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August 2007 — Volume 2, No. 8

In This Issue

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Terms and Definitions

PQRI- Physician Quality Reporting Initiative
On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative (PQRI). PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5 percent of total allowed charges for covered Medicare physician fee schedule services. 

If your claim does not include your individual national provider identifier (NPI) at the line item level, it will not be included in the analysis of satisfactory reporting for PQRI and the bonus payment calculation will not include it. Getting an NPI is easy and free. Over 2 million providers have already applied for and received their NPIs.

Learn more about NPI.

Apply for an NPI. Medicare carriers do accept NPIs on claims and have done so since January 2006.

BTE - Bridges to Excellence
Bridges to Excellence (BTE) has more than five years of national pay-for-performance (P4P) experience.  BTE is a multi-state, multi-employer coalition developed by employers, physicians, healthcare services researchers and other industry experts. The BTE mission is to reward quality across the health care system, and is a grantee of the Robert Wood Johnson’s Rewarding Results grant program. BTE is a not-for-profit organization created to encourage significant leaps in the quality of care by recognizing and rewarding health care providers who demonstrate that they deliver safe, timely, effective, efficient and patient-centered care. 

PROMETHEUS Payment(TM)
Prometheus is a new payment model still in the process of development that is based on the creation of Evidence-informed Case Rates (ECRs).  These ECRs cover all the care a patient should get for a specific condition, inpatient and outpatient.  As such, it provides an opportunity for any provider that delivers care paid for by an ECR to reap the rewards of better patient management. 

For example, assume a normal patient with Type 2 diabetes is covered by an ECR with a price of $10,000 annually. If the physician manages the patient well, that patient's total cost is likely to be less than $10,000 because the $10,000 includes an allowance for hospitalization. And if the physician can manage that (and other patients with Type 2 diabetes) for say $9,000 on average, then that physician would get to keep the difference between actual and case rate, or $1,000 per patient. 

Read the February 2007 issue of the Digital Office for more information on PROMETHEUS.

Find out more in this Prometheus whitepaper. 

News Briefs

Drug Interactions and the EMR: A study of computerized drug-drug interactions at the Veterans Health Administration, published in the January/February 2007 issue of the Journal of the American Medical Informatics Association, found that only 30 percent of clinicians who prescribed medications thought the electronic alerts provided useful information most of the time.

Is P4P Getting Tougher:  A California P4P program's experiment may be the beginning of a national trend. Read this article in Medical Economics magazine. 

State Medicaid Agencies Health IT Initiatives:  Read the August 2007 Department of Health and Human Services Office of the Inspector General Report (OEI-02-06-00270) that summarizes State Medicaid agencies’ initiatives on health information technology (HIT) and health information exchange (HIE). Medicaid is a jointly funded federal and state health insurance program for certain low-income and medically needy persons.  Medicaid has been one of the fastest growing items in federal and state budgets, with costs totaling more than $317 billion in FY05.  HIT and HIE have the potential to reduce healthcare costs resulting from inefficiency, medical errors, inappropriate care, and incomplete information.  These potential benefits of HIT and HIE adoption could be particularly important for Medicaid and its beneficiaries.

According to the report, 12 State Medicaid agencies have implemented a total of 16 HIT initiatives.  These states include Florida, Iowa, Kansas, Louisiana, Mississippi, Missouri, Montana, Pennsylvania, Tennessee, Vermont, Wisconsin and Wyoming.  Some 25 State Medicaid agencies are involved in planning and developing statewide HIE networks and 13 State Medicaid agencies include MITA as part of their HIT and HIE planning.  MITA is the Medicaid Information Technology Architecture, which is a framework developed by CMS to help states modernize their Medicaid information systems. 

The report contains 3 recommendations:

• Continue to support the goals of MITA;
• Collaborate with other Federal agencies and offices to assist State Medicaid agencies in developing privacy and security policies; and
• Continue to work with the Office of the National Coordinator for HIT to ensure that State Medicaid initiatives are consistent with national goals.

CMS concurred with all recommendations.  Appendix A (Table 1) provides a detailed description of current state EHR initiatives. 

