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QPP (Quality Payment Program) 2019 Changes, Medicare Telemedicine Reimbursement, and Physician Fee Schedule E&M Changes

Posted on July 12, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Today, CMS came out with some big changes as part of the 2019 Physician Fee Schedule and proposed rule for the QPP for 2019. These are some of the biggest efforts I’ve seen to try and change what Medicare has been doing for a while.

CMS has put together a fact sheet on the 2019 Physician Fee Schedule proposed rule. Plus, you can also view the fact sheet for the 2019 Quality Payment Program (QPP) proposed rule. If you like all the details, you can find the full rule for both the 2019 Physician Fee Schedule and QPP 2019 (1473 pages) on the Federal Register.

That’s a lot of information and changes to process, but here are some initial thoughts. While what CMS and HHS are saying in their announcement is directionally good, the devil is always in the details. Here are a few of the highlights that could have a big impact on the healthcare IT and EHR world.

E/M Documentation Requirement Changes
The biggest change in this announcement is the change in E/M coding requirements. As part of CMS’ goal to streamline E/M documentation requirements, they’ve proposed some of the biggest changes to E/M since 1997. The one that will likely be talked about most is the opportunity for providers to bill Medicare using “medical decision-making or time.” Here’s a description of the change:

To improve payment accuracy and simplify documentation, we propose new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services. As a corollary to this proposal, we propose to apply a minimum documentation standard where Medicare would require information to support a level 2 CPT visit code for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework, or, as proposed, medical decision-making to document E/M level 2 through 5 visits. In cases where practitioners choose to use time to document E/M visits, we propose to require practitioners to document the medical necessity of the visit and show the total amount of time spent by the billing practitioner face-to-face with the patient. Practitioners could choose to document additional information for clinical, legal, operational or other purposes, and we anticipate that for those reasons, they would continue generally to document medical record information consistent with the level of care furnished. However, we would only require documentation to support the medical necessity of the visit and associated with the current level 2 CPT visit code.

There are other changes to E/M that could be a big deal as well including having providers focus their documentation on what’s changed since the last visit as long as they review and update the previous information. Plus, providers can now just review and verify the information entered by ancillary staff or the patient rather than having to re-enter it.

The goal is quite clear. CMS is trying to battle against the bloated notes that are getting generated by EHRs today to justify a certain billing code level. Doctors will no doubt celebrate this as most doctors describe notes from their peers as awful and difficult to use because of all the note bloat. I don’t know how many times I heard from my medical billing friends at AHIMA that it doesn’t matter what’s actually done if it’s not documented. With the changes mentioned above, CMS is looking to change this.

Of course, EHRs aren’t going to be able to change their interfaces overnight. The new E/M changes are going to take a while to incorporate into EHR software. Plus, we’ll have to see how the non-Medicare payers react to these changes. If they don’t follow Medicare’s lead, that puts the EHR vendors in a tough position. We’ll have to see how that plays out.

Many doctors complain about hating their EHR software. I’ve long argued that the EHR is just the whipping boy for doctors’ ire. What doctors really hated was the crazy billing documentation requirements that were reflected in the EHR. If the changes above go far enough, maybe we’ll finally see if the EHR vendor really is to blame for provider burnout. However, as I mentioned, it will take some time for this to happen.

Medicare Telemedicine and Telehealth Reimbursement
The next biggest thing in today’s announcement was Medicare’s plans to reimbursement for what we would call Telemedicine or Telehealth services. 2 G codes (HCPCS code GVCI1 and GRAS1) were announced that seem like they could present a lot of opportunity for healthcare IT companies to finally get paid for the services they can provide:

Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code GVCI1)

Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (HCPCS code GRAS1)

Practitioners could be separately paid for the Brief Communication Technology-based Service when they check in with beneficiaries via telephone or other telecommunications device to decide whether an office visit or other service is needed. This would increase efficiency for practitioners and convenience for beneficiaries. Similarly, the Remote Evaluation of Recorded Video and/or Images Submitted by the Patient would allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.

