Ophthalmologists strive to align EHR meaningful use criteria with their needs

As deadlines for reporting meaningful use of electronic health records approach, medical practices are working hard to fulfill reporting requirements and qualify for Medicare incentive payments.

Adopters have until 2014 to meet stage 2 meaningful use requirements.

EHRs are designed to partially or completely replace traditional paper files. Advocates of the technology hope it improves health care efficiency, safety and patient care.

Federal government certification of EHR systems centers on functionality, security and interoperability, or the ability of systems to communicate with one another and interface with clinical imaging devices.

According to a data brief issued by the National Center for Health Statistics, 72% of office-based physicians had implemented EHRs by 2012, up from 48% in 2009. In 2012, 66% of physicians planned to participate in meaningful use programs, the brief said.

An increasing number of ophthalmologists will likely adopt EHRs when they are able to focus on practical benefits, without the pressure of meaningful use reporting requirements, according to John B. Pinto, OSN Practice Management Section Editor.

“I suspect the pace of adoption will accelerate from here once the meaningful use payments wind down and practices start making decisions based on functionality and value,” Pinto said.

At Wills Eye Institute in Philadelphia, EHR use is in full swing and expanding. However, full implementation was neither fast nor easy, according to Sara Rapuano, manager of the Cornea Service of Wills Eye Institute and a member of the Wills Eye EHR Implementation team for the past 2 years.

“I think every doctor you talk to around the country will tell you that implementation is the most painful part of the whole process,” she said.

To alleviate the “data entry mess,” Rapuano’s group abstracted patients’ histories from charts ahead of time.

“The first time the doctors use the record, they have much of the old history in the new system, and they can go forward as if they’ve always been on the computers,” she said.

Concerns about meaningful use

The earliest EHR adopters qualified for incentive payments of up to $44,000. Payments are reduced for providers who adopt EHRs after 2014; late adopters face a penalty.

The Centers for Medicare and Medicaid Services issued basic meaningful use criteria in 2010. The criteria comprise three main components: use of EHRs in a meaningful way, such as electronic prescribing; use of EHRs for the exchange of health information and to improve quality of care; and use of EHRs to submit clinical quality and other measures, according to a CMS news release.

In September 2012, CMS issued a final rule that specified stage 2 meaningful use criteria and extended the deadline for meeting stage 2 criteria for 1 year. Physicians and hospitals who adopted EHRs in 2011 or 2012 are not required to meet stage 2 criteria until 2014.

According to a data brief issued by the Office of the National Coordinator for Health Information Technology, physician adoption of EHR technology to meet five core objectives of meaningful use increased by more than 66% between 2009 and 2012.

Between 2011 and 2012, physician adoption of EHRs to meet nine meaningful use core objectives increased by at least 21%, the brief said.

The number of physicians with electronic prescribing increased 119% in the same period, the brief said. In addition, physicians’ ability to meet four other meaningful use objectives related to improving health care quality, safety and efficiency increased by 66%.

Meaningful use criteria focus on public health and primary care, to the exclusion of ophthalmology and other specialties, according to William L. Rich III, MD, American Academy of Ophthalmology medical director of health policy. Leaders in organized ophthalmology are striving to align meaningful use criteria with the needs of their specialty, he said.

“[Public health and primary care] are very important areas for society to emphasize, but the reality is that none of these things are really meaningful to ophthalmology. So, one of the things that we’ve been stressing on the regulatory side is to try to make the entire meaningful use criteria meaningful for ophthalmologists and our patients,” Rich said.

Stage 2 meaningful use criteria present various burdens, particularly on specialties. For example, the criteria require practices to provide portals that enable patients to gain access to their records.

“We ask each patient if they would like a copy of their interaction with the doctor today, and maybe 2% to 3% say yes,” Rich said. “Ophthalmology patients tend to be elderly, and some have multiple comorbidities. We are now asking that these patients log into not only their ophthalmologist’s patient portal but also their primary care physician’s portal, their cardiologist’s portal, etc. According to CMS, only about 40% of physicians participating in meaningful use are currently offering these portals to their patients.”

Initially, physicians also were required to collect data on vital signs, Rich said.

“There are some specific things in stage 2 of meaningful use that are going to be hard to achieve. But that’s not our goal. The goal of the Academy is to get rid of meaningful use requirements that are not actionable or meaningful to our specialty. We don’t need to do blood pressure and [body mass index] and vital signs,” he said.

Rich also said there is concern about the need for all physicians, whether they are in stage 1 or stage 2 in 2014, to upgrade their systems to the 2014 version before attesting to meaningful use next year.

