum to skate by in stage 1 will be far more challenged.

Either way, we encourage all physicians to continue to investigate the changes and engage their EHR vendor to see how the software may be updated to accommodate the new rules. As with most things, a better understanding of what’s to come will aid in framing the issues constructively and hopefully allay the concerns that many of us have any time the government gets more involved in health care.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.

Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.

So, What’s the Big Deal?

If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.

You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.

A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.

One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.

Communication Is Key

Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.

For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).

The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.

Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.

One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.

Quality Matters

Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.

Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.

It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.

 

Be Prepared

As stated previously, many of the rules proposed for stage 2 expand upon those already expected in stage 1. If providers choose to be proactive and exceed the stage 1 targets wherever possible in advance of 2014, they’ll likely find the transition a very reasonable undertaking. Those who have done the bare minimum to skate by in stage 1 will be far more challenged.

Either way, we encourage all physicians to continue to investigate the changes and engage their EHR vendor to see how the software may be updated to accommodate the new rules. As with most things, a better understanding of what’s to come will aid in framing the issues constructively and hopefully allay the concerns that many of us have any time the government gets more involved in health care.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

The highly anticipated time has finally arrived: On April 18, the Centers for Medicare and Medicaid Services launched the attestation program for reporting stage 1 milestones of "meaningful use."

Under the American Recovery and Reinvestment Act of 2009 (ARRA), this will allow providers who have implemented a certified electronic health record to cash in on the Medicare incentives promised for so long. Finally, that $44,000 seems within reach!

To claim the incentive dollars, practices should navigate to the CMS Web site and begin reporting. The site provides detailed instructions, tutorials, and step-by-step screenshots on what to expect throughout the process.

Providers are required to report on 15 core measures, 5 out of 10 additional measures from a menu of options, and 6 clinical quality measures. Each step differs in what information must be provided, and records need to be maintained in case of audit.

The ARRA incentive program is administered at the state level, and therefore the timeline for reimbursement varies based on practice location. Those skeptical about ever seeing the money should be reassured that many have already begun realizing the financial rewards of their EHR: The CMS reports it has already disbursed $65 million since the beginning of 2011 to providers in certain states.

If you find yourself fortunate enough to be among that group, consider yourself lucky. But before taking a much-needed rest on your proverbial laurels, remember what’s looming just around the corner: stage 2.

The wrangling already has begun over the stage 2 requirements. Not surprisingly, there are many who are concerned about the timing of implementation. They argue that it is unrealistic to expect physicians to begin thinking about stage 2 when many have not yet begun to use an EHR in a significant way. If the original timeline is maintained, physicians will need to collect stage 2 data in 2012 to receive bonuses in 2013. But many providers have stated that they will not be able to even consider stage 1 reporting until 2012 at the earliest.

As long as the process is started by next year, practices will still be able to maximize the incentives – but there is no question that the sooner an EHR is adopted, the better the chance of financial reward.

Conversion to electronic records does not occur overnight. It is time consuming to choose the right EHR, and once selected, the transition to actual "meaningful use" can take several months or more. In addition, even in the best of situations, unforeseen roadblocks can significantly slow down the process. Eventually, failure to meet meaningful use will result in reimbursement penalties, and the advent of stage 2 criteria is a reminder that the clock is ticking.

The content of the stage 2 criteria is another concern, with experts disagreeing on what should actually be included. To make things worse, other recent health initiatives have significantly complicated this process.

On March 31, the Department of Health and Human Services released the proposed rule for accountable care organizations (ACOs).

As described, an ACO will be a group of providers that assume responsibility for a defined population of Medicare patients, with the goal of increasing quality of care and decreasing delivery costs. If successful, the providers will share in the cost savings.

While ACOs sound like a good idea on the surface, they will come with a new and completely different set of reporting requirements. Certified EHRs that have been designed around "meaningful use" may not have the capabilities necessary for ACOs, especially when it comes to provider communications and transition of care. This may mean significant software revisions and system upgrades that are both time consuming and expensive.

Many are calling for an alignment of the stage 2 requirements with those of ACOs, as accountable care organizations represent a model that will endure long after "meaningful use" has come and gone. Dr. Farzad Mostashari, who just succeeded Dr. David Blumenthal as the National Coordinator for Health Information Technology, stated recently that he would like to see meaningful use as a "jump-start on what you’re going to need to do to be successful as an ACO." This is probably a best-case scenario for stage 2.

