Dr. Sullivan is a practicing cardiologist who joined DrFirst in 2004, just after completing his term as President of the Massachusetts Medical Society. He is known throughout the healthcare industry as the father of the Continuity of Care Record (“CCR”) and a leader on the future of healthcare technology. He is assisting DrFirst in ensuring that Rcopia continues to add the functionality necessary to maintain its leadership position both in electronic prescribing and in the channel of communication between various sectors of the healthcare community and the physician. Dr. Sullivan is active in organized medical groups at the state and national level, and is both a delegate to the AMA and the Chairperson of their Council on Medical Service as well as past Co-Chair of the Physicians EHR Consortium.

The buzz surrounding Electronic Health Records (EHR) is nothing short of constant.  The daunting task of selection, purchase and implementation is quite confusing, technical, and expensive, with many physicians, clinics and health systems uncertain of their needs and questioning how the technology is going to impact the way they practice medicine and their bottom line. It’s all about workflow and productivity.

More recently, Providers are faced with the intimidating task of deciding which kind of system to install. There are all inclusive systems, often referred to as fully paperless or standard EHRs and there are so called a la carte systems known as modular EHRs.

The Case for Modular

Modular EHR systems allow providers to take a stepping stone approach to health IT clinical documentation and order writing, by choosing the tools and functions which make the most sense in their practices and clinics; improving specialized workflow and efficiency.  Going the modular route can gradually ease the provider and the office staff into a more paperless environment without having to make a full and often-times difficult transition to a fully paperless workspace.

There is need for caution however. The sheer volume of modules available can make selecting appropriate ones an overwhelming task.  Not only do clinicians need to be wary of which modules they are choosing, but also what functions have been certified by an authorized organization.

By combining specific modular systems, it can become “qualified,” making the user eligible for the monetary reimbursements set forth by Title IV of the American Recovery and Reinvestment Act of 2009 (ARRA).

At DrFirst, our Rcopia-MU^TM has taken all of the guess work out of this process and is a completely certified Modular EHR that physicians can implement and start earning incentive money directly out-of-the-box.

The implementation of a complete EHR system can be confusing and time consuming.  Herein lays some distinct advantages of implementing a modular EHR.  Practices that have already implemented e-prescribing or registry modules may not need to relearn a different system, or move their data from one to another (as long as the current module is certified).

Providers who are considering going the modular route can check the certification status of their options at Certified Health IT Products List. The cost for a modular approach is often much less expensive and providers can select the modules from various vendors to meet their financial and practice-based needs.  Upon implementation, providers must show they’re using certified EHR technology in measureable ways to receive their incentive monies from the Federal Government.  With this very high ROI, many providers see the advantage of using the modular approach to postpone the decision process in selecting a complete EHR and yet at the same time earn Meaningful Use incentive money to put towards the cost of  the much more expensive system.

According to the Centers for Medicare and Medicaid Services, doctors who have not adopted an EHR (either modular or complete) by 2015 will be penalized by Medicare — a 1% penalty to begin, then up to 3% within three years. Many providers are banking on the reimbursement that has been made available by the ARRA to help offset the initial costs.

What is your practice considering, complete EHR or modular? Do you see benefits of one over the other?

The CMS FAQ site has a great question up that I have a feeling a number of doctors will be interested in knowing the answer to:
I am an eligible professional (EP) who has successfully attested for the Medicare Electronic Health Record (EHR) Incentive Program, so why haven’t I received my incentive payment yet?

Here’s their answer:

For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year.

The Medicare EHR incentive payments to EPs are based on 75% of the estimated allowed charges for covered professional services furnished by the EP during the entire payment year. Therefore, to receive the maximum incentive payment of $18,000 for the first year of participation in 2011 or 2012, the EP must accumulate $24,000 in allowed charges. If the EP has not met the $24,000 threshold in allowed charges at the time of attestation, CMS will hold the incentive payment until l the EP meets the $24,000 threshold in order to maximize the amount of the EHR incentive payment the EP receives. If the EP still has not met the $24,000 threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March 2012 (allowing 60 days after the end of the 2011 calendar year for all pending claims to be processed).

Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments.

Bonus payments for EPs who practice predominantly in a geographic Health Professional Shortage Area (HPSA) will be made as separate lump-sum payments no later than 120 days after the end of the calendar year for which the EP was eligible for the bonus payment.

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.

This is actually something that I’ve written about before (probably on EMR and HIPAA), but I have a feeling many people weren’t looking at the details to realize why they aren’t getting their incentive money. You have to wait until you have enough Medicare Allowable Charges before they’ll pay you. I think this is a smart plan I do find it interesting that there were some clinics that had enough allowable charges in 3 months to receive the full EHR incentive money right away. I’d love to see some stats on medicare allowable charges per provider. Would be interesting to see how this aspect of the EHR incentive program affects Medicare providers.

Either way, hopefully this information will help someone who is wondering where they EHR incentive money is. Thanks to @jimtate for tweeting the FAQ and reminding me of this part of the program.

A new study sponsored by the American Hospital Association has concluded that developing an Accountable Care Organization is likely to be substantially more expensive than CMS has projected.  Not surprisingly, the AHA expects buying and managing EMRs and clinician decision support systems to be a major percentage of the added expense.

CMS has estimated it will cost an average of $1.8 million to start and sustain an ACO.  But the AHA dismisses that number as far short of the mark. Its own research, conducted by McManis Consulting, concluded that the actual startup and first-year costs for ACOs range from $11.6 million for a 200-bed, one-hospital system to $26.1 million for a 1,200 bed,  five-hospital system.

The AHA estimates that hospitals will spend anywhere from $2 million to $7 million to buy an EMR, and hundreds of thousands to integrate the system and build a health information exchange.  Not only that, health systems are likely to spend anywhere from $1.5 million to $3.9 million per year to maintain the EMR, manage the integration process and keep building out the HIE.  (My instinct is that the study’s estimates of systems integration and HIE linkages are rather low;  check out page two of the report and let me know what you think.)

If the AHA has it right — and I suspect it does — something is out of order here.  It’s hard for me to imagine how the agency could underestimate health IT costs so significantly, unless there’s some political game afoot here.

I’m not surprised to read that HIT costs are just as heavy a burden as recruiting, managing and and supporting affiliated physicians.  And I’m pretty sure that hospital CIOs aren’t kidding themselves on this front either.

Somehow, though, the Medicare folks have made some rather flawed assumptions and embedded them in the proposed  Medicare Shared Savings Program for ACOs.  If you agree that CMS is on the wrong foot here, I encourage you to submit comments on the proposed rule.  (See the beginning of the document for how to file those comments.) You have until June 6, so have at it!

When you read this statement from HIT vendor Orion Health, it sounds oh-so-simple: why not establish an entire county’s HIE network on a single connecting platform?  Given the country’s already high EMR adoption rate — about 80 percent of GPs had one, as of March 2010 — New Zealand’s already part-way there.  Just knit offices up together and you’re ready to go.

Orion, of course has its own technology in mind, naturally. But whatever vendor you use, they may be onto something. I’ll pause here to say that the following proposal could incite a riot at a HIMSS floor full of competing vendors, but hey, ideas are harmless, aren’t they?

What if CMS decided that it would pay incentives not just to meaningfully, sensitively, insightfully install EMRs, but to connect them to an overall HIE?  And to take the thought into more controversial territory, what if it had a vendor or two of choice which doctors and hospitals had to use if they wanted the dough?

As we all know, the value of EMR installations isn’t just in automating, error checking and (hopefully) streamlining workflow in practices. The data is infinitely more valuable when it can be aggregated, shared, cross-checked and mined for best practices.

What are the odds of that, however, if you have an outbreak of regional and state projects using technology from a multitude of vendors?  You can talk standards all you want, but true interoperability isn’t going to happen anytime soon this way.  National connectivity?  Well, give me a couple of decades and let’s see how far that’s gotten.

On the other hand,  if CMS signed contracts with HIE technology vendors, and demanded that they give preferred pricing to those work with them, you’d see a rash of connectivity unrivaled since the invention of the telephone.  Before you scream that this just isn’t fair, doesn’t this kind of thing happen every day in, say, military contracting?