Travie Broome offered some interesting insights into these codes:

CMS also proposed a number of CPT codes for “Chronic Care Remote Physiologic Monitoring” and “Interprofessional Internet Consultation” as follows:

We are also proposing to pay separately for new coding describing Chronic Care Remote Physiologic Monitoring (CPT codes 990X0, 990X1, and 994X9) and Interprofessional Internet Consultation (CPT codes 994X6, 994X0, 99446, 99447, 99448, and 99449).

The also proposed adding HCPCS codes G0513 and G0514 for Prolonged preventive service(s) which seems to include ESRD (end-stage renal disease) patients who receive dialysis at home and mobile stroke units.

QPP (Quality Payment Program, better known as MACRA and MIPS) Changes
I have to admit that the changes to the QPP program didn’t feel nearly as substantial. The QPP 2019 Fact Sheet seemed short on details and I haven’t had a chance to fully digest the full rule. A few highlights though:

  • 2019 QPP will remove the MIPS process-based quality measures
  • MIPS Expands to PTs, OTs, CSWs and clinical psychologists (which was required by law)
  • It will overhaul the “Promoting Interoperability” category (pretty generic and haven’t figured out what this really means, but they say it will focus on interoperability, imagine that!)
  • The Promoting Interoperability scoring has changed and so has some of the weighting, but nothing major
  • Many of those excluded from MIPS in 2018 can opt in to participate if they want in 2019
  • $500 million pool is available for exceptional performance (whith is now at 80 points vs 70 in 2017)
  • Must use a 2015 Certified EHR (officially a 2015 Edition CEHRT)

Those are some of the big changes I saw offhand.  I’d suggest that this is mostly business as usual for the most part.  Significant if you’re in the MACRA and MIPS weeds, but isn’t likely going to change your MACRA and MIPS strategy.

One change I’m still processing is this one:

Changing the application of MIPS payment adjustments, so that the adjustments will not apply to all items and services under Medicare Part B, but will now apply only to covered professional services paid under or based on the Physician Fee Schedule beginning with 2019, which is the first payment year of the program.

Does this change the analysis that Jim Tate did previously that MIPS Penalties (and incentives for that matter) included Medicare Part B drugs? Sounds like it to me. If I’m reading it right, this change means that the penalties will be less for those getting penalized, but the payments will be less for those participating in the program as well. Not a good thing for a program that already has incentive problems. Is that right or am I reading it wrong?

On that note, this explains why the final rule is 1473 pages long. Time to do some reading of the final rule and see what all the experts find as they analyze it. Let us know what we missed in the comments or any analysis of this that we got wrong. We can all learn what this means together.

Plus, remember that this is just the proposed rule and CMS even asked for comment on if it should go into effect in 2019 or 2020. I encourage you all to provide your feedback on the proposed rule so it can be improved when it goes final.

Early Lessons from the Front Lines of Value-based Care: How One APM Has Impacted Community-Based Oncology Practices

Posted on June 11, 2018 I Written By

The following is a guest blog post by Dr. Charles Saunders, CEO, Integra Connect.

The Oncology Care Model (OCM) – an alternative payment model introduced in July 2016 by the Center for Medicare and Medicaid Innovation – launched with the ambitious goal to further delivery of higher quality, more coordinated cancer care at a lower cost. Participants include 184 practices representing approximately one-third of community oncologists in the US. They receive a so-called “MEOS” (monthly enhanced oncology services) payment of $160 per beneficiary per month for the duration of a qualifying 6-month chemotherapy period, plus the opportunity to earn a share of savings if they exceed a target threshold. In return, oncologists are expected to take on increasing accountability for patient outcomes and well-being, while also generating sustainable cost savings across all co-morbidities and care settings, into the patient home.

OCM Performance Period 1 Results Exposed an Unexpected Misalignment   

As part of the OCM program, CMS tracks practices during 6-month intervals – so-called “performance periods” – then shares results back about one year later. In February 2018, practices participating in the OCM program received visibility into Performance Period 1 (PP1) data, including savings achieved, aggregate quality score, and effectiveness of identifying eligible patients. While most practices were unsurprised by their performance scores, many did not anticipate the extent to which CMS would recoup MEOS payments that it deemed paid in error. The most common scenario involved patients with co-morbidities who, while receiving chemotherapy and related services, also visited other providers regularly. Therefore, the oncology practice did not represent the required plurality of E/M codes for that beneficiary. It was not uncommon for practices to be asked to return up to 30% of the sum they had been paid – a major financial hit.