Over the next few months, there will be tremendous attention paid to how health care reform will shape the landscape of electronic health records. As care providers and EHR vendors lobby for delaying the implementation of stage 2, patients and consumer advocacy groups will continue to call for ever-advancing technology focused on better care at lower costs.

 

Regardless of the final guidelines, it is clear to see that information sharing and quality reporting will be essential components in care delivery as the march toward widespread implementation of electronic health records, encouraged by government financial incentives, moves ahead.

This column, "EHR Report," appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected]. Dr. Skolnik and Dr. Notte had no conflicts of interest to declare.

As medical practices grow, so does the number of charts occupying space on their shelves. Most physicians look forward to the day when they can dispense with paper charts completely and reclaim precious office space. Unfortunately, the goal of a paperless office is a very difficult one to achieve. It can take years to get there and, even with the best EHR software, the process of adding old data into the system can be arduous.

There are two basic methods to input old paper records. Historical information such as diagnoses, medication lists, and allergies can be manually entered by the physician or staff. More detailed information, such as reports of procedures or correspondence from other physicians, will need to be scanned into the record. Either way, it will take a significant amount of work to enter even a small number of charts. This can be both time consuming and costly. There are many pitfalls that may not be obvious initially, so it can be helpful to consider the following tips:

Begin by Looking Forward

Typically, it is most beneficial to work forward from the point of installation and insure that all new patient information is immediately entered into the EHR to avoid creating a paper chart entirely. One way to do this is to “scan forward” – that is, to scan documents received only after the EHR is in place. Such scanned documents can immediately be digitized and attached to the patient’s electronic chart. The original can then be shredded instead of adding it to the paper record. By doing so, there will be a single date marking the end of information available on paper. After that date, all staff members will know to look in the EHR to find the data they need.

Take it One Day at A Time

One way to feasibly address the problem of entering old information into the EHR is to do a limited but consistent amount every day. But where to start? Many practices select charts to scan by reviewing the following day’s patient schedule. By “preloading” charts, important data are available at the time of an appointment, and the charts of so-called “frequent flyer" patients are usually among the first to be entered. Once the chart has been inputted, it can be archived off-site or properly disposed of.

To Scan or Not to Scan

Commonly, patient charts are filled with a tremendous amount of irrelevant information. Amidst the reports, notes, and letters are likely dozens of sticky notes, blank pages, fax cover sheets, and antiquated data. For a couple of reasons, it behooves a practice to spend time prepping charts before scanning them.

First, every page that is scanned will need to be indexed for the EHR to properly file it. It would be extremely cumbersome, when searching for an old lab result, to have to wade through dozens of papers at random. Indexing allows all documents to be sorted by type and date, but this process is extremely time-consuming. Each page scanned needs to be individually addressed. To minimize the amount of indexing, a practice may decide to only sort information of a certain age or type. Everything else can be then placed into a general, unsorted electronic file. In this way, the most important data are easy to find, yet even less valuable documents can be located with a bit of effort if necessary.

The second compelling reason is cost, both in staff hours and in storage. Many offices choose EHR solutions that are hosted off site. All data exist on an external server and, depending on the nature of the storage agreement, every page scanned into the system may incur an additional charge. In most cases the rate is about a penny a page. One need not take a very long look at the chart rack to realize how quickly the price will add up. Choosing to electronically archive only the most important items can help minimize the economic impact and make the overall process much more efficient.

When to Say Goodbye to Paper

There are a few commonly cited reasons why practices hesitate to finally eliminate paper charts. First is the fear of unintentionally losing critical patient data. This is reasonable, and data security should be a primary consideration when designing an electronic storage solution. All EHR vendors have set specifications for storage focused on security and reliability. If the data are to be maintained on site, one way to insure safety is through continuous backup. Higher standards are typically maintained at off-site storage facilities with multiple levels of redundancy. A well-chosen storage method should alleviate any fears of data loss.

 

The second reason practices hold onto paper records is concern about the need to produce the chart for possible malpractice proceedings. This represents a misunderstanding about the legality of electronic media. Regardless of where the chart is stored – on paper or in cyberspace – it is acceptable in a court of law.