Visit this page for a full copy of the report.  (Source for report: OIG Press Release)

CCHIT News


Certification Commission Invites Comments on New 2008 Work

The Certification Commission for Healthcare Information Technology has announced that it will publish environmental scans – the first step in developing certification for 2008 – from each of its 10 work groups on Sept. 13.

“During the environmental scan, our work groups gather standards, use cases, and other emerging requirements for health IT, and also make an assessment of the readiness of the marketplace,” said Mark Leavitt, MD, PhD, Certification Commission chairman. “This provides the evidence base needed to make fair and balanced decisions on what criteria to require, and when to do so.”

Environmental scans will be produced by work groups in the following 10 areas: foundation, ambulatory, inpatient, network (health information exchanges), emergency department, cardiovascular medicine, child health, interoperability, security, and privacy and compliance. 

Publication of the materials on Sept. 13 will kick off a 30-day public comment period during which industry representatives and healthcare stakeholders are invited to submit input. Details on how to submit comments will be available on www.cchit.org.

After the environmental scans, the next step in development will be a first draft of the 2008 criteria, which the Commission plans to publish for review and comment in late November.

Town Calls Scheduled

A series of three Town Call teleconferences are scheduled for Sept. 19 to discuss the environment scans. Call times and topics to be covered are as follows:

• 11 a.m. EST – Network, Interoperability, Security, and Privacy and Compliance
• 1 p.m. EST – Cardiovascular Medicine, Emergency Department, and Child Health
• 4 p.m. EST – Foundation, Ambulatory, and Inpatient

Each presentation will be followed by an interactive question and answer session.  Presentation materials and details on how to participate in the teleconference will be posted to www.cchit.org.

Invitation to Assess Certification Progress

The public and healthcare information professionals are invited to participate in a short survey assessing the progress of the Certification Commission to date in developing a certification process for EHR products to be used in ambulatory (office-based) and inpatient (acute hospital) settings. Stakeholders – from healthcare information technology professionals to product vendors to providers – are encouraged to take the survey through Sept. 5 by visiting the Web site at www.cchit.org.

Inpatient EHR certification applications

The application period for inpatient EHR certification ends today. The first certified inpatient EHR products are scheduled to be announced in late October. The next inpatient application period will open Nov. 1.

“We are pleased to follow the success of the ambulatory certification program with a program for inpatient products,” said Alisa Ray, Certification Commission executive director. “Although the size of the inpatient EHR market is smaller than ambulatory, resulting in a smaller number of expected applications, we anticipate that inpatient certification will be just as successful.”

New Certifications Under 2007 Ambulatory Criteria

The first ambulatory EHR products certified under the enhanced 2007 criteria have been announced. Seven products have received CCHIT certification for 2007.  Six of those products were developed by companies that also certified products in 2006.  An up-to-date list of all certified products is posted on the Commission's Web site, www.cchit.org. 

 “For 2007, the Commission raised the bar significantly from the previous year’s criteria.  Ambulatory EHRs now must include electronic prescribing, demonstrate an ability to receive lab results, and show enhanced patient safety, quality, and security features,” said Leavitt.  “Investment in 2007 certified ambulatory EHRs gives providers even more powerful tools to improve quality, safety and efficiency while protecting the privacy of health information.”

Michael O. Leavitt, Secretary of the U.S. Department of Health and Human Services, officially accepted the Certification Commission’s 2007 ambulatory and inpatient EHR criteria during a July 31 meeting of the American Health Information Community.

HIMSS Virtual Conference & Exposition

2008 Annual HIMSS Conference & Exposition

State Dashboard

Visit the State Dashboard for More Information on RHIOs/HIEs

HIT Dash

Your peers belong.
Your mentors belong.
You belong in HIMSS.

Join or renew today


Point-Counter Point: Lessons Learned from the Field

The Digital Office introduced "Point-Counter Point: Lessons Learned from the Field,” in the July 2007 edition.  This new feature allows readers to share their opinions and lessons learned. 

