ACMPE Paper, October 2012

Transcription

1 ACMPE Paper, October 2012 By: Spencer Mills, MA, MBA, FACMPE This case study manuscript is submitted in partial fulfillment of the requirements for election to Fellow status in the American College of Medical Practice Executives This manuscript was prepared as part of meeting various recognition criteria as set forth and may be changed from time to time by the American College of the Medical Practice Executives (ACMPE). The experiences, thought, ideas and opinions set forth are solely those of the author. They do not reflect any position on the part of ACMPE with respect to their completeness, correctness or accuracy of the paper s contents, for example, on points of law or accountancy in effect at the time of or subsequent to the date of paper completion Medical Group Management Association. All Rights Reserved.

2 Case Study Manuscript MGMA-ACMPE Implementing EHR & Achieving Meaningful Use: An Orthopaedic Group Experience By Spencer Mills, MA, MBA, FACMPE Submitted in Partial Fulfillment of the Requirements for Election to Fellow

3 Implementing EHR & Achieving Meaningful Use: An Orthopaedic Group Experience I. Statement of the Problem An orthopaedic group desired to take advantage of incentive payments offered by the Center for Medicare and Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Program. The CMS EHR Incentive Program requires the achievement of meaningful use as defined by a number of program objectives. The group is using a practice management (PM) and EHR system that is certified for the CMS program. However, the group was not utilizing major elements of the EHR component of the software. A new practice administrator had been hired by the group to lead the implementation of a number of initiatives, including the achievement of meaningful use. The deadline for beginning the 90 day reporting period for 2011 was October 3 rd and the new administrator arrived in September to lead the group. To receive the incentive payments, Eligible Professionals (EPs) must meet 15 core or mandatory measures and 5 measures selected from a menu of 10 additional measures, for a total of 20 program measures or objectives. In addition, one of the core measures requires reporting on 6 clinical quality measures. Staff time and resources had already been devoted to investigating the potential of achieving meaningful use. To successfully achieve meaningful use for all program objectives in 2011 would mean addressing a number of technical and training hurdles during the 90 day reporting period. 2

4 a. Group Structure The medical group or clinic consists of four orthopaedic surgeons, one employed physician and four physician assistants. The four surgeons are four shareholders with equal shares in the group. The shareholders make decisions in monthly meetings with the administrator and assistant administrator present. All staff in the clinic report to the practice administrator for administrative and operational matters and to the supervising physicians for clinical matters. Each of the physician assistants is assigned to supervising physicians. There is a staff of five medical assistants, two radiology technologists, and two nurses. One of the nurses, an RN, is assigned exclusively to one of the physicians, serving both as a nurse and scribe. An information technology specialist reports to the practice administrator and handles all software and hardware issues as well as IT help desk functions. The radiology technologist manager also participates in clinic wide initiatives such as meaningful use and compliance. b. Meaningful Use Team In establishing a team for meaningful use, the administrator initially included the assistant administrator, the IT specialist, and the radiology technologist manager. The radiology technologist manager is qualified as a medical assistant and ended up being a primary trainer for the medical assistants. The RN also became a key staff member for the project. What the team lacked was a physician or provider champion for the project, and in hindsight, this negatively impacted the EHR implementation. 3

5 c. Technology The clinic used Sage Intergy, now Vitera Intergy for the software, version This version was the most recent update at the time and was certified for the CMS program. The EHR is fully integrated with the PM system. II. Alternative Decisions Considered 1. Postpone Meaningful Use The meaningful use team considered postponing meaningful use until 2012, after the clinic had been using the EHR components of the Intergy software during an initial trial period. Delaying meaningful use until 2012 would allow for a better planned and more gradual approach to EHR adoption. Barring a change in federal funding for the program, delaying meaningful use until 2012 would not jeopardize the group s ability to fully participate in the CMS EHR Incentive Program. The full first year funding amount of $18,000 per EP could be met during any consecutive 90 day period in The clinic did not have an action plan in place for implementing the EHR. Delaying meaningful use until 2012 may avoid mistakes and implementation problems that may discourage the staff and providers from fully embracing the EHR. On the down side, delaying EHR implementation and meaningful use would delay receiving the incentive payments by a significant time, perhaps by a full year if further delays pushed the 90 day reporting period off to the end of Furthermore, delaying meaningful use may not eliminate the challenge or pain involved in EHR adoption. The clinic had purchased the practice management and portions of the EHR 4