The length of time the data must be maintained varies from state to state, but is typically about 7 years for adults or 7 years after turning age 18 for minors. Fortunately, once all the charts are archived, they can be safely and securely maintained indefinitely without the ever-growing need for a bigger office to store them.

Dr. Skolnik and Dr. Notte write the column, “EHR Report,” which regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants (www.ehrpc.com), helping practices move to EHR systems. Contact them at [email protected].

As medical practices grow, so does the number of charts occupying space on their shelves. Most physicians look forward to the day when they can dispense with paper charts completely and reclaim precious office space. Unfortunately, the goal of a paperless office is a very difficult one to achieve. It can take years to get there and, even with the best EHR software, the process of adding old data into the system can be arduous.

There are two basic methods to input old paper records. Historical information such as diagnoses, medication lists, and allergies can be manually entered by the physician or staff. More detailed information, such as reports of procedures or correspondence from other physicians, will need to be scanned into the record. Either way, it will take a significant amount of work to enter even a small number of charts. This can be both time consuming and costly. There are many pitfalls that may not be obvious initially, so it can be helpful to consider the following tips:

Begin by Looking Forward

Typically, it is most beneficial to work forward from the point of installation and insure that all new patient information is immediately entered into the EHR to avoid creating a paper chart entirely. One way to do this is to “scan forward” – that is, to scan documents received only after the EHR is in place. Such scanned documents can immediately be digitized and attached to the patient’s electronic chart. The original can then be shredded instead of adding it to the paper record. By doing so, there will be a single date marking the end of information available on paper. After that date, all staff members will know to look in the EHR to find the data they need.

Take it One Day at A Time

One way to feasibly address the problem of entering old information into the EHR is to do a limited but consistent amount every day. But where to start? Many practices select charts to scan by reviewing the following day’s patient schedule. By “preloading” charts, important data are available at the time of an appointment, and the charts of so-called “frequent flyer" patients are usually among the first to be entered. Once the chart has been inputted, it can be archived off-site or properly disposed of.

To Scan or Not to Scan

Commonly, patient charts are filled with a tremendous amount of irrelevant information. Amidst the reports, notes, and letters are likely dozens of sticky notes, blank pages, fax cover sheets, and antiquated data. For a couple of reasons, it behooves a practice to spend time prepping charts before scanning them.

First, every page that is scanned will need to be indexed for the EHR to properly file it. It would be extremely cumbersome, when searching for an old lab result, to have to wade through dozens of papers at random. Indexing allows all documents to be sorted by type and date, but this process is extremely time-consuming. Each page scanned needs to be individually addressed. To minimize the amount of indexing, a practice may decide to only sort information of a certain age or type. Everything else can be then placed into a general, unsorted electronic file. In this way, the most important data are easy to find, yet even less valuable documents can be located with a bit of effort if necessary.

The second compelling reason is cost, both in staff hours and in storage. Many offices choose EHR solutions that are hosted off site. All data exist on an external server and, depending on the nature of the storage agreement, every page scanned into the system may incur an additional charge. In most cases the rate is about a penny a page. One need not take a very long look at the chart rack to realize how quickly the price will add up. Choosing to electronically archive only the most important items can help minimize the economic impact and make the overall process much more efficient.

When to Say Goodbye to Paper

There are a few commonly cited reasons why practices hesitate to finally eliminate paper charts. First is the fear of unintentionally losing critical patient data. This is reasonable, and data security should be a primary consideration when designing an electronic storage solution. All EHR vendors have set specifications for storage focused on security and reliability. If the data are to be maintained on site, one way to insure safety is through continuous backup. Higher standards are typically maintained at off-site storage facilities with multiple levels of redundancy. A well-chosen storage method should alleviate any fears of data loss.

 

The second reason practices hold onto paper records is concern about the need to produce the chart for possible malpractice proceedings. This represents a misunderstanding about the legality of electronic media. Regardless of where the chart is stored – on paper or in cyberspace – it is acceptable in a court of law.

The length of time the data must be maintained varies from state to state, but is typically about 7 years for adults or 7 years after turning age 18 for minors. Fortunately, once all the charts are archived, they can be safely and securely maintained indefinitely without the ever-growing need for a bigger office to store them.