Following is a response received to the article, “A Physician Perspective on the EHR: It's Not Just about the Money,” by Dr. Steven Spady, DO, MMM.  You can read Dr. Spady’s article at Point-Counter Point: Lessons Learned from the Field. 

Please note: Comments received in response to Dr. Spady’s article were considered for publication. Derogatory comments of any type, e.g., vendors, professional organizations, individuals, etc., will not be accepted.

A Physician Perspective on the EHR
It’s not just about the money

Dr. Masoud Khorsand
CEO of Catalisse
President of Southeastern New Mexico Hematology and Oncology

The high cost of implementing EHRs has slowed the adoption of all healthcare IT initiatives, especially in smaller practices. As an oncologist operating my own practice, I have found that our needs are best served by a solution that gives us control over our clinical functions while at the same time, addressing our business needs. 

As stated in Dr. Spady’s article, such a comprehensive solution that strongly couples an EHR system with practice management functionality is hard to find and not nearly as simple as the ink and paper practice once universally seen in every doctor’s office. With slow technology adoption rates, small practices require a solution that incorporates the business practices needed to be successful in today’s complex healthcare industry.

Handling specifics tasks within sub-specialty groups that family practice physicians wouldn’t normally have to deal with requires a system that is both easy to use and inexpensive to implement. With a staff handling chemotherapy regimens, drug inventory management andpurchase order tracking on top of trying to accurately collect and maintain up-to-date patient records, the need for a completely integrated solution is clear.

Today’s physicians are more technology and business savvy than ever, making now the optimum time to introduce comprehensive end-to-end solutions that not only help increase reimbursements and improve workflow, but offer greater productivity and better patient care. With a single integrated solution, practices can dedicate more time to improving a patients’ health while managing all aspects of the practice’s patient records and revenue cycle components.

What do you think?  Send your response to the Digital Office

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It’s Not Just about the Technology
Implementation

Chuck Parker
Vice President
Chief Technology Officer/DOQ-IT
MassPro
Waltham, Mass.

We have talked about setting the proper expectations throughout the EMR phases along the roadmap.  This is especially important during the Implementation phase.  It is important that the vendor set expectations of what the company will and will not do (i.e. implementation services included), and when expected services will be delivered. 

It is equally important that the practice set expectations with the vendor.  It is becoming more common for EHR implementations to stall because the customer or vendor does not deliver on a misunderstood, but expected, commitment - whether it is a resource, interface, link to Rx-Hub, custom code, etc.

The vendor wants to do a good job because the vendor’s success depends on it.  The customer wants an EHR that will benefit the practice; the practice’s success depends on it.  Be sure all parties have the same understanding of expectations.

This step in the process can also cause ongoing issues once the implementation is finished, and the practice moves into support-mode.  The level of attention from the vendor is naturally decreased at this point, a phase that may or may not be well understood by the practice.  As a result, progress may stall, even if the initial implementation was successful.

Planning for the Implementation phase means two important decisions must be made:

  1. If you have multiple practice locations:
    1. Consider starting with a pilot site to allow you to:
      • Test workflow redesign ideas and benefit from "quick wins"
      • Prove concepts for the rest of the group
      • Take advantage of a smaller group of enthusiastic providers
    2. Alternately, you can bring all sites up together if a primary goal of the implementation is to reduce overall administrative burdens between sites.
      • Let the organizational goals drive the implementation
      • Instant productivity gains from reduced chart runs will likely offset the productivity losses elsewhere
      • Fewer complications to billing will result as all sites go live
  2. 'Big Bang' versus incremental:
    • Incremental Implementation: A practice uses this methodology to slowly build competency and confidence in an EHR system. In developing an implementation plan, you will need to balance acceptable productivity losses against the length of the transition, implementation, and training period.  This method is typically better for larger offices with more than seven providers.
    • ‘Big Bang’ Implementation: The method recognized for “going live” with all facets and functions of the EHR on the go-live date.  It is typically used in smaller offices where everyone can start and be trained at one time.

Each of the above decisions can either shorten or extend the time required for full utilization; however, don’t assume longer timing means less usage.  It may be best to take a bit longer particularly with larger offices.

