Article Date: 1/1/2010

Real Concerns About Health Care Reform
healthcare reform

Real Concerns About Health Care Reform

Here's what you need to know about stimulus money, the guidelines and electronic health records.

SCOT MORRIS, O.D., Conifer, Colo.
I. BEN GADDIE, O.D., F.A.A.O., Louisville, Ky.

Health care reform (HCR) has moved front and center in the national and world conversation. As of this writing, the U.S. Senate and House of Representatives have both pushed forward final versions of their legislation to support President Barack Obama's pledge to overhaul the nation's healthcare system during his first year. Out of the gate, lawmakers and caucus leaders are struggling to merge or reconcile the two versions of their respective legislation into a final bill that will satisfy both ends of the political spectrum. As with all aspects of the political system, nothing is guaranteed in terms of new legislation, but the process has highlighted the future of electronic health records (EHR), including certification and definitions of “Meaningful Use.”

The final outcome of these conversations will undoubtedly have a significant impact on optometry. There will be changes in reimbursement, coverage, access to providers and most importantly how medicine operates. A crucial cornerstone to the pending health care changes is utilization of technology, more specifically EHR. There is one certainty, optometry cannot stop the coming changes. As a profession we need to be very cognizant of these changes and how they will affect our profession and practices.

In this article, we discuss what we know thus far, including established deadlines and requirements, the steps all optometrists should be taking now to ensure a smooth transition and the consequences for those who delay.

Incentives and penalties

One of the major underpinnings of healthcare reform is adoption and utilization of EHRs. This process began in 1996 with the Health Insurance Portability and Accountability Act, was followed by the Physician Quality Reporting Initiative (PQRI), and continues with the enhanced vocabulary of the pending ICD-10s, and finally, the universal language of EHRs. The ultimate goal is to develop an evidence-based medicine component of EHRs. These capabilities are expected to drive the “improvement in care” aspect of EHRs by guiding us to community- or profession-based clinical recommendations during documentation and case management.

To encourage adoption and utilization of EHRs, Congress set aside $19.2 billion as part of the American Recovery and Reinvestment Act (ARRA) to encourage doctors and hospitals to move quickly to adopt “qualified and meaningful use” systems. According to the Health Information Technology for Economic and Clinical Health (HITECH) provision of the stimulus plan, EHRs must meet the following criteria for certification:

  1. Electronic prescribing (e-prescribing)
  2. Exchange of information to enable improved health care (portability)
  3. Reporting of clinical quality information.

Under the “meaningful use” criteria, doctors who satisfy the implementation requirements are eligible for bonus payments starting in 2011 (see Table 1). At this time, these incentives are related only to a provider's Medicare reimbursement. Commercial payers have not publicly indicated their plans to follow suit. Medicaid panelists may also be eligible for an additional $20,000, depending on individual state mandates.

Keep in mind that more than 70% of the total incentive money will be disbursed within the first two years. Providers engaged in PQRI and electronic prescribing can earn an additional $6,000 to $8,000 per year beginning immediately. Healthcare professionals who do not adopt EHRs by 2015 will be penalized by a 1% to 2% reduction in Medicare reimbursement rates.

As part of the American Recovery and Reinvestment Act, healthcare professionals who implement certified electronic health records are eligible for bonus payments, starting in 2011.

The EHR dilemma

To date, the language used to define a “qualified” EHR system is vague at best. Because of this, many EHR vendors have been slow to release software updates around a “certified” product. Currently, two processes that are believed to encompass the ARRA guidelines and the Certification Commission for Health Informa tion Technology (CCHIT) statutes are being investigated by a subgroup of the CCHIT. At this point, any predictions of the subgroup's findings would be pure conjecture.