6 software in 2006, and while the clinic was forward thinking in being an early adopter, the clinic had not fully embraced the capabilities of the Intergy program. Moreover, the administrator had to consider the impact of a delay. It could diminish the sense of urgency for full EHR adoption. 2. Push Forward The alternative was to move forward with EHR adoption and attempt to achieve meaningful use during the remaining 90 day reporting period in Pushing forward would create a sense of urgency about EHR adoption that was lacking previously at the clinic. Since the group s EHR was already purchased, and some elements of the EHR were already being used, attempting meaningful use in 2011 would bring in revenue at minimal cost. The EHR had been updated recently and the IT staff had invested time in getting to know the system. Staff resources were available and attempting meaningful use could take advantage of recently acquired knowledge and skills while still fresh. Finally, attempting meaningful use in 2011 would take advantage of the impetus provided by the change in administrative leadership. The new administrator hoped to create momentum and excitement about new initiatives at the clinic. The administrator faced some risk with this approach. Attempting to jump start meaningful use prematurely while adopting EHR could create training problems and affect staff morale. Any EHR implementation project is freighted with potential difficulties. In this case, the clinic had to learn the EHR at the same time as meeting the meaningful use objectives and this was a tall order in 90 days. 5

7 III. Procedures Used to Select Solution 1. Background Research The new administrator researched the requirements of the CMS EHR Incentive Program along with key administrative staff, including the IT specialist, the assistant administrator, and the radiology technologist manager. This meant studying the CMS website materials and other resources in order to understand the various requirements. The meaningful use team accessed training with Sage on Intergy s meaningful use features in the event the decision was made to go forward. The administrator then discussed with the team the pros and cons of moving forward in 2011 and the project was presented to the physician owners at the next regularly scheduled shareholder meeting. 2. The Clinic s Use of EHR Prior to Meaningful Use The clinic was using some elements of the EHR and some elements of the structure data features of the software. i The clinic did not use paper charts. Intergy has electronic charts and medical records were being scanned into the charts. The clinic was recording allergies, medications and vitals in the electronic chart and receiving lab results. All the medical records were already being scanned into the EHR and stored as documents in the electronic chart. The clinic used a separate PACS system for images but the interface was expensive so the PACS is not integrated with the EHR. Demographics must be entered separately in the PACS. The providers used Winscribe to dictate and the transcription department entered transcribed dictation directly into the 6

8 EHR, saving the progress notes in the patient electronic chart much like a Word document. The tasking function was being used that allows providers and staff to send internal messages to one another as well as document important clinical tasks directly in the patient chart. Moreover, the PM and billing components of the software were fully integrated as one platform with the EHR so the front desk and business office were using most of the features available to them. Most of the structure data features of the EHR were not being used. A significant challenge was that a major module of Intergy, the encounter note, was not being used and some of the other elements were only partially utilized. For example, transcribed dictation was entered into the chart but not in the form of a completed progress note or encounter note as prescribed by the software. When the clinic was considering meaningful use, it purchased the encounter note module. Learning to use the encounter note functions, specifically the structured data features, involved a great deal of training and the deadline for beginning the reporting period was approaching. 3. Shareholder Meeting The meaningful use team discussed a number of key elements with the physician owners at the shareholder meeting, summarizing the program requirements and the current state of EHR use. The timing of the payments was important. The clinic could receive a large incentive payment in a little over 120 days if the implementation began right away. Delaying would defer the payments over 120 days after the beginning of the New Year and pushing back second year funding by a full year. 7

9 The physician owners brought up the fact that the medical group had been talking about meaningful use for over a year and little progress had been made. They agreed that a sense of urgency was needed to get the ball rolling. Full EHR adoption would require significant effort regardless of when it was undertaken and setting a specific goal could overcome this tendency towards inertia. IV. Decisions The physician owners decided to move forward with EHR adoption and attain meaningful use in The administrator and staff had the approval to use training purchased from the software vendor to begin the project. However, what was lacking at the time was a sense that a physician or physician assistant needed to be an essential member of the core meaningful use team. V. Implementation: 1. Training the Trainers Training the core meaningful use team required time, focus and funds. Sage provided extensive training for Intergy. Some training had been purchased already. Sage was swamped with requests for training time with other clients so time had to be reserved. The training was conducted by teleconference with an online connection that allowed the trainer to navigate through the software while the meaningful team watched and asked questions. Sage representatives also came on site for some training. Additional training time was purchased as needed. In total, about 32 hours of training with Sage Intergy EHR trainers was purchased or received free, including training on 8