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Update On: Medicare Care Management Performance Demonstration

The Medicare Care Management Performance Demonstration started its first operational year July 1 with approximately 700 practices enrolled in the four states.      

The demonstration, which is now operating in Arkansas, California, Massachusetts and Utah, was mandated under Section 649 of the Medicare Modernization Act to promote the use of health information technology and improve the quality of care for beneficiaries. Doctors in small- to medium-sized practices who meet clinical performance measure standards will receive a bonus payment for managing the care of eligible Medicare beneficiaries. 

The three-year demonstration program, according to Jody Blatt, senior research analyst with the Medicare Demonstrations Program Group, supports physicians who want to improve the quality of care they provide to chronically ill Medicare beneficiaries and provides significant financial incentives to medical practices. Practices that have CCHIT-Certified EHRs and are able to report the clinical measures data to CMS electronically will also be eligible for an additional bonus payment.

The demo Web site provides extensive background information on the project and its activities.

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HIMSS Releases Definition, Position Statement for PHR

The HIMSS Personal Health Record Steering Committee has developed a HIMSS-sponsored definition and position statement for personal health records (PHR).

The HIMSS personal health record definition and position defines an interoperable ePHR. It contains guiding principles for ePHR development and is the work of the HIMSS Personal Health Record Steering Committee and its work groups: Defining the ePHR Work Group and the National ePHR Discussion Work Group.

“The HIMSS definition is meant to address the immediate and future developmental direction of ePHRs, with the understanding that any ePHR definition is not static and will evolve with future technology advances and further adoption of EHRs/EMRs and ePHRs,” says Holly Miller, MD, MBA, chair of the PHR Steering Committee. “Such advances and adoption will create shifts in the culture surrounding the utilization and demand of ePHR constituents.”

In its position statement, HIMSS supports the development of interoperable electronic PHRs that are interactive and use a common data set of electronic health information and e-health tools.

“HIMSS champions the development of national standards to ease burdens placed on constituents due to variances in state law,” says JoAnn W. Klinedinst, CPHIMS, PMP, FHIMSS, HIMSS senior director, healthcare iInformation systems. “Development of national and uniform state standards would also address legal concerns raised by ePHRs such as reliability, reimbursement, ownership, access, transfer, and the limitations, rights and responsibilities of patient and provider for the use of e-health and ePHRs.”

For more information on becoming involved in the HIMSS Personal Health Record Steering Committee and its related communities, contact HIMSS Staff Liaison Mary Griskewicz, FHIMSS. The HIMSS PHR definition and position statement are available here.

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HIMSS Meets with Congressional Budget Office

The HIMSS Ambulatory Committee and HIMSS Government Relations staff met with the Congressional Budget Office (CBO) on July 20 to outline the needs of ambulatory care providers related to the adoption and implementation of health IT and the electronic health record. The CBO offers Congress nonpartisan analyses to aid in economic and budgetary decisions for programs covered by the federal budget.

Ambulatory Committee Chair Jenifer Jarriel and Vice Chair Dr. John Maese outlined the current resources and challenges of HIT adoption. Gamble Heffernan, senior vice president-product management, Misys Healthcare Systems, discussed the importance of interoperable EHRs for the medical practice.

Dr. Jim Morrow, president & CIO, North Fulton Family Medicine, PC, a 2004 Davies Ambulatory Care Award Recipient and a 2006 HIMSS Physician IT Leadership Award recipient, explained the return on investment EHRs provide to both medical practices and the patient.

“I always thought I provided good care to my patients prior to having access to an EHR, but now I know I provide good care to my patients with the data and reporting capabilities made available through our practice’s EHR,” he said.

This meeting is one of a series of meetings and site visits coordinated with HIMSS Government Relations and the CBO on the value of HIT and EHR adoption. The Ambulatory Committee will address several topics this year, including EHR adoption and sustainability for medical practices and community health centers, as well as business systems integration issues.

The committee’s goals include the creation of several new Web-based tools and resources, including the development of a model and checklist for integrating EHR with existing practice management systems.

