EHR Issues May Not Be Vendor's Fault, Docs Told

Almost 17% of physicians will at least consider switching electronic health record vendors this year, but the problem may not be in the system, according to an EHR physician consultant. To cure their dissatisfaction with their EHR, doctors may need to see if their expectations are unrealistic or change their implementation strategy, Cephus Daniel Vincent Allin, M.D., of EHR software vendor NextGen in Horsham, PA., said.

Organization problems cause more failed implementations than technology, he said, adding that the staff who use the EHR need good training on a system -- more than just having an instruction manual thrown at them. Practices may need to change their work flow or the way they chart, assess, and bill patients to maximize the EHR system, Allin advised. "It's easier to change your work flow or way of thinking than it is to change the silicon," Allin said, referring to the material computer software is made of.

A big point Allin made was making sure office staff are doing the most they can with the system. For example, the doctor doesn't need to take a history of a patient. They can allow the staff to still do that and review their notes, which takes less time. "I'm actually going to do exactly what was suggested today, go back, regroup, look at your work flow, sort of see if we need to retrain people," Yogesh Trehan, M.D., of Brentwood, CA, said. Allin also suggested planning and budgeting for an EHR update every year. He said every vendor has a team of developers constantly working on developments. "The first thing they do is fix defects," Allin said. "The second thing they do is keep up with the regulatory environment."

Physicians looking to receive "meaningful use" bonuses from the federal government should be aware of increased reporting requirements under Stage 2, health information technology experts said at a separate session here. One notable difference is that 5% of patients should be using a patient portal, said Michael Zaroukian, M.D., Ph.D., chief medical information officer for the Michigan State University HealthTeam in East Lansing. This means practices can't just passively make patients aware that a portal exists, but should push them toward using it. To encourage usage, physicians can consider secure messaging to patients through the portal rather than via phone calls, Zaroukian said. Send certain results and clinic notes through the portal.

"Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clinical care. Providers who show "meaningful use" of certified EHRs can receive up to $44,000 in extra payments from Medicare and $64,000 from Medicaid, but eligible professionals who don't meet such requirements are subject to penalties starting in 2015. "There's very little meaningful use in Stage 1 that's required by the doc," said Peter Basch, M.D., medical director for ambulatory EHR and health IT policy at MedStar Health in Columbia, MD.

Stage 1 of meaningful use focuses on capturing and sharing data, while Stage 2 aims for improved clinical outcomes. As an example of how MedStar used its EHR to try to improve outcomes, Basch said, every primary care provider receives electronic prompts to remind patients about ways to lower blood pressure, cholesterol, and smoking cessation. The result was better use of tools to manage those conditions. For example, Basch said the use of smoking cessation tools jumped from 23% in 2012 to 70% in one year.

Docs Urged to Be Patient with EHRs

Electronic health records (EHRs), although they may be frustrating now, will become more than just legible medical records and will provide more robust tools for improving patient care, predicts an information technology expert. "Improvements in the documentation process hold promise for more than simply efficient data entry and legible notes," wrote James J. Cimino, MD, in a Viewpoint article published online in the Journal of American Medical Association. "If impressions and plans can be captured within EHRs as explicit data elements, using standard terminology rather than being buried in the narrative text of a note, clinicians could use this information to better support clinical workflow. "Furthermore, a "problem or diagnosis entered in this way could allow an EHR to provide a suggested list of appropriate tests and treatments, based on best available evidence," wrote Cimino, chief of Laboratory for Informatics Development at the National Institutes of Health Clinical Center in Bethesda, MD.

Although three out of four physicians report using EHRs, many complain that patients' records are riddled with "note bloat" that obscures the patient's condition, according to Cimino. "The lineage of many commercial EHRs can be traced to billing systems in which clinical data functions (such as review of laboratory results) were tacked on," he said. "Clinical documentations functions were a similar afterthought, added more in support of billing than patient care."EHRs often ask clinicians first about a specific encounter or level of service rather than going straight to patient data, wrote Cimino. Additionally, instead of making record-taking and record-keeping easier, computerized records have required more time and effort with less flexibility, Cimino said. "When the time required for the task exceeds the time available, appropriate completeness is bound to decline," he wrote.In fact, he said, some attempts to make EHR functions more efficient can backfire. Checkboxes and boilerplate paragraphs that may be quickly copied and pasted also may fail to capture the nuances of patient conditions.

Those and "note bloat" are symptoms of bad EHRs that obscure the decision-making behind diagnosis and treatment. Excessive pertinent negatives captured in EHRs, wrote Cimino, hide more essential information.Cimino suggested that EHRs which allow doctors to annotate previous notes -- instead of blanket copy and paste -- would alleviate cumbersome narrative. Instead of daily summaries of hospitalization, which can become needlessly redundant, EHRs should capture the doctor's current thoughts and observations as they arise, and make retrieval of earlier information more facile. "Summaries could be produced dynamically, reflecting the present state of the clinician's thinking (or the state at some previous time point, if necessary)," he wrote. "This more fluid approach could help make it possible for any clinician to view an EHR and immediately understand the thought processes of other clinicians who have been involved in the patient's care."

In a nod to the idea that EHRs have brought some good things along with the bad, Cimino pointed to a Columbia University suggestion that EHRs include a print prescription function. When added to EHRs, the print option "substantially increased compliance with medication list documentation and medication reconciliation."  Studies show that the functionality and user experience of an EHR program affect the way a physician takes notes, Cimino continued. On paper, a physician typically constructs a comprehensive note in one sitting, he said. Electronically, physicians can make notes several times in a day. Yet, EHRs usually are not designed to support this approach, leaving users to devise "inefficient workarounds." An EHR program able to notice keywords and phrasing typical for doctor's notes about patients could offer appropriate medical responses. Subsequently, the EHR program could offer automated medical orders that could be dispatched efficiently. Appropriate follow-up would be born from those orders, and EHR monitoring could reveal the need for alternative responses to treatment. "These computer-based functions have already been developed; they are merely on hold for the necessary improvements in clinician documentation to be implemented," Cimino wrote.

