The following case study looks at the major elements that should be considered to propose a primary ambulatory care EHR system and become a meaningful user.
It is a multi-physician owned primary ambulatory care practice with 4 offices and 16 primary care physicians. The requirements from the board of directors are that the system must meet the meaningful use requirements of the HITECH/ARRA incentive programs and streamline registration, billing, and patient record documentation processes (Schnering).
As with all government programs, rules, and regulations the HITECH/ARRA incentive programs have had many changes over time and have many time related deadlines. This study uses a board of directors’ go-ahead date of October 26, 2015.
One of the first things that I would do is get local assistance through a Regional Extension Center (REC). The Office of the National Coordinator for Health Information Technology (ONC) has RECs located in every region of the country to assist providers with EHR implementation. They help with the EHR adoption process from vendor selection and workflow analysis to implementation and meaningful use. I would engage with a REC because as of 8/7/2015 157,000 providers are enrolled with a REC and more than 146,000 are live on an EHR with more than 116,000 of them having demonstrated meaningful use. These results are better than for those who tried to do it without any assistance (RECs at a Glance)
According to HealthIT.gov there is a six step process to implement an EHR and achieve meaningful use. They are 1) assess your practice readiness, 2) plan your approach, 3) select or upgrade to a certified EHR, 4) conduct training & implement an EHR system, 5) achieve meaningful use, and 6) continue quality improvement (How to Implement EHRs).
According to CMS.gov there is an eight step process to participate in the EHR Incentive Programs. They are 1) determine eligibility to participate, 2) prepare for registration, 3) register to participate, 4) determine certification of EHR system, 5) meet meaningful use requirements and prepare for attestation, 6) attest that you have met the thresholds and all of the requirements, 7) retain documentation in case of an audit, and 8) continue reporting meaningful use every year (Participating in EHR?).
This results in the three top most elements being the selection and implementation of a certified EHR that meets all of the practice’s requirements, the selection, registration, and attestation of each primary care physician with an EHR incentive program, and meeting the objectives and measures specified by the meaningful use guidelines.
These three elements are interconnected and are not necessarily sequential in nature. For example, even though I listed it second, one of the major requirements by the board of directors is participation in a HITECH/ARRA incentive program. Participation and reporting timelines associated with the incentive program will impact both the project timeline and the practice/project financials so it is important to have a good understanding of these programs early in the process.
Lessons from EHR implementation and meaningful use case studies reveals that the top issues are leadership issues, workflow issues, provider issues, training issues, data interface issues, and user interface issues (Hummel).
HealthIT.gov identified “Five Lessons from the Field” that also align with those case studies. They include coordinating with the local health information exchange (HIE) in your area, moving off paper as quickly as possible, ensuring that the paper charts can be abstracted before go-live, making training a priority, and cutting back on patient load during the go-live period (EHR Implementation Lessons).
The major elements involved with the selection and implementation of a certified EHR that meets all of the practice’s requirements are to assess the practice’s readiness, create a plan, select a certified EHR, conduct training, and implement the EHR.
As I already mentioned two of the top EHR implementation issues are leadership and provider issues. The purpose of the practice assessment is to address these issues with the key deliverables including the designated leadership team for the EHR implementation process, a unified vision, and measurable, quantifiable, and realistic goals.
Some of the specific tasks include assessing administrative processes, clinical workflows, and data collection and reporting processes. Clinical priorities and specialty specific requirements also need to be identified. Current technology capabilities such as staff computer literacy and high speed internet connectivity need to be assessed.
The entire staff needs to envision what the future will look like after an EHR has been implemented. This vision will then be used to specify measurable, quantifiable, and realistic goals.
At this point it is critical to gain unconditional leadership support, identify a strong clinical champion, have full provider support, and provider understanding and commitment to their role during the process. Formal project management processes should be initiated at this time. Team structure, stakeholder engagement plans, communication plans, and change management plans are commonly overlooked items.
In addition to leadership and provider issues another top issue is related to workflows. The planning stage will continue to engage leadership and provider stakeholders as the requirements and project plan are identified and developed. A project charter and scope statement will clarify and prioritize important tasks and processes.
The practice’s current workflow and processes will be analyzed, mapped, and documented. Streamlined patient registration, billing, and patient record documentation workflows and processes must be analyzed, mapped, and documented. New workflows and processes resulting from the meaningful use objectives and measures, described in a section below, must also be analyzed, mapped, and documented. The workflow and process analysis and mapping may be complicated by variances between the four offices.
Many workflow issues come from having dual paper and EHR processes so the quicker that the paper processes can be retired the better. The project plan needs to include the transition plan from paper to the EHR. A chart abstraction plan must also be developed to determine what and how data will be transformed from the paper to the electronic charts. A data migration plan to determine what and how existing electronic data will be migrated into the new system will also be required.