I know, I know, this may not be practical. But you can’t argue that It’d be interesting to see how the HIE and EMR market gelled if CMS took a strong lead.

John’s Note: Much of this post will be child’s play for those of you reading the blog that are steeped in meaningful use, the HITECH act, EHR Certification, and the EHR stimulus money. However, I thought this guest post was a nice intro to the EHR stimulus money for a doctor or practice manager which was starting to learn. I’m all about helping doctors, so here it is.

90 days of data collection. This is what is required for year one meaningful use. This means by October 1 you better be collecting data…and hopefully you didn’t just start on October 1…that would be playing with fire.

What really is the purpose of Meaningful Use? In the grand scheme of things, the CMS wants to make sure that a practice hasn’t bundled together a spreadsheet and word processor, call it an EHR, and then try to claim a big reimbursement. So, sure, it makes sense that the CMS would have some requirements for your EHR.

As is the situation anytime you try and get money from the government, the list of requirements is lengthy, the red tape is plentiful and the maze continues to get more complex.

So is the case when “proving” meaningful use. Hopefully you aren’t of the idea that buying a Meaningful Use certified EHR makes you a Meaningful User.

Having an EHR with that “certification” stamped on the box is not like an Easy Button.

Selecting that EHR is the first big hurdle you have to conquer…now you have to show you are a Meaningful User.

The items of proof are shown here in this CMS summary [PDF]. What you’ll see is there are 15 Core Objectives you must be able to report on.

That shiny new EHR should have all of these reports built right in. You better try pulling some of those reports to make sure there is some data in them.

So, those 15 mandatory Core Objectives are already selected for you. Next, there are five more you must select from a gallery of ten.

Which objectives should you choose? Wait for it…IT DEPENDS.

Such the non-answer answer.

It does depend on a number of items, but really which five would you choose?

The easiest to gather? DING DING!

Why not?

Why make this craziness any more difficult than it needs to be.

We’ll go over the Menu Set Objectives, and which ones are the easiest for you to pull, in a future article.

John Brewer is the founder of HIPAAaudit.com. He and his team help physicians run HIPAA Compliant practices in the simplest, most pain free way.

Drummond Group has updated their FAQ with an interesting question about how to obtain a CMS EHR certification ID and the difference between the CMS EHR certification ID and the ONC EHR Certification ID that Drummond Group issues.

Q: How do I obtain a CMS EHR Certification ID? Is it the same as my ONC EHR Certification ID I received from Drummond Group?

A: The unique ONC EHR Certification ID issued by Drummond Group is associated with the CMS EHR Certification ID but distinct from it. The ONC EHR Certification ID is one of the “inputs” into the calculation and creation of the CMS EHR Certification ID. However, it is ultimately the CMS EHR Certification ID number which EPs and hospitals will use for the incentive payments.

The ONC Certified Health Product Listing functionality was updated December 24, 2010 and it now has the addition of a shopping cart to create CMS EHR Certification ID number. Users can obtain the CMS EHR Certification ID number by following these steps:

1. Go the ONC CHPL website: http://onc-chpl.force.com/ehrcert

2. Following the instructions on the site, search for the certified EHR products. There are many ways to search, but one option is to search by the ONC EHR Certification ID assigned to the vendor.

3. When the EHR product(s) is found, select the link on its row called “Add to Cart”. There is a shopping cart icon next to it.

4. When all EHR products used by the EP or hospital have been added to the cart, select the “View Cart” link at the top right which also has a shopping cart icon next to it.

5. Now in the Certification Cart section, verify the products in the cart are correct. Then, select the “Get CMS EHR Certification ID” button in the top right corner to request a CMS EHR Certification ID. However, the button will not be activated until the items in your cart meet 100% of the required criteria. If your EHR product(s) do not meet 100% of the Meaningful Use incentives, then a CMS EHR Certification ID number can not be issued.

6. Finally, you will see the CMS EHR Certification ID. It is typically a 15 digit string made up alphanumeric characters.