Don't give up hope, Cimino wrote."EHRs had to start someplace," he wrote. "Rather than complain about the challenges they have introduced, clinicians should recognize that current EHRs are illuminating the opportunities for the next generation of systems that will support clinicians as active partners across the spectrum of healthcare settings and tasks."

If Practices Don't Change, EHRs Lose Money

The average physician lost nearly $44,000 over 5 years implementing an electronic health record system, a large pilot study found, but the technology itself was just part of the reason. Just 27% of practices achieved a positive 5-year return on investment -- a number that would rise to 41% with the addition of federal incentives to use EHRs, the study in the March issue of Health Affairs stated. But the vast majority of practices lost money because they failed to make operational changes to realize the benefits of EHRs such as ditching paper medical records after adoption, Julia Adler-Milstein, PhD, of the University of Michigan in Ann Arbor, and colleagues wrote.

"Practices with a positive return on investment realized savings by eliminating paper medical records, as well as dictation and billing services and positions of, or hours worked by, staff members who were performing services no longer required after EHR adoption," the authors wrote. "Practices may therefore need encouragement and assistance in changing the way they operate so they can benefit from EHR adoption."

The researchers surveyed practices adopting EHRs through the Massachusetts eHealth Collaborative, a pilot program to help more than 80 ambulatory care practices in three communities in the state. The program was supported by the Massachusetts Medical Society and American College of Physicians and funded in part by $50 million from Blue Cross Blue Shield of Massachusetts. EHRs were implemented between March 2006 and December 2007.

The Health Affairs study sought pre- and post-adoption financial cost/benefit data from practices such as total revenue, total operating costs, and total labor costs. Researchers also asked for information on areas that were impacted by EHRs such as the cost of paper medical records, dictation services, and billing services. The authors tried to calculate how EHRs impacted the practices' bottom line. "Our aim was to decrease potential over attribution that could result from asking practices to focus exclusively on EHR adoption," they wrote. Adler-Milstein and co-authors admitted it was difficult to attribute certain savings to EHR adoption. For example, if a practice's revenue increased by $100,000 after EHR adoption, how much of it was because of EHRs? So the authors reported results as sensitivity analyses.

"Factors such as practice attitudes toward the EHR system may have systematically biased attribution in ways that we were unable to address," the authors noted. Their results showed that the average physician lost $43,743 over 5 years. Primary care practices fared better than specialists. Practices that saw a positive return on EHR investment increased revenue by more than $114,000 per physician over 5 years, results showed. In comparison, practices with a negative return on EHR investment saw revenue increase by an average of only $9,200 per physician in 5 years. Even when adding federal incentives to use EHRs, the majority of doctors would have lost money.

With the additional $44,000 from "meaningful use" incentives, more than half of primary care practices would have realized a positive return on investment, compared with a third of specialists, the study found. Doubling the incentive would cause 59% of practices to break even. Tripling it to $132,000 would result in 67% of practices breaking even. "Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clinical care. However, recent reports have shown a small minority of physicians qualify for the bonuses from Medicare and Medicaid.

Other results from the study include:

• 38% of practices with six or more physicians achieved a positive return on investment, compared with 26% of practices with one or two physicians
• 55% of practices reported a reduction in the cost of paper medical records after EHR adoption
• 22% of practices reported the most common ongoing cost was additional hours of practice time
• 10% of practices noted improved efficiency, allowing them to see more patients each day18% increased revenue through improved billing
• Practices with a practice management system in place to help with billing functions before EHR adoption benefited less on average

Wide usage of EHRs was supposed to help doctors increase revenue through improved billing and efficiency gains that would allow them to see more patients per day. However, doctors have complained that EHRs are cumbersome and cause physicians to spend more time documenting patient visits. "Whether the meaningful-use incentive is sufficient to ensure that practices at least break even probably depends on both the practice setting and the decisions made by practices to organize and deliver care differently after EHR adoption," the authors wrote. "Understanding how to help all practices benefit from adoption is crucial to the success of HITECH and represents an important area for future research."

Many Docs Miss Test Results in VA's EHR

About 30% of physicians in the Department of Veterans Affairs (VA) health system participating in a survey said they had failed to notice important test results, sent via the VA's electronic records system, on at least one occasion. The survey's authors, most of whom worked in the Michael DeBakey VA Medical Center in Houston, blamed "information overload" related to electronic health records (EHR) systems for the findings.

"Because this was a cross-sectional survey, we cannot determine causation," wrote Hardeep Singh, MD, MPH, and colleagues online in a JAMA Internal Medicine research letter. "Nevertheless, our findings suggest that missed results in EHRs might be related to information overload from alert notifications, electronic handoffs in care, and practitioner perceptions of poor EHR usability."

The researchers invited 5,001 primary care physicians in the VA system to participate in the survey, which asked several questions about the respondents' attitudes toward EHRs, and whether they had ever personally "missed abnormal lab or imaging test results that led to delayed patient care." The response rate was 51.8%. About 56% of respondents indicated that the VA's EHR system made it "possible for practitioners to miss test results." Large majorities also said they thought the number of alerts sent through the system was excessive and that the volume was more than they could manage effectively. The median number of alerts per day reported by respondents was 63.