Since privacy and security concerns are a core part of meaningful use and many state and federal regulations the plan must address them early and comprehensively.
Selecting a certified EHR is comprised of three major elements. The first is whether it is certified. The Certified Health IT Product List (CHPL) identifies EHR technologies that have been tested and certified by an ONC-Authorized Testing and Certification Body (Comprehensive List of Certified Health Information Technology). To participate in an EHR Incentive Program the EHR must be certified.
The second is whether the EHR will accomplish the key goals of the practice. This is determined by matching the capabilities of the EHRs being evaluated against the workflows and processes that were mapped out. Since user interface issues is also a top EHR implementation issue the manner in which the workflow functionality has been implemented is very important and needs to be evaluated.
Data sharing is a core goal of meaningful use and data interface issues is one of the top EHR implementation issues. This makes it critical to have identified all legacy system, HIE, pharmacy, lab, and imaging interfaces that are required. The capability, schedule, and cost of these interfaces must be part of the EHR evaluation criteria.
Deployment options, data and chart migration options, and privacy and security capabilities also need to be considered. These are especially important considering that the practice has multiple offices.
The third is whether the vendor is a good match for the practice. This includes determining vendor stability and market presence, the full start-up price for the EHR system including integration costs, defining payment options and schedules, and defining implementation support.
These three elements are all covered by a process that includes site visits, developing and distributing a request for proposals, reviewing the proposals, conducting vendor demonstrations, reviewing specialty specific functionality and general usability, identifying hardware and IT support requirements, ranking and comparing the EHRs, negotiating contract and licensing agreements, and purchasing the EHR. (How to Implement EHRs)
Once an EHR has been selected the implementation plan, schedule, chart abstraction plan, data migration plan, and privacy and security risk management mitigation plan need to be updated and finalized. A possible phased approach that converts the offices one at a time should be considered.
Another top issue that was identified is training. Studies have shown that training is critical to the success of the EHR implementation. Training isn’t a one-time task on the project plan. The implementation plan must account for support and lower productivity during go-live as the staff continues to learn the system as they use it. Support can include vendor support and/or hiring experienced staff for in-house support.
During the EHR implementation and deployment phases, project management execution and monitoring activities such as schedule and budget tracking, risk management, and change control need to be performed.
The major elements involved with the selection, registration, and attestation of each primary care physician with an EHR incentive program are eligibility, registration, and attestation.
The Centers for Medicare & Medicaid Services website describes the two different EHR Incentive Programs. They are the Medicare EHR Incentive Program and the Medicaid EHR Incentive Program. They both provide incentive payments for certain healthcare providers to use EHR technology in a meaningful way. There are also Medicare payment adjustments starting in 2015 for eligible professionals who do not meet the meaningful use guidelines (2015 Program Requirements).
The Medicare EHR Incentive Program is run by CMS and the Medicaid EHR Incentive Programs are run by the individual states. Each state offers the Medicaid EHR Incentive Program voluntarily to their Medicaid eligible professionals and hospitals.
It is important to know that practices cannot participate in the Medicare or Medicaid EHR Incentive Programs (An Introduction to the Medicare EHR Incentive Program for Eligible Professionals). Each of the 16 primary care physicians will be eligible professional (EP) participants. Incentive payments and/or Medicare payment adjustments will be borne by each of the 16 primary care physicians.
The EHR Incentive Program originally consisted of three stages. Stage 1 required data capture and sharing with the patient or other healthcare professionals. Stage 2 required advanced clinical processes. Stage 3 required improved outcomes.
On October 16, 2015 the Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS), published “Medicare and Medicaid Programs; Electronic Health Record Incentive Program – Stage 3 and Modifications to Meaningful Use in 2015 through 2017.” It combined Stage 1 and Stage 2 into a Modified Stage 2.
The rule reconciles measures to align 2015 – 2017 (Modified Stage 2) with Stage 3 to:
- Prepare providers to report Stage 3 criteria in 2018
- Reduce provider burden and create a single set of sustainable objectives that promote best practices for patients
- Enable providers to focus on objectives, which support advanced use of health IT, such as:
- Health information exchange
- Consumer engagement
- Public health reporting
The Medicare EHR Incentive program started in 2011 and payments will continue through 2016. Eligible professionals can participate for up to 5 continuous years throughout the duration of the program. Even though our primary care physicians were eligible to participate as eligible professionals the last year to begin participation and receive an incentive payment was 2014 (An Introduction to the Medicare EHR Incentive Program for Eligible Professionals). This means that none of our physicians are able to receive incentive payments under this program.