“Physicians are going to have to work quickly to learn a new version of the software and adjust to the new metrics,” Rich said. “It also puts tremendous pressure on the vendors in terms of customer support. We are already hearing that vendors are struggling to meet the demand for customer support and technical assistance with meaningful use.”

Ophthalmic clinical registry

EHRs would be more useful for participating in an ophthalmic clinical registry that the AAO is launching, Rich said. Enrollment in the registry is scheduled to start in the fall; the AAO hopes to enroll 2,200 sites by 2015.

“One of the things that we’ve been trying to emphasize with [CMS] is that it’s not the electronic health record that improves quality of care,” he said. “It’s taking those data and putting them into a professional registry where physicians can actually measure their own performance and improve their outcomes.”

Federal legislation that forestalled the “fiscal cliff” called for CMS to request comments on what defines a clinically useful registry, Rich said. In a recent letter to CMS, the AAO asked the agency to count improved outcomes from participation in a registry toward meaningful use. Also, the AAO asked CMS to omit other criteria, such as reporting to an immunization registry, he said.

“Our message to CMS is, ‘Get rid of all this other stuff.’ If you take the time to improve your outcomes with the use of a clinical registry, you’ve met meaningful use, period,” Rich said. “Quality data registries define measures that are most important for a particular base … and therefore have the potential to achieve quality improvement and population health goals in a way that is more relevant and acceptable for specialists.”

Practices stand to benefit across the board from participating in clinical registries, Rich said.

“Basically, the value to a physician is that it improves their quality, it improves their outcomes and it helps you financially to meet all of these regulatory burdens,” he said. “Every single study that has been done shows that if you do use a registry, your outcomes do improve. It’s as simple as that. So, besides professional improvement, there are regulatory advantages and there are specific financial advances, too.”

Interoperability standards

Work groups sponsored by the AAO have collaborated closely with manufacturers to improve the interoperability of EHRs, according to Flora Lum, MD, the AAO policy director of quality of care and knowledge base development and executive director of the Hoskins Center for Quality Eye Care.

“It’s been slow but steady,” Lum said. “It has been an education on both sides, educating our membership and educating the vendors. But we’re getting to the point where meaningful use and EHRs will make interoperability more of an imperative than an optional feature.”

The AAO has sponsored three working groups. One group is in charge of Digital Imaging and Communications in Medicine (DICOM) standards for eye care. The second group is working on Integrating the Healthcare Enterprise (IHE) standards, which allow different devices to exchange information. A third group has completed Systematized Nomenclature of Medicine (SNOMED) terms for eye care. SNOMED standards are included in stage 1 meaningful use criteria.

The DICOM work group completed standards for fundus photography, ophthalmic tomography, refractive instruments and biometry, and produced the DICOM standard for visual field reports for static perimetry. These standards promote the interoperability of imaging devices and EHRs.

The DICOM group is currently starting a general review of standards for corneal topography.

“We have a draft standard in place, and we have to go through the DICOM committee to review that,” Lum said. “That should probably take a year or a little more than a year to complete, and then we’ll have a finalized standard for corneal topography. We think after we finish we’ll have pretty much covered the major ophthalmic devices.”

Meaningful use regulations require clinical document architecture (CDA) for compliance with stage 2 criteria, Lum said.

“It’s really just a structured template to transfer information when you’re transferring a patient to another provider or from a hospital to an outpatient site,” she said. “So, we now have a completed eye exam CDA. It’s a structured way to pass on information from one eye care provider to another eye care provider. … We’re hoping that more EHR systems can adopt that. Right now, we’re working on cataract surgery, which we hope to have ready by this summer. That’s kind of the direction we’re going with IHE, these structured data templates, which have been fostered by meaningful use.”

The group is working on standards for cataract surgery and is planning to draft CDA documents for retina, glaucoma and other ophthalmic subspecialties, Lum said.

E-prescribing

Electronic prescribing is one of the most useful features of any EHR platform, according to Rapuano.

Wills Eye has implemented the NextGen platform, which features e-prescribing capabilities.

“Electronic prescribing has a wonderful capability, one of checking all of the interactions with allergies and other medications, etc.,” she said. “But it also allows us, with the patient’s permission, to go into the national database of pharmacies and pull down all prescriptions that the patient has filled in the last 2 years.”

E-prescribing helps clinicians get vital data on patients who give incomplete information about their medical and ocular histories, Rapuano said.

“Patients walk in and say, ‘I’m fine. I don’t have any medical problems,’” she said. “You pull down their medications, and you realize that they’re diabetic, they have hypertension, they have a lot of medical issues that could be relevant to some of their eye conditions.”