Singh and colleagues also analyzed their data for factors predicting increased or decreased likelihood of reporting having missed test results.

Respondents who said they found the EHR system easy to use were much less likely to say they had missed results (odds ratio 0.64, 95% CI 0.43 to 0.96).Other factors associated with significantly decreased likelihood of missing test results included affirmation that respondents consistently notify patients of abnormal results and that they always follow up on alerts in the VA EHR system. Additionally, respondents indicating that their native language was not English were significantly less likely to report missing test results. On the other hand, physicians who said they thought the number of alerts was unmanageably high and those who said they worried about alerts routed to other practitioners in handoff situations -- indicating concern about care coordination, Singh and colleagues wrote -- were significantly more likely to say they had missed test results.

Negative attitudes toward the EHR system were also associated with increased probability that respondents would say it creates potential for missed test results."Interventions to improve safety of test result follow-up in EHRs must address these factors," the researchers concluded.

12% of Docs Meet Meaningful Use Rules

Just over 12% of about 509,000 eligible physicians said they met requirements for meaningful use incentives for electronic health records (EHRs), early study results show.

Less than 10% of specialists and 17.8% of primary care providers attested to enough meaningful use to receive incentive payments through Medicare and Medicaid as of May 2012, according to a letter published in the Feb. 21 issue of the New England Journal of Medicine.

"Although these data suggest rapid growth in the number of providers achieving meaningful use, this pace must accelerate for most eligible professionals to avoid penalties in 2015," Adam Wright, PhD, of Brigham and Women's Hospital in Boston, and colleagues wrote.

"Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clinical care.

Providers who show "meaningful use" of certified EHRs can receive up to $44,000 in extra payments from Medicare and Medicaid, but eligible professionals who don't meet such requirements are subject to penalties starting in 2015.

In Stage 1 of meaningful use, which focuses on capturing and sharing data, providers must meet 15 core objectives and choose 5 additional specifications from a menu of 10. Stage 2, which aims to create better communication between providers and medical facilities, and Stage 3 are set to take effect in 2014 and 2016 respectively, but medical groups are calling for delays in each to allow providers more time to meet the EHR requirements.

"Successive stages of meaningful use increase in difficulty, and it is not yet clear how many eligible professionals will successfully attest in these later stages," the authors said. "The downstream effects of meaningful use on quality, safety, and efficiency are not yet known, and further increases in EHR adoption, functionality for clinical decision support systems, and research are needed to ensure the effectiveness of the meaningful use program."

The authors' data paint a much harsher picture of EHR use than a December report from the CDC's National Center for Health Statistics, which found that 27% of office-based physicians had an EHR system capable of supporting 13 of the Stage 1 core objectives for meaningful use.

Wright and colleagues calculated attestation rates by combining meaningful use data from the Centers for Medicare and Medicaid Services (CMS) from April 2011 to May 2012 with estimates of eligible professionals from the Government Accountability Office, as well as data from the American Medical Association on physicians categorized by specialty and state.

Wright's work also found attestation rates vary greatly from state to state. While the median was 7.7%, use varied from 1.9% in Alaska to 24.2% in North Dakota. Primary care providers comprised 44% of all attestations.

Physicians used EHRs from a total of 310 different vendors, with the top five vendors accounting for 58.5% of physicians who met Stage 1 requirements. The top 15 vendors accounted for 80.1% of attestations.

Physicians have complained that using EHRs slows their work flow and reduces productivity.

EHR Payoff Comes With Time

Doctors who view electronic health records (EHRs) as time-draining and a waste of resources should take a larger view of their use within the practice, EHR advocates said. Physicians should view EHRs as more of a shared care plan of a patient's health, not just a billing mechanism under a fee-for-service model, experts said at the AcademyHealth National Health Policy Conference here. Practices can use EHRs to help better patient outcomes. "It still may take time, but the end result is far better," said Paul Tang, MD, of the Palo Alto Medical Foundation in Los Altos, Calif.

Most estimates peg physicians' EHR use at around 70% -- almost double what it was 3 or 4 years ago. But the complaint from doctors still is that most EHRs are cumbersome and time-consuming. "What we hear from the docs in the front lines is that it is actually reducing productivity in our arcane system of billing and practice because it takes longer to document," Norman Vinn, DO, president-elect of the American Osteopathic Association, said at the panel on health information technology (IT). Instead, physicians need to have a three-way conversation among themselves, the patient, and other readers of a record, according to Farzad Mostashari, MD, national coordinator of health IT at the Department of Health and Human Services. Information needs to be clinically relevant to allow multiple providers to read a patient's record -- and save time and clinical costs -- later down the road."It's not a waste of time if it's communication and shared decision-making," Mostashari said.

If doctors view an EHR more as a tool they and patients can use as they go from one provider to another, the time spent can be viewed less as a waste of time, Mostashari and others said. David Blumenthal, MD, president of the Commonwealth Fund, acknowledged that physician documentation requirements are increasing and taking up more time. But he notes that the healthcare system isn't going back to paper documentation or giving up on EHRs."You can find testimony to the time-saving value of electronic health records, as well as the time-consuming," Blumenthal, an expert on health IT, said.

Vinn said it takes providers a great deal of time trying to obey health privacy laws, and noted that EHRs are easily shared among providers. He called on policymakers to better outline how physicians can share patient information without violating privacy."We need to create some very defined exceptions to portability among silos of information," Vinn said after the panel discussion. Also, the designers of EHRs could design programs that are more productive and user-friendly for providers, he added.