Dr. Skolnik and Dr. Notte write the column, “EHR Report,” which regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants (www.ehrpc.com), helping practices move to EHR systems. Contact them at [email protected].

As medical practices grow, so does the number of charts occupying space on their shelves. Most physicians look forward to the day when they can dispense with paper charts completely and reclaim precious office space. Unfortunately, the goal of a paperless office is a very difficult one to achieve. It can take years to get there and, even with the best EHR software, the process of adding old data into the system can be arduous.

There are two basic methods to input old paper records. Historical information such as diagnoses, medication lists, and allergies can be manually entered by the physician or staff. More detailed information, such as reports of procedures or correspondence from other physicians, will need to be scanned into the record. Either way, it will take a significant amount of work to enter even a small number of charts. This can be both time consuming and costly. There are many pitfalls that may not be obvious initially, so it can be helpful to consider the following tips:

Begin by Looking Forward

Typically, it is most beneficial to work forward from the point of installation and insure that all new patient information is immediately entered into the EHR to avoid creating a paper chart entirely. One way to do this is to “scan forward” – that is, to scan documents received only after the EHR is in place. Such scanned documents can immediately be digitized and attached to the patient’s electronic chart. The original can then be shredded instead of adding it to the paper record. By doing so, there will be a single date marking the end of information available on paper. After that date, all staff members will know to look in the EHR to find the data they need.

Take it One Day at A Time

One way to feasibly address the problem of entering old information into the EHR is to do a limited but consistent amount every day. But where to start? Many practices select charts to scan by reviewing the following day’s patient schedule. By “preloading” charts, important data are available at the time of an appointment, and the charts of so-called “frequent flyer" patients are usually among the first to be entered. Once the chart has been inputted, it can be archived off-site or properly disposed of.

To Scan or Not to Scan

Commonly, patient charts are filled with a tremendous amount of irrelevant information. Amidst the reports, notes, and letters are likely dozens of sticky notes, blank pages, fax cover sheets, and antiquated data. For a couple of reasons, it behooves a practice to spend time prepping charts before scanning them.

First, every page that is scanned will need to be indexed for the EHR to properly file it. It would be extremely cumbersome, when searching for an old lab result, to have to wade through dozens of papers at random. Indexing allows all documents to be sorted by type and date, but this process is extremely time-consuming. Each page scanned needs to be individually addressed. To minimize the amount of indexing, a practice may decide to only sort information of a certain age or type. Everything else can be then placed into a general, unsorted electronic file. In this way, the most important data are easy to find, yet even less valuable documents can be located with a bit of effort if necessary.

The second compelling reason is cost, both in staff hours and in storage. Many offices choose EHR solutions that are hosted off site. All data exist on an external server and, depending on the nature of the storage agreement, every page scanned into the system may incur an additional charge. In most cases the rate is about a penny a page. One need not take a very long look at the chart rack to realize how quickly the price will add up. Choosing to electronically archive only the most important items can help minimize the economic impact and make the overall process much more efficient.

When to Say Goodbye to Paper

There are a few commonly cited reasons why practices hesitate to finally eliminate paper charts. First is the fear of unintentionally losing critical patient data. This is reasonable, and data security should be a primary consideration when designing an electronic storage solution. All EHR vendors have set specifications for storage focused on security and reliability. If the data are to be maintained on site, one way to insure safety is through continuous backup. Higher standards are typically maintained at off-site storage facilities with multiple levels of redundancy. A well-chosen storage method should alleviate any fears of data loss.

 

The second reason practices hold onto paper records is concern about the need to produce the chart for possible malpractice proceedings. This represents a misunderstanding about the legality of electronic media. Regardless of where the chart is stored – on paper or in cyberspace – it is acceptable in a court of law.

The length of time the data must be maintained varies from state to state, but is typically about 7 years for adults or 7 years after turning age 18 for minors. Fortunately, once all the charts are archived, they can be safely and securely maintained indefinitely without the ever-growing need for a bigger office to store them.

Dr. Skolnik and Dr. Notte write the column, “EHR Report,” which regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is in private practice in Chalfont, Pa. They are partners in EHR Practice Consultants (www.ehrpc.com), helping practices move to EHR systems. Contact them at [email protected].