Electronic health records will need to comply with the National Health Information Network (NHIN) guidelines and the CCHIT. The CCHIT guidelines have been established for medicine, but guidelines for sub-specialties, such as optometry, are not expected to be released until 2011. The American Optometric Association and other groups are pushing for the guidelines to be released in 2010. The sticking point is that the NHIN guidelines are not set to be released until 2014, which is well after the ARRA reimbursement begins. How exactly these conflicts will be resolved is not yet known.

While these issues are being sorted out, many EHR companies are preparing for what they expect CCHIT guidelines to be. In other words, don't expect any EHR company to claim its program is CCHIT-certified. In fact, if they do, their claims are incorrect, because these guidelines have not yet been established.

One concern is that the existing CCHIT and ARRA rules expire in 2012, with tighter rules expected (shorter timelines and harsher penalties, for example) when the 2013 standards are published. Thus, it becomes crucial that current and potential users begin active utilization of approved systems as soon as possible. Yet, because the exact criteria of an “approved” system are unknown and the clock has started ticking on the timelines, we are left in a fog with no concrete answers to several critical questions: What system should we buy? Will current systems be easily upgradable or will they require costly and time-consuming overhauls?

There exists, however, another issue of greater concern.

Slow adopters beware

Based on discussions with our clients and informal polls during our lectures, we estimate that only about 4% to 8% of all eye health providers are actively using a “meaningful system.” Another 10% to 14% of practices may be using EHRs in a way that does not meet “meaningful” guidelines. That leaves more than 75% of eyecare professionals who have not started the preliminary stages of meaningful EHR deployment.

Why this hesitation? Many doctors say converting to EHRs is too expensive. We disagree. The cost of supporting a paper-based office can exceed $50,000 per year per provider.1

When you also consider the potential income that could be earned in the next few years between ARRA remuneration, e-prescribing and PQRI incentives, that argument falters.

Another line of reasoning we hear is, “We're going to wait until everything is worked out.” There are two drawbacks to this approach. First, the rules may not be completely finalized until well after the first two years of the ARRA incentives, so providers who wait will miss out on incentive dollars (not to mention they will continue to spend that $50,000 per year on their paper systems). Second, even now, EHR companies are struggling to adequately integrate and implement their software packages into the small number of practices currently seeking their services. Considering that every medical provider from primary care to large hospitals will need to comply with the same timelines, there simply will not be enough qualified manpower to fulfill all of the implementation requests, nor will there be enough IT technicians to help with integration.

Our advice? Select, integrate and implement soon or you may end up on a multi-year waiting list and suffer financial, operational, clinical and marketing consequences. Although a Web-based solution is being developed whereby all hardware, software, peripherals, IT, storage and security issues can be addressed in one uniform place, it may be another year before comprehensive solutions that require a fraction of the manpower by the EHR companies, IT firms and medical practices can be automated.

Need another reason?

Fortunately, EHR software solutions are advancing rapidly. Early adopters are already benefiting from integrated diagnostic technology and business operational technology, such as document management, inventory management and accounts receivable automation. More impressive is the rapid advancemen of clinical decision support (CDS) in some of the current EHR programs. This tool helps clinicians determine better standards of care, establish new practice guidelines and deliver overall better care by providing true outcomes-based reporting intelligence. CDS also allows for more accurate management of inventory, human resource workflow, marketing intelligence and benchmarking.

With the push for value-driven healthcare and, eventually, evidence-based medicine, CDS features will be instrumental in achieving better clinical outcomes, higher payment for performance and increased operational efficiencies in every aspect of the optometric practice o tomorrow. Will you be on board? OM

  1. Morris S. EMR: The Real Costs. Optometric Management. 2007;42: 28–36.
Dr. Morris is medical director, Eye Consultants of Colorado, LLC, and CEO of Ocular Technology Solutions, Inc. He is founder of the Ultimate Technology Symposium for Eye Care. He can be reached at
Dr. Gaddie is CEO of Gaddie Eye Centers and president of Gaddie Consulting. He can be reached at

Optometric Management, Issue: January 2010