10 meaningful use, the practice portal, practice analytics, encounter notes and customizing forms. Significant time and effort was required to understand the CMS program objectives. It is one thing to read through the 25 program measures. It is another to fully understand the measures well enough to take the necessary steps in training staff to comply with meeting at least 20 of them. The meaningful use team read the measures, created binders with program materials and met to discuss each of the measures and what they meant. Then, during the training time with the vendor, questions could be asked about how to achieve each of the measures. In addition, the clinic employed an outside consultant who provided back up for understanding the CMS EHR Incentive Program. The relationship with the healthcare consultant was already in place and the consultant brought first-hand knowledge regarding the wording of the final federal regulation or rule as published by the Department of Health and Human Services. The use of the consultant was planned and the hourly consulting fees, amounting to only two to three thousand dollars, were well worth the money spent. The consultant s time was in the form of some conference calls and communication. 2. Training the Nurses, Medical Assistants, Front Desk Staff and Transcription Meaningful use requires involvement of everyone from the front desk to the providers, clinical support staff and transcription. Some staff picked up the 9

11 requirements easier than others but all staff had to be trained on an ongoing basis to achieve success. The front desk staff had a limited need for further training in the entry of required demographic information. The nurses and medical assistant were trained as a group and then the training was reinforced with them individually. Additionally, follow up training meeting had to be held. Transcription was included as seemed necessary. As time went on the MAs and nurses commented that everyone was making entries differently and this had to be addressed in additional meetings, even going into the second reporting year. 3. Training the Physician Assistants The physician assistants picked up the EHR faster and with greater ease than did the physicians, perhaps because as a later generation they are more adept at technology applications. The CMS program allows the physician assistants scores to be compiled by the EHR with the physicians, who are the Eligible Professionals, as long as it is done in a consistent manner. Intergy provides for this reporting capability. Therefore, the physician assistant scores sometimes brought up the supervising physician scores. 4. Training the Physicians Training the physicians was the most difficult because their time commitments were greater and their need to spend time entering the structured data into forms and templates is the greatest. The process proved frustrating to the physicians. The clinic did not have time to have physicians view training videos prior to training sessions with the meaningful use team and Sage s training staff. What evolved over time was that 10

12 both the physicians and the physician assistants came to the IT specialist regularly as a help desk on EHR. Of particular difficulty was the time required to go through the Intergy forms and click off the required boxes to complete an encounter note in the structured data format. In addition, there seemed to be the need for some free texting to flesh out the note. This all meant additional time was required to complete a note as opposed to dictating a note, as was done previously. The EHR also allowed for dictation. Intergy allows for what are called dictation markers. These markers are placed into the various sections of the note. The transcriptionists then match the dictation to the markers and send the transcribed note back to the providers for review. The provider then approves the note and signs off on it. Some of the physicians retained dictation as the primary method of completing a note. In such a case, meaningful use was accomplished by ensuring enough was done to meet the requirements but much of the structured data capabilities of the software were not utilized. Even those physicians who jumped into the EHR all the way and eliminated dictation needed to have the forms customized for them and this required sitting down the IT specialist for a number of hours at a time. For example, one physician spent about 8 hours customizing forms and then the IT specialist spent an additional 12 hours completing the adaptations for that physician and that was just the beginning of the need expressed by that physician. Customization remained an outstanding issue with the EHR implementation. 11

13 5. Monitoring and Reinforcement The meaningful use team was responsible for monitoring the scores on meeting the program objectives. The software program provides a meaningful use dashboard that shows scores for each physician and physician assistant. The IT specialist became the primary monitor of the scores and the scores were reviewed regularly with the meaningful use team. Initially it was a challenge to understand how to use the dashboard correctly. The system required a patient encounter to become a billable encounter, passing through the system before it became visible in the scores. In addition, there were technical problems that had to be brought to the attention of the vendor. However, Sage generally resolved the problems in a timely manner and the team used the dashboard scores to keep staff and all providers updated on their progress to date. VI. Meaningful Use Objectives 1. Core Measure One: Computerized Provider Order Entry (CPOE) ii The requirement states that licensed healthcare professionals must use a computerized system for entering orders for medications and that the computerized system must document in a digital or structured format the data captured by the order. The threshold is 30 percent of all unique patients with a least one medication in their medication list. For all the meaningful use measures a unique patient means any patient seen during the reporting period. If a patient is seen more than once during the 12

14 reporting period, the EHR counted that patient only once in the denominator for the purposes of calculating the percentage threshold. The group s system was set up to achieve this objective and the group was already using CPOE for medication orders. However, since the clinic is an orthopaedic clinic, many of the Schedule II-IV or narcotic medications, which are the bulk of the medications, could not be electronically prescribed. The program requirements allowed that orders could be entered into the system in accordance with local, state and professional guidelines. The clinic entered the medications into the CPOE system and captured orders in a structured data format even though narcotics could not be electronically prescribed. When meaningful use went into effect, the federal government ban on narcotic e-prescribing had been lifted but the program requirements provided for exceptions based on the status of the previous federal guidelines. 2. Core Measure Two: Implement Drug-Drug and Drug-Allergy Interaction Checks iii This measure requires that the EHR is capable of providing drug-drug and drugallergy interaction checks. The clinic s EHR had this functionality and it was enabled during the entire reporting period, so it was able to attest yes to this program requirement. The clinic s providers are able to check for these interactions through the EHR when documenting a patient s chart and prescribing medications. 13