However, beginning in 2015, eligible professionals who do not successfully demonstrate meaningful use will be subject to a payment adjustment. If a provider is eligible to participate in the Medicare EHR Incentive Program, they must demonstrate meaningful use in either the Medicare EHR Incentive Program or in the Medicaid EHR Incentive Program. The payment reduction starts at 1% and increases each year that an eligible professional does not demonstrate meaningful use, to a maximum of 5% (An Introduction to the Medicare EHR Incentive Program for Eligible Professionals).
The Medicaid EHR Incentive program started in 2011 and payments will continue through 2021. Eligible professionals can participate for up to 6 years throughout the duration of the program. To qualify the eligible professional must have a minimum 30% Medicaid patient volume or be a pediatrician and have a minimum 20% patient volume. Participation doesn’t have to take place across consecutive years. To receive the maximum incentive payment, eligible professionals must have started participation by 2016. Eligible professionals who demonstrate meaningful use of certified EHR technology for each year of participation in the program can receive up to $63,750 over 6 years. The payment is a fixed amount each year. The first year, providers can receive an incentive payment for adopting, implementing, or upgrading a certified EHR. Also, for the first year they participate, eligible professionals have the option of adopting, implementing, or upgrading to a certified EHR system instead of meeting the meaningful use objectives and measures. In the remaining 5 years they must meet the meaningful use guidelines like the Medicare EHR Incentive Program. There are no Medicaid payment reductions if a physician chooses not to participate (An Introduction to the Medicaid EHR Incentive Program for Eligible Professionals).
Based on this information and the use of tools available from CMS each primary care physician needs to determine their eligibility to participate in one of the EHR Incentive Programs and then register to participate.
During the EHR implementation they should prepare for attestation that they have met all of the meaningful use objectives and measures. This includes determining their reporting period and how to report on their individual metrics for each of the measures.
At the proper time each physician will need to attest that they met the thresholds and all of the requirements. It is important that each physician continue to reporting every year to avoid any future payment adjustments.
A process to retain the measure metrics for each physician needs to be created to support any possible audits.
The major elements involved with meeting the objectives and measures specified by the meaningful use guidelines are to achieve meaningful use and continue quality improvement.
As previously mentioned, current modified stage 2 objectives are meant to focus providers on the advanced use of health IT for functionality such as health information exchange, consumer engagement, and public health reporting.
Modified stage 2 objectives and measures that need to be met in 2015 through 2017 include protect patient health information, clinical decision support (CDS), computerized provider order entry (CPOE), electronic prescribing, health information exchange, patient specific education, medication reconciliation, patient electronic access, secure electronic messaging, and public health reporting. Specified Clinical Quality Measures must also be reported (EHR Incentive Programs: 2015 through 2017).
These processes and workflows must have been included in the requirements and mappings for the EHR selection and implementation process.
It is important to realize that meeting the goals and needs of the practice and the objectives and measures of meaningful use is an ongoing effort that never stops. This is a major element that the board of directors, physicians, and staff needs to realize and understand. Even post implementation workflows and processes need to be continually improved and optimized to achieve the practice’s goals while leveraging the functionality of and meaningfully using the EHR.
"2015 Program Requirements." CMS.gov. Centers for Medicare & Medicaid Services, 20 Oct. 2015. Web. 27 Oct. 2015.
“Comprehensive List of Certified Health Information Technology.” Certified Health IT Product List. n.d. The Office of the National Coordinator for Health Information Technology. Web. 28 Oct. 2015.
Holland, Elizabeth S. "CMS Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs Final Rule Overview." EHR Incentive Program. 8 Oct. 2015. CMS.gov. Web. 27 Oct. 2015.
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Schnering, Patricia; Sayles, Nanette B.; McCuen, Charlotte (2013-06-11). Case Studies for Health Information Management (Page 37). Cengage Textbook. Kindle Edition.
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United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services. An Introduction to the Medicare EHR Incentive Program for Eligible Professionals. CMS.gov, n.d. Web. 28 Oct. 2015.
United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services. EHR Incentive Programs: 2015 through 2017 (Modified Stage 2) Overview. CMS.gov, n.d. Web. 28 Oct. 2015.
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United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services. “Medicare and Medicaid Programs; Electronic Health Record Incentive Program – State 3 and Modifications to Meaningful Use in 2015 Through 2017.” Federal Register. The Daily Journal of the United States Government, 16 Oct. 2015. Web. 27 Oct. 2015.
United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicaid Electronic Health Record Incentive Payments for Eligible Professionals. CMS.gov, May 2013. Web. 28 Oct. 2015.
United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Electronic Health Record Incentive Payments for Eligible Professionals. CMS.gov, May 2013. Web. 28 Oct. 2015.