Interesting that the CHPL website has been redesigned to be able to know which EHR are certified to which module and knows if you’ve reached a 100% certified set of software.

Looks like it also pays off to have a number for your EHR product name so that you’re listed first on the CHPL site.

At this point, I’m guessing that most people have heard of meaningful use and many likely know about the 25 meaningful use criteria (15 core MU measures and 10 menu). I’m not sure how well communicated the exclusions that are available for most of the meaningful use criteria. Elizabeth Woodcock explains some of the details in her Modern Medicine article:

For the 13 of the 25 criteria that have exclusions, CMS designates narrow windows for physicians to report that the objective or measure does not apply to them because “They have no patients, or no or insufficient number of actions that would allow calculation of the meaningful use measure.” For example, a physician who has no patients age 65 or older or age 5 or younger would not have to meet the requirement to send an appropriate reminder to 20 percent or more of all patients in those age groups during the EHR reporting period.

Also of some comfort to dermatologists is that CMS lowered thresholds for many of the meaningful use measures. For example, the measurement for electronic prescribing will be for more than 40 percent of all permissible prescriptions written by the physician to be transmitted electronically using certified EHR technology. CMS backed off from its initial proposal setting the minimum e-prescribing threshold at 75 percent of all permissible prescriptions.

Some are still saying that specialists are still left out of the meaningful use and EMR stimulus programs. They rightfully note that meaningful use was and is focused on primary care and not specialists. In fact, ONC hasn’t been shy about generally making the same observation.

The question is whether exclusions like the one mentioned above does enough to encourage specialists to implement an EHR. I’m inclined to lean with many of the specialist medical societies that are saying that it doesn’t.

I’d make an even bolder prediction. Don’t be surprised to see specialists still leading in number of EMR implementations done despite not being stimulated to do so by the government.

NOTE: I had this post sitting ready to be posted back in July and never got around to it. I think it’s still pretty relevant even though we are a few months farther along. Some of the time frames might not be quite right now, but the sentiments are interesting.

DKBerry sent me a passionate email in reference to this Modern Healthcare article about the EHR subsidies unanswered questions and the possibility of EHR Stimulus money flowing in May 2011. While I don’t agree completely with DKBerry, I have to admit that it’s quite disturbing that an 800 page meaningful use final rule later and we still have lots of questions. The following is DKBerry’s reaction/summary of the article:

Trudel makes it sound like a doc could validate his meaningful use on 30 April (end of the first possible 90 day period for reimbursement) … and would get paid by CMS in May.  Wonder how long she has worked for CMS?

I especially like this line …

“John Halamka, committee co-chairman, asked whether the reimbursements paid to office-based physicians would be counted by the Internal Revenue Service as taxable income. Trudel said that question was out of her purview.”

Of course its taxable income Dr. Halmaka!  It’s based on Medicare reimbursement payments … and that’s revenue.  Had the bozzos who set up this idiotic incentive program provided tax credits instead of partial reimbursements for meaningful use adoption of a certified EHR … then maybe they would have gotten more than 15 docs to sign up.

You will love the dialog between Judith Faulkner (Epic Systems) and Doug Fridsma (ONCHIT).

“Faulkner asked whether he thought “we’re going to make” the Jan. 1, 2011, start date by having both these certification and testing organizations and vendors with tested products in place by then.

Fridsma made no promises.”

He said his hope is that having multiple testing and certifications organizations authorized will “eliminate some of the bottlenecks.” Still, he said, there will be “challenges” to get systems certified if providers “bundle” pieces of EHR systems together to achieve meaningful use, a common scenario at many hospitals.

“We are working as hard as we can to meet those timelines and get the capability in place,” Fridsma said.

I appreciate that you are working as hard as you can … but that’s not good enough.  ONC has to get it done now.  Any date after 30 September and its costing hospitals money.  They are going to be still screwing around with this in January … 2 years after they put it out in ARRA.  If I were a doc I would just say screw it … I’m closing my panel to Medicare patients.  This isn’t worth the pain and effort.