15 3. Core Measure Three: Maintain An Up-To-Date Problem List of Current and Active Diagnoses iv The problem list requirement states that a list of current and active problems or diagnoses for patients must be maintained by the certified EHR. The requirement threshold is 80 percent. That is, more than 80 percent of all unique patients must have an entry in the problem list in a coded format. The list must be up-to-date with the most recent diagnoses known to the EP. If no problems are known, then that fact must be entered into the problem list. As a condition of certification, Certified EHRs are required to link ICD-9 or SNOMED-CT with problem list items, and therefore, EPs must maintain an active list of diagnoses linked to ICD-9 or SNOMED-CT. The problem list requirement created significant challenges. It is time consuming and the question of who was to enter the problems came forward and remained an ongoing challenge. Since the medical assistants and nurses typically entered the chief complaint into the EHR as well as items communicated through the health information intake form, it was thought that they should also enter the problems. However, the providers physicians and physician assistants in this case must review any problems entered by the MAs for accuracy and for completeness. The MAs have been instructed to search for and enter only generic descriptions for conditions and medical problems, leaving the review to the providers since the final responsibility for the accuracy and specificity of the problem list and of all diagnoses entered is the providers and the supervising physicians. The clinic s EHR vendor had done a good job 14

16 in creating the features needed for updating the problem list, with options for the status of conditions, chronicity, date of onset and a long list of potential assessments such as Improved, Worsening or Stable. Once a problem is entered and saved it remains in the system. The software allows for designating an entry as Entered in Error and to set a problem as Inactive. Additionally, the software allows for searching in the Medcin database of diseases and conditions and provides for the entry of a Favorites list of diseases and conditions. The clinic previously maintained a significant list of common conditions and diagnoses and entered that list into the favorites list for selection as appropriate. The software also allowed for entry into the problem list on a given patient encounter by selecting from a list of diagnoses from the previous visit and from all diagnoses entered into the system in the past for that patient. For example, when the patient encounter was complete and diagnosis codes were selected by the providers in the course of documenting the visit or by coders based on the documentation, those diagnoses would then be available for entry and updating in the problem list on the subsequent visit. The problem list is important because it is also included in another CMS program requirement, that of providing each patient with a visit summary for each patient office visit. The clinic s software entered the problem list into the visit summary once the clinical staff cited it into the patient encounter note. Since the problem list requirement is that each unique patient has at least one entry on the problem list during the 15

17 reporting period, it is not necessary that the problem list be updated at every encounter during the reporting period, except as determined to be appropriate by the healthcare provider. 4. Core Measure Four: Generate and Transmit Permissible Prescriptions Electronically (erx) v The e-prescribing requirement is intended to encourage the use of electronic prescribing capabilities of an EHR. The threshold is 40 percent, or more than 40 percent of all permissible prescriptions. Permissible prescriptions were defined as those prescribed medications not restricted by the Department of Justice for controlled substances in Schedule II-V. As discussed above, any prescriptions not restricted from e- prescribing by federal regulations in place when the EHR Incentive program was established would count for the purposes of determining the required threshold. While the federal regulations were subsequently changed to allow for e-prescribing of controlled substances, the CMS EHR Incentive Program retained the previous definition of permissible prescriptions and EPs were not penalized if their software and e- prescribing systems capabilities had not caught up with the change in federal law. This is particularly important for orthopaedic practices since the majority of orthopedic prescriptions are for controlled substances such as narcotic pain relievers. Since medical groups were required already by CMS to document a minimum e- prescribing capability to receive an e-prescribing incentive payment or be penalized in Medicare Part B payments the following year, the clinic had been e-prescribing for non- 16

18 controlled substance medications prior to implementing meaningful use and continued to do so. EPs can only receive one of the incentive payments for e-prescribing; either the e-prescribing payment or the EHR incentive payment. Since the EHR payment is much larger in comparison, the clinic attested for that incentive and applied for, and received, an authorized exemption under the e-prescribing penalty. 5. Core Measure Five: Maintain Active Medication List vi This measure states that EPs must maintain an active medication list as structured data. The threshold is 80 percent. An active medication is a medication the patient is currently taking. The clinic instructed the MAs and nurses to review this list with patients in preparation to being seen by the providers. Again, the provider has the responsibility as a healthcare professional licensed to prescribe medications to review the medication list for accuracy and completeness and to ensured proper supervision of all prescriptions. This requirement is time consuming for clinical staff but is not overly burdensome in terms of being complex. 6. Core Measure Six: Maintain Active Medication Allergy List vii This measure requires EPs to maintain a list of medications for which a given patient has known allergies. The threshold is 80 percent. If a patient has no known active medication allergies then that fact must be entered in the active medication allergy list. The clinic software enabled recording medication allergies in structure data and automatically provides an alert for drug-allergy interactions. 17