Meanwhile, stage 2 of HHS' EHR Meaningful Use incentive program, which takes effect in 2014 for providers, intends to lay the foundation for further interoperability. "Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use EHRs in a meaningful way that significantly improves clinical care. Mostashari said vendors will be working hard over the next 10 months to meet the stage 2 meaningful use goals of interoperability. He shared his agency's three goals for creating better interoperability among providers for EHRs:

• Develop specific technology standards for vendors to agree to in their EHR products
• Outline reasons why providers need to be able to transfer information between practices, and in which circumstances information can be shared
• Establish trust among patients that they will be able to obtain their information and that it won't be breached by others

"There have to be standards that you can reach or that the different vendors can agree to for being able to exchange complex information," Mostashari said. He noted that delivery models are becoming more reliant on better coordinating care and sharing information.

Many more doctors using electronic health records

More than two-thirds of family doctors now use electronic health records, and the percentage doing so doubled between 2005 and 2011, a new study finds.If the trend continues, 80 percent of family doctors -- the largest group of primary care physicians -- will be using electronic records by 2013, the researchers predicted.

The findings provide "some encouragement that we have passed a critical threshold," said study author Dr. Andrew Bazemore, director of the Robert Graham Center for Policy Studies in Primary Care, in Washington, D.C.  "The significant majority of primary care practitioners appear to be using digital medical records in some form or fashion. "The promises of electronic record-keeping include improved medical care and long-term savings. However, many doctors were slow to adopt these records because of the high cost and the complexity of converting paper files. There were also privacy concerns. "We are not there yet," Bazemore added. "More work is needed, including better information from all of the states."

The Obama administration has offered incentives to doctors who adopt electronic health records, and penalties to those who do not.

For the study, researchers mined two national data sets to see how many family doctors were using electronic health records, how this number changed over time, and how it compared to use by specialists. Their findings appear in the January-February issue of the Annals of Family Medicine. Nationally, 68 percent of family doctors were using electronic health records in 2011, they found. Rates varied by state, with a low of about 47 percent in North Dakota and a high of nearly 95 percent in Utah.

Dr. Michael Oppenheim, vice president and chief medical information officer for North Shore Long Island Jewish Health System in Great Neck, N.Y., said electronic record-keeping streamlines medical care. These records "eliminate handwriting errors, and help with planning and caring for patients with chronic medical problems," Oppenheim said. Plus, the files can be accessed by a doctor when the initial provider is unavailable, he said.Electronic health records also save money in the long term, he noted. "If a patient has a complaint and just had a blood test, and then shows up at the ER (emergency room) with the same complaint, the ER doctor can access the record and not reorder the same test," he said.

Oppenheim said medical penalties are driving adoption of e-records, but there is still some hesitancy. "Doctors are nervous about the cost and worried about how it will affect their practice," he said. "The conversion process is complex. "Doctors can do it themselves or outsource the system. "You pay in productivity or dollars," he said.Electronic health records are good news for all involved, agreed Dr. Adam Szerencsy, an internist at New York University Medical Center in New York City and the Epic Medical Director there. Epic is NYU's electronic health record system. When the concept first surfaced, many patients were concerned about their privacy. Today's electronic health records are secure and often have protocols attached to make sure that they don't fall into the wrong hands, he explained.

A key reason that family doctors are leading the transition is that government incentives make it a little more lucrative for family practitioners than specialists, he said.Also, "primary care doctors manage patients over time, while subspecialists usually don't," Szerencsy said. For example, a surgeon may treat appendicitis, and then the case is closed.The Holy Grail is thought to be a universal health record where doctors everywhere can access patient records. "We are getting closer," Szerencsy said. "Within the next couple of years, electronic health records will explode across the board."

Electronic Medical Records A Disappointment for Some

Electronic medical records arrived with a fanfare in 2005, promising huge cost savings, better accuracy and efficiency - most health care professionals and authorities have been disappointed, stating that systems overall are not user-friendly and badly integrated, says a new report issued by the Rand Corporation, a non-profit organization.

The authors of the new report state that the potential of health information technology to reduce spending as well as improve patient care will never materialize if health care providers do not reengineer their processes to focus on the benefits that could be achieved.

Dr. Art Kellermann, senior author, and Paul O'Neill Alcoa, Chair in Policy Analyziz at Rand, said jointly: "The failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place."

A team of IT experts from Rand Corporation in 2005 published an analysis that predicted "widespread adoption of health information technology" that would eventually save America over $81 billion in better delivery and efficiency of health care annually.

Co-author Spencer S. Jones, and Kellerman concluded that a much more compelling vision is required to attract funding into health information technology. They offer the following suggestions:

• For health information to work properly, it needs to be stored in a single IT system and be easily retrievable by others, including physicians and hospitals, who belong to other health systems. The authors stress that this is vital, especially in emergency situations.
• Patients should by right have easy and ready access to their electronic health information, in the same way a bank customer has access to his/her account data. Patients must be able to see their own records, share them with doctors and other health care professionals and providers of their choice.
• Health information technology systems must be geared towards making a doctor's job easier and more efficient. If all it does is add to his/her workload, it is a complete waste of money and time. Systems should be user-friendly, which the authors describe as "intuitive". Busy health care providers should be able to use them easily without having to attend extensive training programs.
• Physicians and other health care providers should be able to use systems across different health care settings with ease, in the same way a consumer drives various models and makes of cars.

Several media reports  mention that a significant number of healthcare providers would rather bypass the incentive checks and even pay up the eventual penalty fees than have to deal with the bother of implementing electronic health record systems. If this is occurring in a big scale across the USA, something needs to be done urgently to make the implementation and everyday usage of these systems more practicable.

