What Does Meaningful Mean?

Physicians Scramble to Meet EMR "Meaningful Use" Criteria



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Cover Story – November 2010

Tex Med. 2010;106(11):14-23.

By Crystal Conde
Associate Editor

Two years and $200,000 into an electronic medical record (EMR) system implementation, Dawn Buckingham, MD, says her seven-physician ophthalmology practice is "in a holding pattern."

Dr. Buckingham, a member of the Texas Medical Association Council on Legislation and an Austin ophthalmologist, and physicians like her are scrambling to determine what the final rules on "meaningful use" of EMRs mean for their practices. They're also awaiting EMR meaningful use certification this fall.

"I think at this point it's going to be difficult and require a lot of work for us, or any ophthalmology practice for that matter, to meet the meaningful use criteria," she said.

According to Dr. Buckingham, EMRs for the ophthalmology specialty are "incredibly specific" and contain functions not found in any other EMR.

The Centers for Medicare & Medicaid Services (CMS) released final rules in July. Physicians now have defined criteria they must meet to achieve meaningful use and qualify for up to $44,000 in Medicare incentive payments from 2011 to 2016 and up to $63,750 in Medicaid incentive payments from 2011 to 2021. (See "Medicare and Medicaid EMR Incentive Comparison" [PDF]) Physicians may participate in either the Medicare or the Medicaid incentive programs but not both.

To view the rules and learn how to register for the incentive programs, visit the CMS website or the TMA website. CMS and the Texas Health and Human Services Commission anticipate registration will begin Jan. 1, 2011.

Dr. Buckingham has reason for her concern when it comes to complying with the CMS criteria. The American Medical Association says obstacles lie ahead, especially for smaller practices new to EMR technology.

"Despite CMS's attempt to simplify the meaningful use requirements, challenges remain. Among the concerns are questions about product availability, the tight timeline for adoption, and the high overall number of measures physicians are required to meet. While the volume of measures was reduced overall, the final rule requires physicians to meet 20 measures in the first year, which is still too high," AMA said in a press release.

At press time, AMA worried about the lack of an EMR system on the market that could execute all of the functions physicians need to successfully meet meaningful use criteria. CMS expects systems that support meaningful use to become available this fall.

TMA, REC Resources 

Luckily, physicians may access valuable resources from TMA and regional extension centers (RECs) to help them reap the benefits of EMRs and meet the meaningful use requirements.

Matt M. Murray, MD, a Fort Worth pediatric emergency medicine physician and member of TMA's Ad Hoc Committee on Health Information Technology (HIT), is a board member of the North Texas REC. He says the centers can help physicians choose and implement the right EMR system; analyze their workflow before EMR implementation; evaluate the EMR implementation plan; answer questions and concerns during implementation; provide technical assistance; and assess the EMR's functionality and how a practice uses the technology to achieve meaningful use after implementation. (See "Meaningful Use Help From RECs.")

"Working with the RECs allows me to help doctors get the aid they need to implement health information technology. RECs are going to be crucial in helping physicians select and implement EMRs and achieve meaningful use," Dr. Murray said.

Physicians who need help selecting and implementing an EMR system and achieving meaningful use may contact TMA to take advantage of the association's numerous resources and help available through TMA Practice Consulting. For more information, call (800) 880-5720 or e-mail HIT@texmed.org.

In addition, TMA offers a meaningful use webinar that covers EMR benefits in quality of care, patient safety, and efficiency. The webinar summarizes eligibility for the Medicare and Medicaid incentives and what physicians need to do to meet meaningful use measures. This on-demand resource is $25 and includes answers to some of the most common questions and access to additional tools.

Physicians can earn 1 AMA PRA Category 1 CreditTM credit for completing the webinar. For more information, contact the TMA Knowledge Center at (800) 880-7955 or visit the Distance Learning Center on the TMA website.

TMA Weighs In

TMA submitted comments on the proposed rule for meaningful use earlier this year. CMS made a few changes to the final rules based on TMA's recommendations.