19 7. Core Measure Seven: Record All of the Following Demographics: a. Preferred Language b. Gender c. Race d. Ethnicity e. Date of Birth viii This measure was one of the few measures for which the front desk staff participated in meaningful use, others being promoting the patient portal and responding to secure requests for appointments. The patient intake paperwork had to be modified to gather information on language and ethnicity since the clinic did not place an emphasis on this previously. In addition, since the reporting period was the last 90 days of the year, many established patients had to be asked these questions even though they had previously filled out all required paperwork. The solution was to have all new and established patients complete the ethnicity and language portion with established patients verifying the other information. The front desk staff often had to exercise patience and tact while explaining to patients that this was a government requirement for this program. A Decline to State entry is allowed for this meaningful use measure and the same entry is used for patients who do not know their ethnicity. 18

20 8. Core Measure Eight: Record and Chart Changes in the Following Vital Signs: a. Height b. Weight c. Blood Pressure d. Calculate and Display Body Mass Index (BMI) e. Plot and Display Growth Charts for Children 2-20 Years, Including BMI. ix This requirement was completed by the MAs when rooming a patient. The threshold is 50 percent of unique patients aged 2 and over. The software has a tab in the patient s encounter note for entering the vitals and it automatically computes the body mass index (BMI) and graphs growth charts. This same tab is where the chief complaint is entered by the MAs. This requirement was relatively straightforward. However, since not all patients had been weighed and measured in the past, depending on the nature of the visit, the requirement did highlight the way patients were roomed and added on additional time to the visit for some patients. In addition, one of the clinical quality measures under meaningful use required documentation for providing health information on weight management to patients with BMI above a specified number. The clinic s providers typically advised certain patients regarding their weight when medically necessary since the orthopaedic practice is a surgical practice and BMI and weight could be a factor in a successful surgery and recovery. However, this was not common for most patients. With meaningful use, the clinic now provided this 19

21 information in the form of a generic pamphlet even though the CQM measure probably did not require this effort. The meaningful use team wanted to err on the side of overperforming on meaningful use rather than risk a failure to understand the requirement, so the weight management pamphlet was provided routinely in the beginning. In this case, having data to report was a more sure way to comply than having no data for a measure. Nevertheless, the MAs and nurses did not feel comfortable in addressing weight issues with a patient, believing that was the role of the providers. This created a challenge because the meaningful use team wanted the MAs to handle as many measures as possible in order to leave the providers to grapple with documenting the patient encounter note in the EHR. However, the providers did not generally step in on providing weight management counseling since it was not considered medically necessary in most cases and this remained an outstanding issue. The clinical quality measure was documented but the amount of weight management information provided patients was not meaningful. 9. Core Measure Nine: Record Smoking Status for Patients 13 Years Old or Older x This measure was relatively easy to comply with but it brought forward an issue that was not generally a part of an orthopaedic practice. This measure is more geared towards primary care. Questions about smoking status are on the clinic s health information form and the MAs would ask patients regarding smoking status and now click the appropriate box in the EHR in terms of smoking status. Beyond the core 20

22 meaningful use measure there were two clinical quality measures related to smoking and the provision of smoking cessation materials. Again, since smoking status can be relevant to a surgical practice in that smoking can affect recovery for patients who smoke, the meaningful use team decided that it was again important to err on the side of over-performing and gather data on providing smoking cessation materials. A pamphlet was obtained and provided to patients who smoke. In this manner, three meaningful use measures were combined in one effort. The meaningful use team thought it was curious that in all likelihood patients who smoke may now be receiving smoking cessation materials from a variety of providers who are participating in the program. 10. Core Measure Ten: Report Ambulatory Clinical Quality Measures to CMS xi One of the 15 core meaningful use measures requires reporting on what are called Clinical Quality Measures (CQMs). These CQMs are derived from various quality programs, such Physician Quality Reporting System (PQRS) and the National Quality Forum (NQF). EPs must report data to CMS when attesting for meaningful use on 3 core CQMs and 3 additional CQMs chosen from a list of 38 CQMs. In the event that no data is available for the 3 core CQMs, there are 3 alternate cores to choose from. If no data is available for the additional CQMs, EPs must go through the entire list and attest that no data was gathered by the EHR that was relevant to the EPs medical practice or specialty. 21

