Article Date: 1/1/2011

The State of Meaningful Use in Eye Care
MU update

The State of Meaningful Use in Eye Care

Where will optometrists find the greatest challenges in reaching EHR's meaningful use objectives?

Scott Jens, O.D., F.A.A.O.

Recently, the most-touted benefit of electronic health records (EHR) is a government-funded financial incentive. Specifically, under the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Centers for Medicare & Medicaid (CMS) will pay doctors whose healthcare practices demonstrate meaningful use (MU) with a (government) certified EHR system up to $44,000 for five years under the Medicare program and up to $63,500 f or six years for the Medicaid program.

In the few months since the MU criteria were announced, many optometrists have found they have a long — and likely challenging — path to follow to receive the incentive money. This article will discuss that path and offer insights into the challenges of achieving MU and ultimately receiving the HITECH incentive dollars.

The first steps toward MU

The path to MU starts with the certification of EHR products (which is done by the software vendor — see “About ONC and Certification,” below), followed by registration by the healthcare provider.

CMS will accept registration for meaningful EHR use beginning this month. To register, you'll need an active National Plan & Provider Identification number from CMS, and you must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).

Doctors and hospitals are required to demonstrate MU for 90 days within the first year after they register with CMS. MU is implemented in the following stages:

►The Stage 1 MU objectives (discussed in this article), apply to 2011 and 2012.
►The Stage 2 objectives will be outlined this year, so that healthcare providers can prepare for their implementation in 2013.
►The Stage 3 objectives will likely take effect in 2015, according to observers. These will be outlined through future rule making.

(See “Commentary: The Staged Approach to increased EHR Functionality,” below.)

Stage 1 criteria

Meaningful EHR use for Stage 1 is comprised of two sets of objectives that you must meet to receive the incentive money. The Core Set represents 15 core healthcare processes that the government believes all healthcare providers should perform for their patients. The Menu Set of objectives is a list of 10 processes that the healthcare provider should consider performing, and doctors will be allowed to attest to performing five of those 10 to demonstrate MU. It's expected that all healthcare providers will morph their practices by use of certified EHR technology into a consistent pattern of healthcare delivery that will result in the enhanced health wellness of the American public.

The list below identifies the MU objectives and includes an italicized note that quantifies the actual MU measure. Also, I provide a grade for each measure. The grading scale is:

Easy — can be achieved without significant change to clinical practice. Optometrist and para-optometrics will utilize existing EHR functionality with minimal training.

Effort involved — can be achieved with significant changes in clinical practice and patient interactions. Optometrist and paraoptometrics will need training and in-office implementation planning.

Challenging — can be achieved with fundamental changes in clinical practice. Optometrists and paraoptometrics will need to create individualized EHR use rules and establish previously unneeded plans for data sharing.

CORE 1. Record patient demographics along specific standards including:

► gender
► race
► ethnicity
► date of birth
► preferred language

MU measurement: More than 50% of patients have data recorded.

Grade: Easy

CORE 2. Record vital signs, applicable across all specialties, including:

► height (Ht) (can be self-reported by the patient)
► weight (Wt)
► bood pressure (BP)

The EHR must also:

► calculate body mass index (BMI)
► Plot and display growth charts for patients age two to 20 years old.

MU measurement: More than 50% of patients ages two and older must have Ht/Wt/BP recorded.

Grade: Easy

CORE 3. Maintain a Problem (Diagnosis) List:

All active diagnoses for the patient must be available in a list. To format problems, use either the Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT) or ICD-9-CM codes.

MU measurement: More than 80% of patients must have at least one entry.

Grade: Easy

CORE 4. Maintain a current medication list. All active medications for the patient must be available in a list.

MU measurement: More than 80% of patients must have at least one entry.

Grade: Easy

CORE 5: Maintain a current medication allergy list. All active medication allergies for the patient must be available in a list.

MU measurement: More than 80% of patients must have at least one entry.

Grade: Easy

CORE 6. Record smoking status of patients aged 13 and older. The documentation list for smoking status must include:

► current every day smoker
► current some day smoker
► former smoker
► never smoker smoker – current status unknown
► unknown if ever smoked

MU measurement: More than 50% of patients have smoking status recorded.

Grade: Easy

CORE 7. Clinical summary for office visit must be available in a “human readable format” to the patient and can be delivered as an electronic format document, including a summary of:

► diagnostic test results
► problem list
► medication list
► medication allergy list

MU measurement: More than 50% of patients must receive a clinical summary for an office visit within three business days.