To learn more about HIMSS ambulatory care, click here. To learn more about the HIMSS Davies Award, click here. If you are interested in serving on a task force or work group, contact Mary Griskewicz.

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Billings Clinic Enhances Quality of Care Under Federal Demonstration Project

The information that follows here is from a news release that appears on the Web site of the Billings Clinic in Billings, Mont. The Billings Clinic also has a large rural population treated during and as part of this first year of the demonstration project.  Read on to find out more about the clinic and initiative. 

As noted on the clinic Web site, “Billings Clinic is a leading community organization and the largest employer in Billings, Montana. At its core is a multi-specialty group practice of over 200 physicians and non-physician providers. It is a not-for-profit organization, governed by the community, with physician leadership at all levels. Its structure is similar to that of the Mayo Clinic. The Billings Clinic is a 'community of physicians' working together in a collegial manner toward our mission of providing outstanding health care, education and research in our region and the nation.” 

The clinic is part of the Centers for Medicare & Medicaid Services three-year Medicare Physician Group Practice (PGP) Demonstration. In July, CMS announced that all participating physician groups improved the clinical management of diabetes patients in the first year of this demonstration.

The goals for Billings Clinic during this program focused on providing quality disease management by engaging information technology, developing patient registries and preventing avoidable admissions and readmissions for all of our patient population.

Billings Clinic had the challenge of engaging a number of rural clinics in implementing its diabetes management strategies and has been able to offer a unique view on the demonstration project’s results due to the extreme geographic dispersion of many of our patients. Approximately 40 percent of the Medicare patients analyzed in the project reside outside of Yellowstone County.

“Billings Clinic is very pleased with the quality improvements in diabetes care we have been able to implement as a member of this pilot program,” said Dr. Nicholas Wolter, CEO of Billings Clinic, in the news release on the clinic Web site. "We also remain very committed to provider organizations assuming more accountability for both quality and efficiency in the provision of care to Medicare beneficiaries and to all of our patients. We appreciate the opportunity to work with the other participating sites, not only to compare results, but also to learn from one another about these important improvement processes."

The 10 participating physician groups in the demonstration are:

  • Billings Clinic
  • Everett Clinic
  • Dartmouth-Hitchcock Clinic
  • Forsyth Medical Group
  • Geisinger Clinic
  • Middlesex Health System
  • Marshfield Clinic
  • Park Nicollet Health Services
  • St. John’s Health System
  • University of Michigan Faculty Group Practice

Each of this physician groups improved their quality scores on nationally developed evidence-based diabetes measures, achieving national benchmarks or quality improvement targets for care provided to Medicare beneficiaries with diabetes.

The physician groups were measured on performance using all health care spending for patients assigned to the group in relation to a comparison population of Medicare patients from their local market area. A total of 223,893 Medicare patients were assigned to the 10 physician groups in performance year 1, which ended March 2006.

The PGP Demonstration has fostered a nation-wide learning collaborative for the groups who voluntarily participated in this demonstration as a result of their leadership in their communities and profession. CMS is working with the groups to identify successful health care redesign and care management models developed under the demonstration that can be spread across the health care system.

Visit the Billings Clinic Web site to read the entire news release.

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Vendor Update


Learn more about Dr. Hugh McLaughlin’s medical practice, an article that appeared in the July 2007 edition of the Digital Office.

 

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Thinking about Implementing Health IT...
Final Katrina-Phoenix Medical Clinic Opens


Karen Lemoine, an associate with the Jefferson Parish Chamber of Commerce, celebrates the opening of Dr. Christy Valentine’s medical practice with…Dr. Valentine.

The Valentine Medical Clinic will open with an EMR in place, but this practice is one that was rebuilt with the electronic medical record with donations from the HIMSS Foundation and the HIMSS Katrina Phoenix project.  Read on to find out more about why this clinic no longer has to spend time “thinking about” implementing the EMR.