23 There is no threshold for reporting the data. The data must simply be gathered from the EHR and reported to CMS. While this sounds relatively straightforward it was not. It required some work just to understand all the CQMs. The meaningful use team desired to ensure that adequate data would be available for the 3 core or alternate core and for 3 additional CQMs. Since the 3 alternate core were more designed for pediatric practices, they did not apply to orthopaedics. Therefore, the team focused on ensuring that data would be available for the 3 core CQMs and for 4 or 5 additional CQMs, just in case. In the absence of understanding exactly how Intergy would record the data on CQMs, even after asking many questions, it seemed wise to focus on making sure some data was available for both the numerator and the denominator of the metric. The team focused on the three core: 1. Preventive Care and Screening Measure Pair: a. (NQF0028a, QM12) Tobacco Use Assessment b. (NQF0028b, QM13) Tobacco Cessation Intervention The team chose to focus on this CQM because smoking status was being asked already for a core meaningful use measure. The MA staff and providers could meet all the requirements at once. As stated above, while generally tobacco use is a topic more closely link to primary care, the clinic could not say it had no relevance at all to orthopaedics. The Preventive Care and Screening Measure Pair had two parts, asking patients about tobacco use and gathering data on providing tobacco use cessation materials. It was decided to provide the materials and therefore to have data for both 22

24 the numerator and denominator of the percentage, even though this was not strictly necessary. 2. (NQF0421, QM8) Adult Weight Screening and Follow-Up (BMI) The team decided to focus on this CQM because again, although health issues concerned with weight loss and weight management are more related to primary care, an orthopaedic practice cannot claim that a patient s weight has no relevance because weight clearly does impact a number of orthopaedic conditions and can be a concern for surgery patients. As stated above, a pamphlet of very general information is provided to some patients with BMI above a specified level (see Meaningful Use Measure 8 above). The MA and nurse staff was reluctant to provide this information and desired the providers to do it. In an effort to avoid patient complaints, the providers have taken the position that when they deem it clinically important they are able to provide appropriate counseling to patients on a case by case basis. 3. (NQF0013, QM10) Hypertension: Blood Pressure Measurement The team decided to focus on this CQM for similar reasons as the other core CQMs above. Since vitals were now being routinely taken for all patients and problem list items were being entered into the EHR from the health information form and from other medical records, it seemed that the clinic would be able to show data for both the numerator and denominator on this measure. While the measure is more closely related to primary care, surgical practices must consider hypertension at times in caring for orthopaedic patients. In all cases, when the clinic attempted to meet the 23

25 requirements of meaningful use and data was gathered on these health statistics, it was decided that providers would refer patients back to their primary care providers as was medically appropriate. The gathering of this meaningful use statistic was not to change the focus of orthopaedic care. following list: The team considered achieving data for at least 3 additional CQMs from the 1. Smoking and Tobacco Use Cessation 2. Controlling High Blood Pressure 3. Ischemic Vascular Disease (IVD): Blood Pressure Management Control 4. Preventive Care and Screening: Pneumonia Vaccination for Patient 65 Years and Older 5. Low Back Pain: Use of Imagining Studies All of these CQMs were considered for inclusion as potentially relevant to an orthopaedic specialty practice. The smoking measure was to be linked to the other meaningful use measures, as was controlling high blood pressure. In the end, the clinic successfully gathered data on a variety of CQMs, some not relevant to an orthopedic practice but that could still be used for attestation purposes. Readers of this case study may question whether or not the team understood the purpose behind, and requirements of, the CQM measure, in that it may not have been necessary to ensure data for both the numerator and denominator. In fact it was not. The numerator in every case could be zero and the denominator could be zero as well, but if the 24

26 denominator was zero, it was required that attestation of zero be made for the entire list of quality measures. What was important for this clinic was being confident of meeting the measure, attempting to gather a data point for at least the denominator, and leaving the rest for later analysis. In the end when the clinic attested for meaningful use on CQMs, the Intergy software produced data for a number of measures, and the clinic attested for all three of the core and for the following additional measures: 1. (NQF0027, QM29) Smoking and Tobacco Use Cessation 2. (NQF0043, QM5) Pneumonia Vaccination 3. (NQF0031, QM6) Breast Cancer Screening As this list shows, the three additional measures that were reported on were not very relevant to the practice of orthopaedics, but the Intergy system had gathered the data and so the team reported it, the pneumonia vaccination and the breast cancer screening being reported with numerators of zero. 11. Core Measure Eleven: Implement One Clinical Decision Support Rule Relevant to Specialty or High Clinical Priority Along with the Ability to Track Compliance with that Rule xii CMS did not provide a lot of guidance regarding this measure and the decision support rule functionality may be more relevant to primary care practices or specialties 25