Learn from other countries, say some experts
Some say that the USA should liaise with other countries which have successfully created and implemented electronic health care records systems in a big way nationally, such as the United Kingdom.

Professor David Blumenthal of Harvard University, and Dr. Jenniffer Dixon, of the Nuffield Trust, UK, stress that in technology, organization and financing, the two nations could learn a a lot from each other. They said "Comparing health reforms in the USA and England seems to be an unlikely project: many people in both countries view the other as having a pariah health system that is not to be copied in any circumstance. But both countries are under pressure to get more value out of health care spending and reduce growth in expenditure to sustainable levels, and are consequently experimenting with new ways to encourage clinicians, patients, and institutions to help achieve this."

Several studies have looked at the benefits of electronic health records, with mixed results:

• Researchers from Weill Cornell Medical College reported in the Journal of General Internal Medicine that doctors who go digital provide considerably better healthcare, compared to those who do not.
• A team from the RAND Corporation wrote in the American Journal of Managed Care that electronic health records usage has only had a limited effect on improving medical care quality in hospitals in the USA.
• Northwestern Medicine researchers reported that patients who are at high risk for CVD (cardiovascular disease) are more likely to receive a prescription medication for cholesterol-lowering drugs when their doctors use electronic health records. They added that those patients are also more likely to achieve lower long-term cholesterol levels. They reported their findings in the Journal of General Internal Medicine.

EHRs May Turn Small Errors Into Big Ones

As electronic health record systems become more interconnected, errors may propagate much farther than under old paper-based systems, a recent study suggested. According to a review by the Pennsylvania Patient Safety Authority, mistakes and near misses involving electronic health records were analogous to those made with paper-based records with one caveat: those made with EHRs tend to be amplified and can affect a larger group of people.

The Authority's study looked at 3,099 reports from Pennsylvania hospitals detailing 3,946 problems. More than 2,700 incidents involved near misses and 15 involved temporary harm to patients. The study focused on incidents from 2004 to 2012 in which electronic health records were the root cause in the event, as opposed to being incidental.Electronic health records are designed to be more efficient than paper-based records, but the two systems have one thing in common: they're developed and maintained by people. The most common source of problems identified in the study rested with data entry and, to a much lesser extent, with technical glitches.Medication errors accounted for about 80% of the cases, or 2,516 reports. Many of the remainder involved lab tests.About half of the drug errors involved the wrong medication, with underdosing the problem in about 30%.One problem is EHRs are connected to other systems like a hospital pharmacy, and they will only get more connected as EHR information is transmitted using health information exchanges. That means that any incorrect information entered in the record is widely distributed.Another complication is that the deadlines established by the federal government in the 2009 economic stimulus package led to some providers rushing to set up an EHR system without adequate staff training in place.

The study noted that one big problem is several institutions are trying to use paper-based and electronic records in tandem, which creates incomplete information in one source or the other. This issue has led to overmedication in some cases and underdosing in others.Wrong medication was the No. 1 source of mix-ups, just as with paper-based records. Talking to reporters in a webinar about the study, William Marella, program director for the Patient Safety Authority, said, "There's no question in my mind that EHR is the smart way to go, but in the short term we are seeing safety issues."He added that the scale of the problem has changed, so you can have a single problem that can cascade.Marella recalled one incident discovered in the review in which a technical glitch caused medication orders to randomly appear on some electronic medical records. The problem was not noticed until a request for an erectile dysfunction drug appeared on a female patient's record. In a separate incident, a note that a patient was allergic to penicillin was made in the free notes section of an EHR rather than in the section addressing allergies. The patient was subsequently given ampicillin, which sparked an allergic reaction.

One way to address the current issues with electronic health records is to make systems smarter, particularly with natural language processing. Such a system could catch information even if it's not entered in the right place.The study highlighted the need for tracking the number of near misses and mistakes caused by electronic health records. It pointed out that an Institute of Medicine report called attention to the lack of hazard and risk reporting data on health information technology as a hindering factor in building safer systems.

Most Docs Won't Qualify for EHR 'Meaningful Use'

Two-thirds of office-based physicians plan to apply or have already applied for meaningful use incentives for using electronic health records (EHRs), a government survey found.

However, only about a quarter have computer systems that support Stage 1 meaningful use objectives -- a prerequisite for receiving the incentives. Physicians must meet all 15 of the Stage 1 core objectives to qualify for meaningful use incentives as of 2012, along with a few other requirements.

"Among physicians who had already applied or intended to apply for incentives, 27% had EHR systems capable of supporting 13 of the Stage 1 core objectives for meaningful use, which is an overestimate of the percentage meeting the 2012 requirements," according to a report released from the CDC's National Center for Health Statistics.

"Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clinical care.

The survey found 41% had already applied for the incentive program and another 25% planned to. "Intent to participate among physicians also varied by state," the report stated.

Also, some of the physicians meeting the Stage 1 requirements may not meet the additional two requirements for Stage 2, which is part of the incentive program, the report noted.

And under the proposed Stage 2 rule published in February, providers who haven't proven they've met the Stage 1 requirements of meaningful use by Oct. 3, 2014, face a 1% cut in Medicare Part B pay starting in 2015, and the percentage is expected to increase a percentage point each year thereafter for at least a couple of years.

The federal government will provide incentive payments of up to $44,000 per clinician over 5 years through Medicare and $63,750 per clinician over 5 years through Medicaid to providers who are meaningful users.

The CDC's survey found 72% of office-based physicians used an electronic health record in 2012, up significantly from 48% in 2009 and 57% from last year.