Grade: Effort involved

CORE 8. E-copy of health information/summary of record must be available to patients in human readable format in an electronic format document, including a summary of:

► diagnostic test results
► problem list
► medication list
► medication allergy list
► discharge summaries
► procedures

MU measurement: More than 50% of patients must receive an e-copy summary of their record within three business days.

Grade: Effort involved

CORE 9. The EHR must electronically generate prescription and prescription-related information.

MU measurement: More than 40% of prescriptions (non-controlled substances) must be transmitted electronically.

Grade: Easy

CORE 10. Doctors must demonstrate computerized provider order entry (CPOE) for Medications. In future stages of MU, CPOE must also be performed for:

► lab work
► radiology/imaging

MU measurement: More than 30% of patients with at least one medication in list must have medication ordered through CPOE.

Grade: Easy

CORE 11. The EHR must enable drug-drug or drug-allergy interaction checks. Doctors who write fewer than 100 prescriptions during the reporting period are exempt.

MU measurement: Functionality must be enabled for the entire reporting period.

Grade: Easy

CORE 12. Your EHR must have the ability to electronically exchange key clinical information (certification will check receipt and display of diagnostic test results, problem list, medication list, medication allergy list, and procedures).

MU measurement: Functionality must be enabled for entire reporting period and a test of delivery must be completed.

Grade: Effort involved

CORE 13. A clinical decision support rule, relevant to specialty or of high clinical priority for the clinician, must be implemented, along with the ability to track the compliance of that rule.

Data elements to be considered as the foundation of the rule are:

► problem list
► medication list
► demographics
► laboratory test results

MU measurement: At least one rule must be implemented during the reporting period.

Grade: Effort involved

CORE 14. You, the healthcare provider, are required to review all privacy and security features enacted by the EHR. Certification done by the EHR vendor of the software will test:

► access control – user access via username and password
► emergency access – allowing the user to gain access in emergencies
► automatic logoff – system logoff due to inactivity
► audit log – internal tracking of entries, users, time/date (reportable)
► authentication – assurance that a user is who they say they are
► encryption – security of data as it is moved

MU measurement: You must conduct a review of security, implement security updates, and correct identified security deficiencies.

Grade: Easy

CORE 15. Clinical quality measures (CQM) must be reported to CMS. This year, provide attestation of compliance. In 2012, the EHR must electronically submit CQMs that are documented by EHR as performed to improve patient wellness.

Core Measures (conform to three of six for MU):

► hypertension management: BP measurement
► tobacco use assessment and cessation intervention offering
► adult weight screening and follow-up
► weight assessment and counseling for children/ adolescents
► childhood immunization status reporting
► influenza immunization status logging for patients age 50 and older

Eye Measures:

► Primary open angle glaucoma – optic nerve evaluation completed
► diabetic retinopathy (DR) – document +/− diabetic macular edema and retinopathy severity
► DR – confirm communication to healthcare provider managing diabetes mellitus

MU measurement: The healthcare provider (practice) must provide aggregate numerator and denominator of patients for whom measures can be reported.

Grade: Challenging

MENU 1. Drug-formulary checks.

MU measurement: The healthcare provider must have access to at least one formulary during the reporting period.

Grade: Easy

MENU 2. Generate lists of patients by specific conditions.

MU measurement: The healthcare provider must be capable of creating a listing of patients who have a specific diagnosis.

Grade: Easy

MENU 3. Provide patient-specific education resources.

MU measurement: The healthcare provider must be able to provide such resources to more than 10% of patients.

Grade: Effort involved

MENU 4. Provide summary-of-care record for patients transferred to another provider.

MU measurement: As the healthcare provider, your practice must provide such a summary to more than 50% of patients being referred or transferred.

Grade: Effort involved

MENU 5. Send patients reminders for preventive or follow-up care.

MU measurement: The healthcare provider must send reminders to more than 20% of those patients, ages 65 and older or 5 and younger.

Grade: Effort involved

MENU 6. Perform electronic medication reconciliation between two or more medication lists.

MU measurement: The healthcare provider must compare two or more medication lists, and create a single list in 50% of cases.

Grade: Easy

MENU 7. Provide patients with timely electronic access to their health information (labs, diagnoses, medications, medication allergies).