27 other than orthopaedic. However, Intergy was prepared to train the team in using the system to set up a clinical decision support rule. The team chose three separate decision support rules: i. Hip Replacement: Anterior/Posterior/Lateral X-Ray of Hip ii. iii. ACL Repair: Anterior/Posterior/Lateral X-Ray of Knee Low Back Pain: Need for Imaging Study Intergy decision support provides a reminder under the patient s health tab to perform the indicated treatment or procedure. In each case, in order for the software to provide an alert the appropriate problems have to be entered under the patient s problem list. For example, for a hip replacement, the problem list must include Joint Replacement-Hip and also convalescence, surgical. This would mean that under the patient s health tab in the chart, a message would indicate the need for the appropriate x-ray for a first post-op. The same would occur if under the problem list was entered sprain, cruciate ligament and convalescence, surgical for a first post-op x-ray on an ACL repair. 12. Core Measure Twelve: Provide Patients With an Electronic Copy of Their Health Information Upon Request xiii Intergy is equipped with an online patient portal. The portal had been purchased separately and the meaningful use team implemented the portal (See Implementing a Patient Portal below). The threshold is 50 percent. Through the portal, 26

28 patients may access health information electronically through a secure application. The clinic began a marketing effort to make patients aware of the patient portal and many patients did sign up for it. Apart from the portal, no patients requested their health information in any other electronic format during the reporting period. 13. Core Measure Thirteen: Provide Clinical Summaries for Patients for Each Office Visit xiv This measure was a challenge to meet and became the focus of much administrative, clinical support and provider activity in the clinic. The measure requires that EPs provide to patients a summary of specified information regarding their visit. The threshold is 50 percent. The summaries must include the following information: a. Updated medication list b. Updated vitals c. Reason for visit d. Any updates to the problem list e. Procedures and other instructions based upon clinical discussions that took place during the visit f. Immunizations or medications administered during the visit g. Time and location of next appointment or tests that the patient needs to schedule with contact information h. Recommended patient decision aids 27

29 i. Laboratory and other diagnostic test orders j. Test/laboratory results (if received before 24 hours after visit) k. Symptoms xv The summaries must be provided to the patient within 3 business days, counting the day of the visit as day one. The summaries may be provided in paper form or electronic. However, since providing summaries electronically would require a secure environment, such as the patient portal, and patients signed up for the patient portal on a voluntary basis, almost all the summaries went out in paper form. The clinic chose two different approaches to visit summaries: (1) the summaries could be handed to the patient at the end of the visit before they departed the clinic, and (2) the summaries could be mailed to the patient within the 3 day limit. Which alternative was chosen depended on the nature of the visit and the completeness of the clinical documentation when the patient was ready to leave the clinic. Some providers were enthusiastic about giving out the summaries to each patient personally and letting them know it contained important information about their visit. Others did not have time to fully document the encounter note with the required information prior to the patient departing. The meaningful use team trained staff on how to cite encounter note information and print the summary. When a summary was handed to the patient, the visit summary box could be clicked in the EHR. If not, either the MA and nurse staff or the transcription staff mailed the summaries the next day. The staff who mailed the summaries was responsible for ensuring all the required information was available to 28

30 produce the summary. Otherwise the summary was not mailed and the clinic did not record the measure as being met for that visit. 14. Core Measure Fourteen: Capability to Exchange Key Clinical Information Among Providers of Care and Patient Authorized Entities Electronically xvi Intergy has the interoperability feature to encrypt files for secure transmission. In the patient charts there is an interop tab where a continuity of care document can be created, exported, encrypted and saved. This document can then be sent as a secure to another authorized provider or entity. The measure only requires that one test be performed to transmit data securely. The measure does not require a successful transmission, only that a test was performed. In fact, the IT specialist at the clinic successfully transferred encrypted information electronically to another clinic for which there is a strong patient referral relationship. 15. Core Measure Fifteen: Protect Electronic Health Information Created or Maintained by the Certified EHR Technology Through the Implementation of Appropriate Technical Capabilities. (Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1) and implement security updates as necessary and correct identified deficiencies as part of its risk management process.) xvii 29

31 The clinic has routinely maintained best practices in terms of protecting patient health information, whether electronic or otherwise. Sage Intergy provided a 10-step process for satisfying this measure, including instruction to achieve: (1) access control; (2) emergency access; (3) automatic log-off; (4) record actions; (5) integrity; (6) detection; (7) authentication; (8) general encryption; (9) encryption when exchanging electronic health information (see Core Measure 14 above); and (10) recording disclosures made for treatment, payment, and health care operations. xviii Step 10 is the privacy functionality of Intergy that includes tabs in the patient chart for consent, release authorizations, disclosures, confidentiality status, and advanced directives. The IT specialist performed all of these steps. In addition, in meeting this requirement, the IT specialist had a security assessment performed by FRSECURE, Information Security Consulting that included a comprehensive review, including: 1. Administrative and Physical Controls, 2. Security Network Assessment, and 3. External Penetration Testing. The consultant conducted a vulnerability scan of the system network and software and looked at the physical buildings, clinic policies and even geographical proximity to community resources such as law enforcement, fire and emergency services. The consultant provided a 142-page assessment plus recommendations. The clinic scored very well on the assessment and benefited from the recommendations. 30