Lack of Data Hinders Practices’ Ability to Accurately and Proactively Identify Beneficiaries

In May 2018, practices received their Performance Period 2 (PP2) Attribution Lists, which summarized which CMS beneficiaries met OCM eligibility criteria, which episodes were attributed to each respective practice, and episode start dates from January 1, 2017 through June 30, 2017. Unfortunately, because there is a significant lag between actual Performance Period and delivery of CMS findings – delayed up to nearly a year after each performance period has ended – OCM participants were unable to retroactively apply PP1 learnings to PP2.

Why is this especially problematic? Practices are faced not only with MEOS recoupments for erroneous payments but, with only a 1-year window to submit claims, are often unable to bill in full for patients who were missed. Indeed, there are many opportunities to miss appropriate patients, as practices needed to have an accurate view of: 1) all beneficiaries; 2) those with a qualifying diagnosis; 3) those with a new chemo episode; 4) those not only prescribed an oral agent, but those who subsequently filled it; 5) those not in a hospice; and more. Given all the dimensions to track and measure, practices without advanced tools face delivering enhanced services that they cannot correctly bill for.

Best Practices from Community-Based Oncology Practices Include Robust Data

What best practices arose to get attribution right? A vanguard of OCM practices realized that they would need to take proactive steps to enable near real-time visibility into their patient populations, embracing the tenets of population health management. Below is an example of the best practices adopted by several of these community-based oncology practices:

  • Increased transparency into oral chemotherapies: Existing practice protocols did not open an episode when oral agents were prescribed, since there was no in-office administration. To address this, the practice introduced a rule-based algorithm to identify all OCM eligible patients, including those who had been prescribed orals. In addition, they enlisted a combination of automated and personal follow-ups to validate qualification and ensure orals had been filled.
  • Avoidance of duplication: To identify missed billing opportunities while also reducing the risk of duplicated claims, practice leadership invested in a robust analytics tool that enabled personalized queries at the patient level. These reports compared eligibility against their practice management report to identify gaps, from unpaid and unbilled to denied.
  • Targeted patient intervention: To balance the practice’s financial and clinical objectives while optimizing OCM performance, the practice introduced complex care management services and employed a series of triage pathways. This approach ensured engagement with attributed beneficiaries and decreased avoidable high-cost events among at-risk patients, such as inappropriate ER visits and inpatient stays.
  • Optimized treatment choices. As part of its commitment to ensure each patient received the most effective treatment for his or her disease, the practice provided increased transparency around the availability of equally effective generic or biosimilar drugs. They also supported better end-of-life planning for patients facing second or third-line therapies not expected to provide any clinical benefits, but that could significantly degrade remaining quality of life.
  • Continuous performance improvement: To track the effectiveness of these quality improvement initiatives, the practice leveraged its analytics tool to monitor resource utilization and care management performance, then intervened to address outliers in real-time.

In short, to optimize performance under the OCM, practices are beginning to leverage the data to which they already have access – both clinical and financial – to risk-stratify their patient populations; identify OCM eligible patients; and gain near real-time visibility into quality and cost performance. Practices are also investing in better data integration and analytics that enable rules-based identification of eligible patients.

Population Health Analytics Help Practices Be Proactive and Succeed Under the OCM

Oncology is on the forefront of value-based care adoption and these early experiences from the OCM have provided a guide for other specialties. Based on their early results, what has come to the forefront is the need for a combination of comprehensive data management and robust analytics, coupled with the principles of population health management, which enable practices to step up and take control of the cost and quality for their attributed populations.

Meaningful Use Becomes Advancing Care Information Becomes Promoting Interoperability – MACRA Monday

Posted on May 7, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

I’m quite sure you’ve all seen the news coming out from CMS about the name change for the various Medicare EHR Incentive and MACRA programs. I decided to not dive into it in depth here since so many organizations are already doing it. Plus, this is just the proposed rule. However, if you want some light reading, here’s all 1883 pages of the Promoting Interoperability proposed rule.