Almost two years to the day after Hurricane Katrina devastated Southeast Louisiana, the Valentine Medical Center will open as the final Katrina-Phoenix medical clinic in New Orleans.  Valentine Medical Center is a new family healthcare, urgent care and occupational medical clinic in Gretna, a suburb of New Orleans.  

Dr. Christy Valentine, whose practice in Plaquemines Parish, La., was devastated by Hurricane Katrina on Aug. 29, 2005, chose to stay in Louisiana and rebuild her practice.  She is able to open this clinic with a state-of-the-art electronic medical records system, thanks in part to HIMSS Katrina Phoenix project funding, donations, and assistance from the Louisiana Health Care Review (LHCR), a statewide healthcare quality improvement organization in Louisiana. 


Dr. Christy Valentine and staff of the Valentine Medical Center, which will open in Gretna, La., a suburb of New Orleans.

In action since September 2005, the Katrina Phoenix project of the HIMSS Foundation has organized vendor donations for electronic health record (EHR) software and hardware, as well as services for practices decimated by Hurricane Katrina. Those practices lost thousands of paper records each.   HIMSS volunteer physician mentors, vendors and LHCR staff members are assisting EHR implementation in the Katrina-Phoenix practices.

In addition, eight other practice sites in the Gulf Region have benefited from the HIMSS Katrina-Phoenix Project with three practices in various stages of EHR installation or implementation. 

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Already There...Implemented the EMR
Dr. Salvatore Volpe


Dr. Salvatore Volpe appreciates the flexibility of accessing patient health information at home or the office. With him (left to right) are his two sons, Sal and Gino.

Dr. Salvatore Volpe is a solo practitioner with several part-time staff, including a registered nurse and office manager.  With 2,500 patient encounters annually, this physician has always worn multiple hats since the completion of his combined pediatrics/internal medicine residency some 17 years ago.

“One very important ‘hat’ was that of a managed care assistant medical director/medical director. These positions complimented my medical school/residency program training. The ‘business side’ of medicine is often not adequately taught to physicians. The managed care experience has broadened my approach to healthcare and prepared me for the economic pressures now felt by physicians and patients alike.”

Implementing the electronic medical record allows Dr. Volpe to “work smarter not harder,” a philosophy that continues today.  Some of the EMR benefits for his practice include:

“The EMR has given us the ability to accomplish tasks more quickly and efficiently: address requests for appointments, medication refills, referrals to other doctors. We feel it is easier to document the day’s activities, since we do not have to pull charts anymore.”  Dr. Volpe also distributes the office visit note to the patient at the completion of each visit.

The EMR has resulted in increased patient participation in the health care process, said Dr. Volpe, “turning passive practice members into active practice members.” Increased productivity with lower office overhead has provided the added benefit of increased job satisfaction for Dr. Volpe and his entire staff.

As other physicians have noted, Dr. Volpe says that the EMR has provided more time to spend with his wife, two sons and parents, “who did not see as much of me in the first 17 years of my practice. I can now work from home after attending a soccer game or band performance.”

But, implementing the EMR did include some challenges for Dr. Volpe and his EMR implementation team.  They had to develop a hardware budget that would meet the specifications of the software vendor but not put the practice “in the red for too long.”  One cost-savings step:  many of the previously purchased computers were recycled as workstations. While the staff had experience using e-prescribing and patient portal applications, they had to accept, and transition to, a mostly paperless workplace.

“This was done over several weeks as we reviewed workflows with staff and patients. While my patients had been slowly exposed over the years to our every increasingly ‘electronic’ medical practice, I felt there was value in talking to several patients about the proposed transition to get a better feel of their points of view,” said Dr. Volpe.

Here’s a quote from a patient’s daughter who manages her parents’ healthcare, a statement that demonstrates how the EMR in Dr. Volpe’s practice has helped provide the quality and consistent care so important in today’s medicine.

“I am a working mother and am responsible for both my parents’ medical care. Your computerized systems have made it easier to manage my parents’ health care and records. I love being able to walk out of the office at the end of a visit and have a summary of the visit in my hand…all the info is right there to refer to and there is no guess work. I keep these filed and other family members can refer to these if needed. I would like to see more doctors use a system like this.”

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