Access to information on the patient’s overall medical condition is “a huge, powerful part of all electronic medical record systems,” Rapuano said, especially because meaningful use measures target patients who need regular care, such as patients with diabetes, so that early treatment might yield better long-term outcomes.

Add-ons and upgrades

Web-based add-ons can enhance EHR use in a practical way, Rapuano said. For example, one private practice at Wills has customized its platform to incorporate IOL calculations within the EHR, she said, which has significantly enhanced efficiency.

Wills Eye is preparing to implement EHR updates, when they become available, that will enhance data sharing among different practices, Rapuano said.

“Our EHR systems currently interface with many of the diagnostic machines, such as B-scans, visual field machines and OCTs, but we are working for better and faster ways to interface with all of the technology in our offices,” she said.

When it becomes available, a software upgrade compatible with new International Classification of Diseases (ICD-10) codes will be implemented, Rapuano said. The new version is scheduled for release in the fall.

“Everyone will have to upgrade their software to be compatible with ICD-10, or you won’t be able to send your claims,” she said. “We are all holding our breath and getting ready for that next conversion.”

Pearls for prospective adopters

Pinto offered a few tips for ophthalmology practices considering EHR adoption. First, he recommended that new adopters choose a large vendor with a lot of long-term ophthalmic users.

Pinto said that adopters may have to devote up to 10 hours per week in the first year to working out the bugs of EHR adoption.

Practices should assemble a task force comprising physicians, technicians, office staff and administrators to make collaborative decisions about EHR-related issues, Pinto said.

“Have the task force make at least two site visits to practices like yours using the vendor you have selected for more than 1 year,” Pinto said. “You are not just doing this to prove that the system works and to get pearls. You are mainly doing it so that 6 months post-purchase, when you are pulling your hair out, you will realize that things really will get much better.”

Choosing an experienced EHR trainer is as important as choosing the right vendor, Pinto said.

“As fast as vendors are adding staff, many trainers are greenhorns,” he said. “Ideally, your trainer will have done at least a few transitions from your current system to whatever the new vendor is. Call these sites as references on the trainer in question.”

Pinto advised practices to budget in advance for hardware, software, transient lost production and scribes to record most patient-physician encounters.

“For large practices, it is not unusual to have a full-time degreed IT tech in house or strong local on-call support,” Pinto said. – by Matt Hasson

In implementing EHRs, how long should it take to make an ophthalmology clinic more efficient and profitable?

Conversion swift but challenging

Not very long, if it is well-planned. In our practice, we launched in three phases. The first phase was patient flags and phone notes. The second phase was new patients only. The third phase was adding established patient encounters. This allowed everyone to get used to using the EHR and each new workflow addition. We had allowed for the three phases, each 2 months apart. We closed the gap between phases two and three to 2 weeks because it was going so well. The operational efficiencies are gigantic.

Amid all of the positive operational benefits of EHRs, the financial impact is great. The increased line item expense is chronic and needs to be actively managed. Offsets need to be sought out. For example, we needed more reception staff but did not hire; our medical records staff is now primarily a phone patient service representative. We realized many other efficiencies, such as our previous charge entry staff being converted to billing compliance auditors.

We are much more efficient as a practice, are managing our expenses well and remain profitable. Adopting EHRs requires all hands on deck, continual examination of financial and operational aspects, and a commitment to maximize every area of effect. One thing every member of our practice agrees on is that we would never go back to paper. As one of my physicians, Annette Chang Sims, MD, explained, “EHR is a self-fulfilling prophecy.” If you are not optimistic, are unbelieving in the benefits, and can only see the hassle factor and expense side of conversion, that is what you will get.

Laurie K. Brown, COMT, COE, OSA, OCS, CPSS, is practice administrator for Drs. Fine, Hoffman & Sims, LLC, Eugene, Ore. Disclosure: Brown has no relevant financial disclosures.

Conversion may be slow to improve efficiency

It will take the typical ophthalmology clinic at least 1 year to see increased efficiency from its start date with EHRs. However advanced, no electronic records system is truly turnkey. Each of us works differently, and each of us will have to make an investment in altering a system to meet our unique needs.

Simply put, any system that claims to be one-size-fits-all will be quickly outgrown by a practice as its use of EHRs evolves.

I would encourage colleagues to get involved personally in customizing their systems and look upon this customization as an opportunity to redesign every process in their practice to be more efficient. Only then does the EHR system really serve the user instead of the other way around.

John A. Hovanesian, MD, is OSN Cataract Surgery Section Editor. Disclosure: Hovanesian has no relevant financial disclosures.