The name change of Meaningful Use/Advancing Care Information to Promoting Interoperability is an interesting way for CMS to signal what they want these programs to accomplish. It’s always been clear that ONC has wanted to find a way to promote interoperability. Now they literally have a program that will work to drive that goal.

I’ll admit that I’ve been a fan of this idea since May 15, 2014 when I suggested that ONC and CMS blow up meaningful use and just focus it on interoperability. It only took 4 years for them to figure this out.

While I still think this is directionally an interesting way to go, I’m afraid that the current programs aren’t a big enough incentive for CMS to really move the needle on interoperability. Plus, can CMS really create a rule that would push effect interoperability? I’m skeptical on both counts.

What’s interesting is that CMS could really push interoperability if it wanted. It could just say, if you want to get paid for Medicare, then you have to start sharing data. No doubt there are some complexities to this idea, but if CMS is really serious about promoting interoperability, that’s what they’d really do. That would move the needle much better than thousands of pages of rule making that won’t cause doctors and healthcare organizations to change.

What are your thoughts on the proposed rule? Were there big pieces of it that you saw and you think others should be watching? Are these changes going to relieve doctors of the massive reporting burden they should today? Please share your thoughts in the comments or on Twitter with @HealthcareScene

MIPS Twitter Roundup – MACRA Monday

Posted on December 11, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

As we near the end of 2017, I found a number of tweets from CMS and other people that I thought would be useful to those that are interested in MACRA and MIPS.

First up is this tweet from CMS that it’s not too late to still participate in MIPS and collect some performance data before the end of 2017. This is them promoting the Test Option which would allow you to avoid the 4% penalty:

Next up is a fact sheet from CMS which outlines the different between 2017 and 2018 when it comes to MACRA/MIPS. I particularly like page 6 of the document. As you go through it, you’ll realize why 2018 is going to be much harder than 2017.

Next up is a stat from MGMA. I’d be interested in learning about the 14% of practices that think that their value-based reimbursement is going to decrease. Are these people going to direct primary care? I don’t see it going down for almost anyone. What do you think?

Finally, Matt Fisher asks a question about whether MIPS should be voluntary. I don’t think they can make it any more voluntary given the current legislation and do any of us think that congress is going to take up this topic? I don’t. So, it’s kind of a moot point. However, there is a lot of doctor angst about MIPS/MACRA. I just don’t see enough of it to really move the needle on things. I think we’re stuck with MACRA/MIPS for the forseeable future.

MIPS Penalties Include Medicare Part B Drugs – MACRA Monday

Posted on November 13, 2017 I Written By

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

I’m sure most regular readers can tell that we’re pretty worn out and tired of MACRA, MIPS, and related government regulation. No doubt you’ll see us posting fewer MACRA Mondays going forward, but we’ll still try to cover major MACRA events as they occur. We just won’t be publishing MACRA Monday every Monday like we’ve been doing.

Jim Tate recently posted about the Real MIPS Timeline which included:

  • Phase 1 – Denial
  • Phase 2 – Shock/Anger
  • Phase 3 – Acceptance

You should read his full writeup, but he’s right. There’s a lot of denial that’s going to lead to shock and anger until the majority of healthcare have to finally accept that MIPS and MACA aren’t going anywhere.

Jim Tate also wrote another important piece related to the MIPS penalties and Medicare Part B drugs. You can read the full details of the change, but for those too lazy to click over, here’s the summary:

  • Many organizations argued that Medicare Part B Drug Costs Shouldn’t be Included in the MIPS Penalties (I mean…payment adjustments)
  • The MACRA Final rule still includes Medicare Part B drug costs (for the majority of people) in the MIPS reimbursement and eligibility calculations

If you’re a practice with a high volume of part B drugs, you better start figuring out your MIPS strategy now! Otherwise, that payment adjustment is going to hit pretty hard.

Thanks Jim for the great insights into MACRA and MIPS. If you need help with MIPS, be sure to check out Jim’s company MIPS Consulting.