32 16. Menu Set Measure One: Implement Drug Formulary Checks xix Intergy is set up to provide formulary checks for all medications in the EHR. When a prescription is written, whether ordered electronically, or in the case of certain controlled substances, by phone or paper, the prescription is entered into the patient chart. Intergy will automatically run a formulary check and display the results to the provider writing the prescription. The check queries the patient s health plan formulary through a number of clearinghouses or prescription networks and pharmacy connections. 17. Menu Set Measure Two: Incorporate Clinical Lab Test Results into EHR as Structured Data xx The clinic is set up with Quest Diagnostics through an interface to securely receive lab test results and import them directly into Intergy EHR. The MA or provider enters a lab requisition in the patient s chart in Intergy and prints off a label and requisition form for pick up by Quest. When the results come back, the provider receives a task message that the results are in. The provider must then review the results and enter them into the patient s electronic chart. In most cases meeting this measure was straightforward. The threshold is 40 percent. However, some providers did not order and receive many lab test results and so it was important to carefully monitor results on this measure. There had to be adequate labs during the 90 day period to ensure all physicians were able to successfully attest. 31

33 18. Menu Set Measure Three: Generate Lists of Patients by Specific Conditions to Use for Quality Improvement, reduction of disparities, research, or outreach xxi This measure was straightforward to meet. The clinic produced lists from the Practice Analytics features for orthopaedic relevant conditions, including: Pain, Joint, Lower Leg/Knee Pain, Low Back 19. Menu Set Measure Six: Use Certified EHR Technology to Identify Patient-Specific Education Resources and Provide those Resources to the Patient if Appropriate xxii The clinic routinely incorporates patient education materials into its practice. Using this feature and recording this in the EHR was straightforward. The problem list entries alert providers and clinical support staff to provide patient education materials when appropriate. Then, clinical support staff or providers must document that materials were provided. If the entry is made, the clinical summary will show what materials were provided. In addition, the Intergy EHR allows providers to print off medication information for patient prescriptions that are entered into the system. 32

34 20. Menu Set Measure Nine: Capability to Submit Electronic Data to Immunization Registries or Immunization Information Systems and Actual Submission According to Applicable Law and Practice xxiii Intergy allows an immunization file to be created. The IT Specialist then contacted the state agency that administers the immunization registry and learned how to submit to the registry. The file is downloaded from the state website; the clinic s immunization file is then incorporated and securely uploaded. The required state formatting was already completed by Intergy. VII. Implementing a patient portal The patient portal was an interesting project but the number of patients that signed up was too few to meet the requirements for one of the menu set measures, that of providing patients with timely electronic access to their health information within 4 business days of the information being available to the EP. That menu set measure had a threshold of 10 percent and the patient portal initially got off to a slow start. Signing up for the patient portal is voluntary. Nevertheless, the patient portal has remained an important outreach tool for the clinic. The front desk staff encourages every patient to sign up, a brochure is given out to patients with instructions on setting up a secure access to their health information, and other marketing efforts, including radio advertisements are directed towards the use of the patient portal. Patients may access certain health information online, request appointments and prescription renewals, view and pay bills online, providers, and fill out forms. 33

35 VIII. Information Technology Workload The IT workload was significant and ongoing throughout the 90 day reporting period. The information technology specialist at the practice became a primary champion of meaningful use and was sought out continuously as a help desk aid. The certified EHR software did not always have the bugs worked out for meaningful use so regular contact with Intergy s technical support and training staff was key to success. IX. Challenges and Adaptations Some of the meaningful use objectives required little or no extra effort but others had to be monitored and worked on frequently, including making entries in the problem list and making sure e-prescribing was taking place. The providers also found that customizing the EHR encounter note was critical because of the extra time it took to complete a note as opposed to dictating. The work flow and job duties of the transcriptionists also changed and created new challenges. There was less transcription and transcription was now doing more editing of the free text for grammar and proper usage. In addition, the transcriptionists made sure the encounter notes were complete enough so that a visit summary could be mailed out if it had not been given to the patient and the transcriptionist mailed out many of the summaries. X. Running Reports and Attesting Once technical issues were resolved with the Intergy dashboard, running the reports to monitor results was relatively straightforward. When it came time to attest 34