I wrote previously about the Signapore government accepting proposals for a national EHR. Today I got the news that Accenture has been contracted to implement the Singapore National Electronic Health Record (EHR) system. Obviously Accenture is a big name and a big group. I’ll be interested to learn which EHR software system they plan to implement to create the national EHR system. International EMR movement like this is very interesting.

Here’s the press release from Accenture about the announcement.

Accenture Wins Contract to Implement Singapore’s National Electronic Health Record System

SINGAPORE; Aug. 2, 2010 – The Singapore Ministry of Health has awarded Accenture (NYSE: ACN) a contract to implement the National Electronic Health Record (NEHR) system, a key enabler of Singapore’s vision toward a national, integrated health care system. The NEHR is designed to improve the quality of healthcare for citizens, lower the costs of health services, and promote more effective health policies.

Under the NEHR, key medical information such as patient demographics, allergies, clinical diagnoses, medication history, radiology reports, laboratory investigations and discharge summaries will be exchangeable among healthcare providers. Patients also may benefit from proper, right-sited disease management and cost savings, as duplicate or unnecessary tests are eliminated and medication errors are reduced.

“As the centerpiece of Singapore’s connected health vision, the NEHR is intended to provide a holistic view of a patient’s health information. With this market-leading offering, health care providers can have the right information at the right time to make the best care decisions,” said Stephen J. Rohleder, group chief executive of Accenture’s Health & Public Service operating group. “We congratulate the Ministry of Health for taking this bold step to create a new foundation to help support meaningful advances to Singapore’s health care system.”

The National Electronic Health Record vision – “One Singaporean, One Health Record” – was previously announced by Singapore Health Minister Khaw Boon Wan. With the initial system release in April 2011, Singapore will be one of the first countries in the world to implement a national electronic health record system.

The Accenture team includes Oracle, Orion Health, Initiate Systems, Inc., and Hewlett-Packard.

UPDATE:
Mark told us who will be providing the software for the Singapore EHR in the comments. EHR Software is being delivered by 3 Partners;

Oracle’s HTB is the core Clinical Data Repository
Initiate is providing the Master Patient Index; and
Orion Health the Clinical Viewer & Messaging fabric using their Concerto & Rhapsody products.

Today, I thought it would be interesting to list the meaningful use final rule comments that I know of and to invite my readers to tell me about other meaningful use final rule commentary that they know about. Just reply in the comments of this post or on the EMR and EHR contact us page and I’ll update this post with all the meaningful use final rule resources we can find.

Full Meaningful Use Final Rule, Press Conference Video and EMR and HIPAA MU Thoughts
Comparing the Preliminary Meaningful Use Rule to the Final Meaningful Use Rule Done by Inga from HISTalk and a great resource.
List of Meaningful Use Webinars – Done by EMR and HIPAA
Everything HITECH Analysis of Meaningful Use
Advice on Addressing Meaningful Use – Good advice from the Healthcare IT guy on not being in a hurry to address meaningful use.
Interview with David Blumenthal About Meaningful Use
Mr. HISTalk and John Glaser Reactions to MU (have to scroll down a bit to see the obligatory meaningful use section)
Meaningful Use and It’s Impact on Physician Productivity
HISTalk Initial Comments and Reactions to MU – Just read the comments on this one.
Summary of Meaningful Use Announcement and Rule
CMS Page on Meaningful Use
Meaningful Use Final Rules Are a Big Deal – Wm. T. Oravecz Take on Meaningful Use Final Rule on HITECH Answers
David Blumenthal’s Thoughts on Meaningful Use
John Halamka’s Summary of Meaningful Use Final Rule Changes
Halamka’s Presentation on the Meaningful Use Final Rule
Summary and Other Meaningful Use Documents – The Summary Chart that’s embedded on this is an interesting one. Too bad it’s partially cut off on my screen.
Summary of the 2 Reginas and Meaningful Use – Matthew Holt talks about the 2 Reginas that spoke about Meaningful Use of an EHR
Chilmark Research Quick Meaningful Use Analysis – An always insightful look at healthcare IT
The Fox Group’s Thoughts on Where to Go from Here

I’m sure that there are plenty more. If you know of some good ones, let me know and I’ll add them to the list.