MACRA Twitter Roundup – MACRA Monday

Posted on October 30, 2017 I Written By

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

We took last week off from our MACRA Monday series of blog posts. It seems like we’re in a kind of lull period for the program. Either you’ve started collecting the data you’ve needed or you haven’t. Plus, we’re kind of waiting for the next MACRA Final rule to drop for more details.

With that in mind, I did want to see what some of the latest things that were being shared on Twitter when it comes to MACRA. I found a lot of strong opinions about the program, some good resources, and some forward-looking thoughts on what could be coming in the next MACRA final rule.


It’s hard to argue with John. Not just because he’s a smart guy, but because he’s right that it’s hard to imagine a path forward that’s fee for service and doesn’t include a shift to value based care in some form or fashion. At least given the current market dynamics.


This caution from Workflow Chuck should have us all nervous about the shift. I see a lot of healthcare organizations going after the target as opposed to the goal of value based care.


MACRA is going to impact your biz. I liked the way Kelly broke it out into 4 areas. No doubt some of these things could be argued both ways.


This is still how most doctors I know feel about MACRA and even meaningful use before it. They feel like they’ve been thrown under the bus.

Here are two forward looking resources that look at what we might get from the MACRA Final Rule:

What else are you hearing about MACRA? Would love to hear your thoughts, insights, questions, perspectives, rants, etc in the comments.

Optimizing Your EHR for MIPS and Other Quality Payment Programs – MACRA Monday

Posted on October 9, 2017 I Written By

The following is a guest blog post by Meena Ande currently acts as Director of Implementation for Advantum Health. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

As quality reporting requirements ramp up under value-based payment programs like MIPS, healthcare organizations are busy retrofitting their EHRs to make way for new measures. In some settings, not much has changed by way of tech utilization since initial EHR investments were made. Many outpatient settings still lack the internal expertise needed to optimize their implementations.

The truth is many EHRs have the functionality providers need for quality reporting, but many providers don’t know that due to limited exposure to the system. Couple that stunted tech knowledge with the well documented lack of familiarity with MACRA and the recent rise of the service model in healthcare is no surprise. Many practice administrators are relying on their EHR vendor or engaging outside experts to help lead the charge on system reconfiguration to meet Quality Payment Program demands.

There are several EMR capabilities providers can take advantage of to support QPP reporting efforts. Here are a few tips to keep in mind as you customize your EHR for MIPS and other value-based models.

Don’t boil the ocean when selecting CQMs.

Most EHRs give the option of tracking more than what is required for quality reporting. Initially, track applicable measures that exceed reporting requirements. After three to four weeks you’ll know which are your strong areas. Pick the best of the litter and proceed.

Providers can be overwhelmed by too many measures, particularly in multi-specialty practice settings. While it can be difficult to find overlap in measures between specialties, taking advantage of shared metrics whenever possible can reduce reporting burdens. Sit down as early as possible and develop an EHR configuration that works for your practice’s various clinicians.

Case in Point:

A gastroenterologist and a cardiologist may work in the same multi-specialty organization and on the same EHR, but the clinical quality measures they care about differ. There is no reason to give the gastroenterologist access to the cardiology problem list in the EHR. Specialty views improve ease-of-use and support more complete documentation.

Most EHRs offer role-based and specialty-based customization. Administrators can enable or disable EHR features related to some quality measures at the practice level and sometimes at the individual provider level. Clinical quality measures are based on details about the patient, but what is captured at each point of care should be tailored to the specific provider role.

Consider the roles impacted by different CQMs.

Keep the role of the person who may be responsible for different quality measures and Advancing Care Information workflows in mind when selecting and carving out space for CQMs in your EHR. Select measures that spread reporting work across multiple roles to relieve clinicians of unnecessary burdens.         

Case in Point:

The insurance eligibility verification required under Meaningful Use is managed by the front office. Front-office staff members should be made aware of the processes they need to complete before a patient checks in, and where to document that task in the EHR.

Control what is included in MIPS denominators.

Like Meaningful Use, patient encounter volume is important under MIPS. The size of the patient pool under any given quality measure directly impacts your adherence percentage. While most primary care encounters do meet patient visit requirements under MACRA, that is not always the case in specialty settings. Clinicians can exercise some control in determining what is included in patient denominators when reporting under MIPS.