MU measurement: The healthcare provider must provide the above for more than 50% of patients within four days of the information being updated.

Grade: Effort involved

MENU 8. Incorporate clinical laboratory results.

MU measurement: For lab results of numerical data, healthcare providers must enter data in 40% of cases.

Grade: Effort involved

MENU 9. Submission of electronic immunization data.

MU measurement: The healthcare provider must perform at least one test of data submission.

Grade: Challenging

MENU 10. Submission of electronic syndromic surveillance data to public health agencies.

MU measurement: As the healthcare provider, your pracitce must perform at least one test of data submission.

Grade: Challenging

When can practices expect the incentive money?

The federal government plans to make incentive money available for the earliest demonstration of MU in the second quarter of 2011, but several healthcare experts believe that many doctors will not qualify until 2012.

When a doctor qualifies, the funds will be paid directly to the doctor or to a corporate entity, as assigned by the healthcare practice, and will be paid in proportion to the number of Medicare or Medicaid patients that are seen by the doctor during the reporting period.

According to the CMS website, the incentive dollars are considered ordinary income and, thus, subject to taxation. (See “Beyond Incentives: Immediate Benefits of EHR,” page below.)

Getting comfortable

From a clinical care perspective, optometrists must become comfortable with new types of discussions of the patient's health, such as being able to properly explain the healthcare system's movement toward all healthcare providers, being attentive to height, weight, BMI and the need for smoking cessation.

And in areas of practice that are core MU objectives, O.D.s will need to become accustomed to reporting the ratio of patients who have thorough care documented for chronic diseases, such as glaucoma and DR, while also using the software to give them clinical-decision support.

All in all, EHR represents substantial changes in how we practice. But such an investment can provide a solid payoff through improvements in patient care and more efficient — and effective — practice operations. OM

About ONC and Certification
As part of the national EHR adoption initiative in the HITECH Act, the government has established the Office of the National Coordinator (ONC) for Health Information Technology of the U.S. Department of Health and Human Services. There are many resources available on the ONC website to help educate doctors about the issues related to MU as well as certification of EHR software. (EHR software certification is not a primary concern to optometrists, though, as it is the EHR vendors who proceed through the certification process.)
ONC certifies government-sanctioned certifying bodies called ONC-Authorized Testing and Certification Bodies (ONC-ATCBs). Software vendors have a choice of a number of ATCBs with whom to test their EHR programs. The ATCBs judge the EHR programs against a set of EHR functionality standards set forth by the National Institute of Standards and Technology (NIST).
When EHR software has passed the certification process, the systems are posted on the ONC website's Certified HIT Products List along with notations for which particular functionalities have been tested. Doctors will have the choice of using a Complete EHR that has been certified to perform all MU standards or using a number of Modular EHRs that together allow the doctor to demonstrate MU. At press time, four optometry EHR systems have achieved ONC-ATCB certification and can be found at http://onc-chpl.force.com/ehrcert

Commentary: The Staged Approach to Increased EHR Functionality
There is certainly no shortage of commentary on EHR from any number of sources. However, journal and Internet commentary on the staged implementation of EHR help provide perspective about the influence of EHR adoption on the healthcare system. For example, in a recent issue of The New England Journal of Medicine, David Blumenthal, M.D. and Marilyn Tavenner, R.N. write:
“The meaningful use rule strikes a balance between acknowledging the urgency of adopting EHRs to improve our healthcare system and recognizing the challenges that adoption will pose to healthcare providers. The regulation must be both ambitious and achievable. Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself.”

Beyond Incentives: Immediate Benefits of EHR
Chart reviews of optometry records demonstrate that doctors who use paper records actually document less data than they collect. So, there is an immediate patient care advantage to EHR: The software prompts the healthcare provider to ask questions — pand input answers — based on the specifics of the patient visit. The result is that healthcare providers document all the data they collect.
EHRs also provide a substantive advantage vs. paper records in accuracy and legibility of documentation, data review capabilities and data exchange opportunities. (These issues and others are discussed in greater detail throughout this month's special section on EHR.)

Dr. Jens is a practicing optometrist in group private practice in Middleton, WI. He co-founded and serves as CEO of RevolutionEHR, a web-based optometry EHR/PMS software product. He has no interest, financial or otherwise, in any other company in the eyecare industry. Contact him at sjens@revolutionehr.com, or send comments to optometricmanagment@gmail.com.


Optometric Management, Issue: January 2011