The numbers mostly reflect other surveys gauging EHR usage, which taken together estimate that between 70% and 75% of doctors use electronic records.

Not surprisingly, the CDC found that EHR usage varied greatly from state to state, ranging from a low of 54% in New Jersey to 89% in Massachusetts.

About 40% of physicians reported having an EHR system that met the requirements of a "basic system," up from 22% 3 years ago.

The report looked at data from the National Ambulatory Medical Care Survey, an annual, nationally representative survey conducted by the CDC's National Center for Health Statistics. This year, the survey was mailed to more than 10,000 physicians, and 67% responded.

A report from the Department of Health and Human Services Office of Inspector General hammered the Centers for Medicare and Medicaid Services, which administers the meaningful use incentive program, for not doing more to ensure that the incentives went to physicians who deserved them.

Electronic Health Records Can Identify At-Risk Untreated Patients And Lead To Better Preventive Care

In a new study, Northwestern Medicine researchers found that patients at high risk for cardiovascular disease (CVD) are more likely to receive a prescription for cholesterol-lowering medication, and to achieve lower long-term cholesterol levels, when doctors use electronic health records (EHRs) to deliver personalized risk assessments via mail. The paper was published in the Journal of General Internal Medicine.

"It is important to get high priority preventive care messages to patients in a variety of ways," said Stephen Persell, MD, assistant professor of general internal medicine and geriatrics at Feinberg, and first author on the paper. "Sending a mailed message that depicts one's actual cardiovascular risk may lead some patients to action even though talking about treating cholesterol with their physician did not."

CVD remains the number one cause of death globally, and is the leading cause of death for both men and women in the United States. High blood pressure, high LDL cholesterol and smoking are well-known key risk factors for heart disease, and about half of Americans (49 percent) have at least one of these three risk factors.

However, according to the study's authors, risk assessment is not performed often in primary care, and doctors may have inaccurate perceptions of patients' risks.

Persell and the Northwestern team believed the use of EHRs to automatically identify candidates for risk-reducing interventions would result in better care delivered directly to patients. They enrolled 29 physicians and 435 eligible patients in the study, and assigned 14 physicians with 218 eligible patients to the test, or intervention, group.

"This is the first study that took a population-wide approach to identifying all patients who might benefit from this kind of an intervention in a primary care setting," said Persell. "Prior studies have only tried this kind of approach with select groups of patients."

Working with the Northwestern Medical Enterprise Data Warehouse, a sophisticated EHR data repository developed jointly by Northwestern University, Northwestern Memorial Hospital, and the Northwestern Memorial Faculty Foundation, researchers identified a pool of at-risk patients who were not being treated with cholesterol-lowering drugs.

Physicians in the test group received automated notification of these high-risk patients, who were then mailed personalized risk assessments. The assessments encouraged them to discuss risk-lowering options with their physicians.

Ultimately, those in the test group were twice as likely as the control group to receive a prescription for lipid-lowering medication, and after extended follow-up 18 months later, 22 percent had lowered their cholesterol significantly (by 30 mg/dl or more) vs. 16.1 percent of controls.

Though these tactics improved results compared to usual care with no follow-up messages, Persell believes there is still room for improvement.

"Many patients who had increased cardiovascular risk and got the risk message sent to them still did not get their cholesterol lowered. Future studies can examine if repeated exposure to these messages leads to bigger changes over time," he said.

Persell said an ongoing study is currently testing whether a similar approach combined with telephone outreach can help patients in federally qualified community health centers control their cardiovascular disease risk.

Quality Of Patient Care Improved By Electronic Health Records

A new study by Weill Cornell Medical College researchers, published in the Journal of General Internal Medicine, provides compelling evidence that electronic health records (EHRs) enhance the quality of patient care in a community-based setting with multiple payers, which is representative of how medicine is generally practiced across the United States.

The use of EHRs is on the rise, in part because the federal government has invested up to $29 billion in incentives promoting the meaningful use of these systems, with the aim of tracking and improving patient outcomes. Previous studies have provided conflicting evidence about the impact of EHRs, and until now it had been not clear whether they improved the quality of patient care, particularly in typical communities that use commercially available systems. "The previous studies on the effects of electronic health records in the outpatient setting have been mixed," says the study's lead investigator, Dr. Lisa M. Kern, associate professor of public health and medicine at Weill Cornell Medical College. "This is one of the first studies to find a positive association between the use of EHRs and quality of care in a typical community-based setting, using an off-the-shelf electronic health record that has not been extensively tailored and refined. This increases the generalizability of these findings."

"This study starts to grow the evidence that the use of these systems can systematically improve the quality of care, although their maximum value likely lies in their ability to support new health care delivery models," says the study's senior investigator Dr. Rainu Kaushal, director of the Center for Healthcare Informatics and Policy and the Frances and John L. Loeb Professor of Medical Informatics at Weill Cornell Medical College. "The findings of this study lend support to the very significant investments in health information technology that are being made by the federal government, states, and health care providers."

This study was conducted with the Health Information Technology Evaluation Collaborative (HITEC) - a multi-institutional effort directed by Drs. Kaushal and Kern and funded by New York State, in order to evaluate and assess the impact of New York's health information technology strategy. In 2008, the researchers collected data about the quality of patient care across nine measures from nearly 500 physicians and 75,000 patients in ambulatory practices in the Hudson Valley region of New York, where there has been a concerted effort to implement EHRs. They gathered data from five different health plans, including two national commercial plans, two regional commercial plans and one regional Medicaid health maintenance organization.

"This study reflects data from five different health plans, which is another strength of the study and which is critical for understanding the experiences of patients in the community," says Dr. Kern. "If you only have one health plan, then you will not be seeing the whole picture."