Case in point:

Some primary care visits can be omitted. Let’s say a two-physician practice sees 50 patients a day. Only 15 of those patients might be seen by a physician. The rest of the patients may be there for a simple procedure like a blood pressure screening, stress test, or echocardiogram, where quality reporting elements are not verified. Such visits should be excluded.

Evaluate your reporting paths.

MIPS offers both EHR-based and registry-based reporting paths. Most specialties can submit CQM data via their EHR while others will have to rely on paid registry reporting. Additional reporting options might include submitting through associations that member clinicians are affiliated with, or through registries created by large hospital affiliates to help related providers.

Another hurdle for clinicians is deciding whether to submit data as a group or independently. Groups interested in participating in MIPS via the CMS web interface or administering the CAHPS for MIPS survey had until June 30, 2017, to register. Beyond that, clinicians have until the March 31, 2018, MIPS submission deadline to decide whether to report independently or as a group.

Case in point:

Big groups with different levels of EHR proficiency among providers may be better suited reporting at an individual level. Individual reporting takes more time for attestation, but the advantage is that higher-performing clinicians can avoid a penalty if the group doesn’t collectively meet reporting criteria.

Each month, sample 10 percent of EHR CQM data, including instances where criteria have been met and where it has not. Catch outliers with trouble following through on processes and extend targeted training to the team members bringing numbers down.

Conclusion

Optimizing the EHR and other tech resources providers have in place can be a huge MIPS enablement factor. Up-front customization work helps providers meet reporting requirements and save time over the long run. EHR optimization also enables future value-based care initiatives and lays the groundwork for population health management programs. Gains made in EHR use benefit the life of the practice through increased efficiency and, at the end of the day, better patient care.

About Meena Ande
Meena Ande currently acts as Director of Implementation for Advantum Health where she manages Implementation of services along with EHR optimization, with emphasis on workflow management for value-based reporting.

Should We Return to the Move from EMR to EHR?

Posted on April 8, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Over the 10 years I’ve been blogging about EMR/EHR, it’s been amazing to watch the evolution of the terms and how people use them. Based on most people’s usage, I’ve long been an advocate that the two terms should and are used interchangably. If you say one or the other, most people are assuming the broadest use of the term. Although, the HITECH Act’s use of the term EHR has certainly made it more popular and in vogue (even if most doctors I know still call it an EMR).

Semantics aside, now that meaningful use has matured, I believe that healthcare is ready for a return to the conceptual differences between an EMR and an EHR. Conceptually an EHR was a record that included the patient provided data along with the clinic’s data (ie. EMR data). This concept was partially included in meaningful use, but not in a very meaningful way.

What are some patient features that would constitute an “EHR”?

Medical Record Access – Patient access to the EMR data should be a core feature of an EHR. Most EMR/EHR vendors provide this feature and more and more doctors are excited to give their patients digital access to their medical record. However, along with access to the medical record we need to build features that allow the patient to submit corrections to the medical record.

Secure Messaging – Patients are increasingly demanding electronic access to their doctor’s office. This secure messaging is often done through the EHR. Most EMR/EHR software have this as an option, but many doctors are afraid of what this messaging will mean for their workflow. Luckily, more and more doctors are sharing the experience that this type of messaging makes their workflow faster and better. High maintenance patients are going to be high maintenance regardless of options they have available to access you.

Patient Generated Data – This feature is still something that many are trying to figure out. Can they allow patients to submit their own health data to the doctor? If they do, what’s the doctor’s liability for that data? How can/should the doctor use the data that’s being shared with the clinic? There are plenty of questions about how this should be executed, but there are also a lot of opportunities. It’s time we start working through these challenges.

There’s a whole suite of other services that we should look at offering patients as well such as: online appointment scheduling, online patient payment, refill requests, etc etc. However, if we could start with just the above 3 items we could truly start calling our systems an Electronic Health Record and not just an Electronic Medial Record. Regardless of what we call it, I believe these types of features and even more patient focused access are going to be the future wave of what patients will expect from their doctor.