In other areas, CMS did not listen, and TMA will continue to recommend changes. To read TMA's comments, visit www.texmed.org/stimulus.

Generally, the measures require physicians to meet certain ratios measuring what percentage of their patients received specific services electronically or had those services documented electronically.

TMA asked CMS to base meaningful use measures only on patients with records maintained in the EMR system, rather than on all patients maintained in paper records. The agency heeded TMA's suggestion. The association believes this makes reporting the percentage for each measure required to achieve meaningful use much less onerous.

TMA urged CMS to allow physicians some leeway in the number and form of clinical quality measures required to report on during Stage 1 of the incentive program. CMS listened and rather than requiring physicians to meet a rigid set of 25 criteria, it now says physicians must meet 15 core criteria and select an additional five from a menu set of 10.

"The menu set allows a doctor to pick and choose. That gives us more flexibility on achieving meaningful use because not all of us see the same types of patients and provide the same type of care," Dr. Murray said. (See "Meaningful Use Criteria" [PDF].)

TMA asked CMS to place more emphasis on patient safety and address the "unintended consequences" of EMRs, particularly in hurried implementations. For example, what's known as a "pick list" in an EMR might limit medications, failing to display those appropriate for a patient's diagnosis, age, and gender. A pick list is a drop-down menu in an EMR that shows medication options. If the list fails to show medication dosages for infant patients, for example, this oversight could result in selecting the wrong form of medication or the wrong medication altogether.

TMA strongly encourages the development of a national "no-fault" reporting system for errors and near-misses that occur through the use of EMRs. A physician's ability to report EMR safety issues to such a system should be part of the criteria for achieving meaningful use, TMA argued.

Physicians and others using an EMR would be able to notify the no-fault reporting system when a problem surfaces with a particular EMR product. The complaint data can then be aggregated, and the EMR vendor can be made aware of the problem and take action to correct it.

Furthermore, a no-fault reporting system would allow a physician to report problems with EMRs without liability for what may have happened as a result of an EMR problem.

Criteria Could Present Challenges

Joseph H. Schneider, MD, MBA, is chair of TMA's Ad Hoc Committee on Health Information Technology and chief medical information officer for the Baylor Health Care System. He says some physicians will face obstacles when trying to meet the meaningful use criteria and qualify for the incentive payments.

"The biggest challenges remain for physicians who are still in a paper environment," he said. "The transition takes a significant commitment of time and effort."

Another barrier to meaningful use, Dr. Schneider says, is the need to develop health information exchanges (HIEs). The meaningful use objectives require doctors to exchange data with other entities. Dr. Schneider says data exchanges are necessary between physicians and ImmTrac (the state's immunization registry), public health departments, and other outside entities. Right now, he says, the technological infrastructure isn't mature enough to allow exchanges to occur easily.

Another concern is that EMR vendors are only now beginning to address certification, which may delay the availability of certified EMRs, Dr. Schneider says.

According to CMS, to be eligible for the Medicare or Medicaid incentive program, EMRs must be certified by an Office of the National Coordinator for Health Information Technology Authorized Testing and Certification Body (ONC-ATCB). It will test and certify that complete EMRs and EMR modules comply with the standards, implementation specifications, and certification criteria adopted by the Health and Human Services secretary.

Dr. Schneider says at this point, only about 100 EMR systems have met the Certification Commission for Health Information Technology's requirements. Certification was first available for EMRs in 2006.

"I suspect those same 100 EMRs, as well as some others, will seek meaningful use certification by ONC-ATCB, since it is now required. The first rounds of certification should take place by Dec. 31 since the clock starts ticking for physicians on Jan. 1," he said. "There may still be a few EMRs that are not certified that physicians who are not eligible for meaningful use will use."

While the possibility of earning the bonuses likely will entice some physicians to adopt an EMR, Dr. Murray says that alone shouldn't be the reason his colleagues implement an EMR system. As the technological environment changes for physicians, they'll need to adapt their medical practices to stay competitive.