The team found that the 56 percent of physicians who used commercially available EHRs provided significantly better quality of care than physicians using paper records for four measures, including hemoglobin A1c testing in diabetes, breast cancer screening, chlamydia screening and colorectal cancer screening. EHRs typically provide reminders about these clinical tests. Moreover, the combined score across all nine measures indicated that EHRs led to better patient care than paper records.

"EHRs may improve the quality of care by making information more accessible to physicians, providing medical decision-making support in real time and allowing patients and providers to communicate regularly and securely," says Dr. Kaushal. "However, the real value of these systems is their ability to organize data and to allow transformative models of health care delivery, such as the patient-centered medical home, to be layered on top."

To follow up on this study, the researchers plan to determine how the effects of EHRs on patient care vary over time and across different locations in New York, to examine the effects EHRs on the cost of patient care and to work on improving ways to measure the quality of patient care.

Tougher EHR requirements set in finalized meaningful use stage 2

Starting as early as 2014 physician practices will be required to achieve more difficult objectives to demonstrate meaningful use of electronic health records to earn federal bonuses and prevent future penalties. The Centers for Medicare & Medicaid Services finalized its requirements for stage 2 of the EHR incentive program in in August 23rd regulation. The final rule mandates that doctors meet a larger number of core objectives -and stricter guidelines for some of those objectives already in place -during the next part m the three-stage program. Physicians also must adopt and demonstrate meaningful use of EHR system by October 2014, or be assessed a 1% penalty from Medicare.

Doctors who successfully adopt early enough can earn up to $44,000 over five years from Medicare or up to $63,750 over six years from Medicaid. Demonstrating meaningful use of a paperless record will required annually to prevent penalties that will take effect starting in 2015. CMS reports that about 55,000 physicians had earned Medicare incentives bad incentives through June 2012 under the less-stringent stage 1. Slightly more than 34,000 had earned Medicaid bonuses. Several organizations representing physicians and other participants have urged CMS to design the program to be more flexible so it encourages even greater ERR use. Organized medicine groups, including the American Medical Association, had called for the administration to soften the stage 2 meaningful use requirements that it outlined in a proposed rule issued in February.

The AMA "has provided ongoing input since the inception of the ERR incentive program and has urged greater flexibility to make the program more reasonable and achievable for physicians," said AMA Board Chair Steven J. Stack, MD. "In a comment letter submitted by the AMA and 100 state and specialty medical societies in May, recommendations were outlined to eliminate physician roadblocks and encourage greater physician participation." The Association and the other societies that signed onto the comment letter were reviewing the final rule, Dr. Stack said. He said he hoped the review would find changes that promote adoption and meaningful use of EHRs by physicians.

Stages 1 and 2 each require meeting 20 total objectives, but stage 2 makes mandatory some EHR measures that are optional for stage 1, such as whether the electronic systems can incorporate clinical laboratory test results. Other measures stay the same but have higher thresholds, such as a requirement that ERRs send more than 50 % of applicable prescriptions electronically, up from more than 40%. The number of required core set measures goes up to 17 in stage 2 from 15 in stage 1. Physicians also must choose and comply with three out of six additional "menu" set measures, as well as report at least nine clinical quality measures.

Some additional time granted
The effective date of stage 2 has been one of the most contentious issues for the program. After physicians and others complained that early adopters of paperless systems would be forced to meet the more stringent require­ments sooner than those who waited a year, the White House floated a plan in late 2011 to set the earliest possible stage 2 deadline for doctors to 2014 instead of 2013. The final rule released in August makes that delay official.

Physicians who earned EHR bonuses in 2011 and 2012 will be required to meet stage 2 requirements starting in 2014. Doctors who start achieving meaningful use in 2013 or later will report under stage 1 rules for two years before moving onto stage 2, regardless of whether they incur any noncompliance penalties for being late adopters. Despite the effective delay for early adopters to 2014, a significant majority of comments on the proposed rule said that deadline still was too aggressive. "Some commenters suggested that the time was insufficient regardless of resource constraints, while others suggested that currently vendors of [EHR systems] lack the necessary capacity to make the necessary upgrades to their products and implement them for their customers in time," CMS acknowledged in the final rule.

The physician organizations specifically asked that CMS delay the start of stage 2 until 2015. The agency rejected the request, saying it "would have a ripple effect through the timeline of stages." However, CMS did give physicians some more time to make the necessary changes to their systems by requiring only a three-month reporting period in 2014, meaning EHRs would not necessarily need to be upgraded by the start of the year.

Reporting periods for meaningful use will be three months long regardless of what stage an eligible professional is following, said Rob Anthony, a health specialist with the CMS Office of E-Health Standards and Services, during an Aug. 24 seminar. Also beginning in 2014, a group can submit a meaningful use attestation for all of its eligible professionals in one file, saving the practice from entering each person's information separately. Demonstrating meaningful use during stage 2 will rely on patients interacting with physicians and EHR systems online. For instance, CMS had proposed that eligible physicians send a secure EHR-based message to at least 10% of unique patients. Another proposed measure directed doctors to provide half of their patients with the ability to view online information about their care and ensure that a minimum of 10% did so.

Many commenters objected to these measures, because physicians would be held accountable for patient inaction on a measure. The AMA and other medical societies recommended the patient measures be made optional, but CMS did not follow the advice.

"While we recognize that [eligible professionals] cannot directly control whether patients use electronic messaging, we continue to believe that [eligible professionals] are in a unique position to strongly influence the technologies patients use to improve their own care, including secure electronic messaging," CMS said. But the agency did reduce the reporting thresholds for those measures from 10% to 5% in the final rule. CMS also will exclude physicians from the requirements when they practice in areas without sufficient Internet access.