Wow, That was Fast

Posted on February 19, 2016 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Well that sure didn’t take long…

In response to CMS Administrator Andy Slavitt’s comments last month regarding the future of the Meaningful Use Program and the need to recapture the hearts and minds of physicians I posted on open letter to Mr. Slavitt yesterday in an attempt to reach out to him regarding those issues.

I did not expect what happened next.

He answered within a couple of hours:

“Very thoughtful letter and I think likely reflects the views of many. I will share it internally because culturally people need to see the gulf between the policy ideas and the front line of medicine.

Believe all the fatigue and the laws we still need to implement and the current state of technology means it will take some time before differences are felt where they matter. Implementing laws like MACRA is a complex undertaking but the core of what you said I believe is the most important thing– It all begins with listening. The details matter here more than the principles but I’m a believer in that’s where it starts. And we have more focus groups and front line interactions than I have seen before. We are not just listening to “Washington” docs.

I try to always begin by calling it like we see it including hard truths. I believe we have work to do and want to orient people to the proper course. You always risk setting expectations when you lay out an agenda, particularly when there is no silver bullet. But it’s better than the alternative.”

Within moments I also received equally gracious responses from Patrick Conway and Kate Goodrich, also from CMS:

We both inherited the “meaningful use program” 6-12 months ago and do think the MACRA legislation providers an opportunity to transform the program, lessen burden, make much more simple, and flexible to meet docs needs. Happy to take ideas and input from you anytime and thanks for your work.”

Wow. You have to admit that this is not what one would expect from the “faceless, heartless bureaucrats” I have been criticizing in print and on Internet radio all this time. Is the paradigm changing? Maybe. Maybe not. But one thing is for sure – we physicians have to give them the chance to make good on their rhetoric. I certainly intend to to that.

Stay tuned….

An Open Letter to Andy Slavitt, Acting Administrator CMS

Posted on February 18, 2016 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Mr. Andrew Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Washington, D.C..

Dear Mr. Slavitt:

No doubt you were surprised at the strong, widespread reaction to your comments regarding the Meaningful Use Program as part of your speech to the JP Morgan Healthcare Conference several weeks ago. Your quote regarding the hearts and minds of physicians was particularly noteworthy. After decades of Federal regulatory hostility towards physicians, some of us doctors were pleasantly surprised – even shocked – to hear you acknowledge:

– physicians exist beyond just being another cog in the healthcare machine.
– physicians actually have hearts and minds.
– physicians’ opinions might have value to you.
– programs that are poorly designed distract physicians from patient care.
– CMS aspires to a “cultural focus on listening and learning”

Many of us physicians reacted like starving prisoners when the Commandant announces that there will be extra cockroaches for dinner. Though the news was small, many of us were overjoyed.

But most of us (60% by a recent survey) reacted differently. The majority of us understand the political savvy of saying something controversial about your enemy. Such a move can create a useful distraction, driving the enemy to argue amongst themselves while you continue with work that you would rather we didn’t notice…and that is exactly what has happened. Like an octopus squirting ink into the water you have created an effective smokescreen to let you spend the next few months coding Meaningful Use into MACRA without any interference from us.

So the purpose of this letter is to ask the question: Which of the above interpretations of your comments is correct? What are your intentions?

If your comments are sincere then consider this letter a warm introduction to the group of rapidly growing, grass-roots full time practicing physicians whom this letter represents. Over the past few years we have acquired the policy expertise and political skills to be effective leaders and collaborators with you to bring truly meaningful improvements to America’s health care. Realize that the leaders of organized medicine with whom you currently work – including the AMA , whose membership represents less than 15% of practicing physicians – do NOT represent the “hearts and minds” of physicians that you profess to seek. If you mean what you say then we are reaching out to you.

If, on the other hand, your comments are nothing more than political subterfuge, then this letter serves as a warning. We are not buying the political offal that you are selling. This physician group will use all of its intellectual, financial and political resources to make it far more difficult for you to destroy what is left of health care in America.

The choice is yours. We look forward to hearing from you.

Michael Koriwchak, M.D.
Vice President
Docs4PatientCare Foundation