"When I talk with physician groups, I tell them the reason to implement an EMR shouldn't be solely to obtain incentive payments. The reason to adopt an EMR is to improve the quality of care the practice provides and to leverage the capabilities of an EMR to streamline operations," he said.

He cautions physicians that the incentive payments likely won't cover the total cost of implementing an EMR.

According to the second edition of TMA's Electronic Medical Record Implementation Guide: The Link to a Better Future, total start-up costs can exceed $30,000 per physician. Start-up costs include software licenses, vendor implementation and training, e-prescribing, practice management, technical support, other fees, and hardware. Other associated costs, such as data conversion and software for eligibility verification, secure messaging, reporting tools, and voice recognition can run from $6,000 to more than $10,000 per physician.

A price comparison of the most commonly used EMRs in Texas is available on the TMA website

"I'm concerned about doctors implementing an EMR to get the money," Dr. Murray said. "If they don't have an idea of how a technology will help their practice meet patient care or operational goals, they will fail to obtain the maximum benefits."

An EMR can have a significant impact on a practice. To learn more about this, see the EMR survey results on the TMA website, www.texmed.org/hit.

Despite these obstacles, David Fleeger, MD, a colorectal surgeon in Austin and member of TMA's Council on Practice Management Services who implemented an EMR system in January, says he's not throwing in the towel on meeting the meaningful use requirements. And he encourages his colleagues not to give up either. (See "Measure Twice, Cut Once," October 2010 Texas Medicine, pages 33-36.)

"There's still time. I don't think doctors should give up or panic that there's not enough time. They need only 90 days worth of meeting meaningful use by Dec. 31, 2012, to document the measures and get the first year's maximum Medicare reimbursement of $18,000," he said.

CMS bases the maximum payment amount on 75 percent of a physician's Medicare allowable charges. Therefore, to qualify for the maximum reimbursement of $18,000, a physician's Medicare allowable charges must total at least $24,000 for the year. But if for example, a physician's Medicare allowable charges total $10,000 for the year, the reimbursement amount would be $7,500.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde.



Meaningful Use Help From RECs

Now that the Centers for Medicare and Medicaid Services (CMS) has released final rules on meaningful use, physicians can go about realizing the benefits of an EMR system and the incentive payments offered by the government. Regional extension centers (RECs) are ready to provide education and technical assistance for physicians – particularly those in primary care – to achieve "meaningful use" of certified EMR technology.

Physicians participating in Medicare are eligible for up to $44,000 over five years, and those participating in Medicaid can receive up to $63,750 from 2011 to 2021.

Texas is home to four RECs:  

  • North Texas Regional Extension Center, anchored by the Dallas-Fort Worth Hospital Council;
  • Gulf Coast Regional Extension Center, led by The University of Texas Health Science Center at Houston;
  • CentrEast Regional Extension Center, directed by Texas A&M Health Science Center Rural and Community Health Institute; and
  • West Texas Regional Extension Center, headed by Texas Tech University Health Sciences Center.

To contact the RECs and enroll in their services, visit the TMA website.

The federal government subsidizes the RECs' consulting services. All four Texas RECs charge an annual subscription fee of $300 for their services.

RECs can help physicians with workflow analysis and practice redesign, EMR vendor selection, education, and meaningful use achievement.

TMA worked hard to make sure physicians hold half of the seats on the REC governing boards. "The implementation of the HITECH [Health Information Technology for Economic and Clinical Health] initiative could have profound effects on physician practices, and we need to have a strong voice at the table," said Sidney Ontai, MD, MBA, of Plainview, a member of the West Texas REC. He also is the immediate past chair of TMA's Council on Practice Management Services and is a member of TMA's Ad Hoc Committee on Health Information Technology (HIT).

TMA will educate physicians about REC services. For more information, visit www.texmed.org/rec. Also, see "RECs to the Rescue: Regional Centers Help Physicians Use HIT," April 2010 Texas Medicine, pages 61-66.

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