Some organizations reviewing the final rule lauded the agency for including some additional flexibility for incentive program participants. "Extending the start for stage 2 until 2014 was a necessary step to permit medical groups sufficient time to implement new software," said Susan Turney, MD, president and CEO of the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Assn. and the American College of Medical Practice Executives. “Permitting group reporting will reduce administrative burden, as will lowering the thresholds for achieving  certain measures such as mandatory online access and electronic exchange of summary of care documents.”

Doctors can seek penalty exemptions
Agency officials carved out several hardship exceptions to the noncompliance penalties, and some will require the reporting physician to complete an application prior to the penalty's assessment. The exemptions are available for physicians who:  

• Have insufficient Internet access for any 9O-day continuous period between Jan. 1, 2013, and July 1, 2014 .
• Are new to Medicare.
• Encounter extreme circumstances outside the physicians' control, such as practices closing, natural disasters, EHR vendors going out of business and similar scenarios.
• Practice in multiple locations and have a lack of control over the availability of EHR systems. Have a lack of face-to-face visits or other patient interactions, or the need to provide follow-up care.

In 2014, CMS also will align reporting for the clinical quality measures component of meaningful use with the Medicare physician quality reporting system so doctors are not facing two different reporting standards. PQRS, a separate program from the EHR initiative, will penalize physicians starting in 2015 for not reporting certain quality measures to the government.

WHAT EHR UPGRADES WILL BE REQUIRED?

Stage 2 of the federal electronic health record initiative will include 17 core measures and six additional "menu" objectives, from which a physician would choose at least three. Doctors must use their EHR systems to meet requirements for at least 20 measures, including all 17 in the core set.  

CORE SET

• Use computerized physician order entry (more than 60% medication, 30% lab and 30% radiology orders)
• Prescribe permissible drugs electronically (more than 50%)
• Record patient demographics (more than 80%)
• Record and chart changes in vital signs (more than 80%)
• Record smoking status (more than 80%)
• Use clinical decision support (at least five interventions)
• Incorporate clinical lab results into EHR (more than 55%)
• Generate lists of patients by specific conditions (at least one list)
• Identify patients who need reminders for preventive or follow-up care (more than 10%)
• Provide at least half of patients with access to health information (more than 5% use access)
• Provide clinical summaries for patients within one business day (more than 50%)
• Identify patient-specific education resources (more than 10%)
• Communicate with patients on relevant health information (more than 5%)
• Perform medication reconciliation during care transitions (more than 50%)
• Send summaries of care during referrals (more than 50%)
• Submit electronic data to immunization registries (ongoing submis­sions during reporting period)
• Protect EHR information  

MENU SET

• Access imaging results through EHR (more than 10%)
• Record patient family health histories (more than 20%)
• Record electronic notes (more than 30%)
• Submit electronic syndromic surveillance data to public health registries (ongoing submissions)
• Identify and report cancer cases to a public health registry (ongoing submissions)
• Identify and report noncancer cases to a specialized registry (ongoing submissions)  

Documents Developed by the AMA Summarizing the Meaningful Use Stage 2 Final Rule which was recently released by the Centers for Medicare and Medicaid Services:

Highlights of the CMS Medicare and Medicaid EHR Meaningful Use Stage 2 Requirements
Stages 1 and 2 Requirements For Meeting Meaningful Use of EHRs

Liability Claims Drop with EHRs

Switching over to electronic health records (EHRs) appears to dramatically cut malpractice suits, according to a small study of insurance claims. The adjusted rate of malpractice claims fell six-fold among physicians in practices that adopted computerized records, Steven R. Simon, MD, MPH, of the VA Boston Healthcare System and Brigham and Women's Hospital, and colleagues found. The shift reflected a reduction in the number of all closed claims, rather than just in payouts, the group reported in a research letter published online in the Archives of Internal Medicine. Thus, "our findings suggest that a reduction in errors is likely responsible for at least a component of this association, since the absolute rate of claims was lower post-EHR adoption," they wrote.

Federal incentives under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act pay out bonuses through Medicare and Medicaid for "meaningful use" of EHRs to improve care, although only a fraction of physicians appear to have qualified so far." The reduction in claims seen in this study among physicians who adopted EHRs lends support to the push for widespread implementation of health information technology," Simon and colleagues noted.

Electronic records may cut down on risk factors for errors and resultant malpractice claims, such as poor communication among providers, difficulty getting patient information in a timely manner, unsafe prescribing practices, and poor adherence to clinical guidelines, they explained. The documentation in EHRs may also improve the likelihood of successful defense against suits, they added. Their study examined closed malpractice claims among Harvard-affiliated physicians by using data from the Massachusetts malpractice insurer Controlled Risk Insurance Company/Risk Management Foundation and from a survey on EHR implementation from a random sample of physicians in the state.

Overall, 33 of the 275 physicians included in both databases in either 2005 or 2007 were named in at least one malpractice claim. Of the 51 claims, 49 were related to events before adoption of EHRs. While 27% of the pre-EHR claims resulted in a payout, neither of the two claims related to events after EHR adoption resulted in payment.After accounting for duration of coverage by the malpractice insurer and of EHR use, the use of electronic health records was associated with an estimated relative risk of 0.16 for malpractice claims (95% CI 0.04 to 0.71). The researchers cautioned that other unmeasured factors could have at least partially accounted for this apparent protective effect.

"For example, physicians who were early adopters of EHRs may exhibit practice patterns that make them less likely to have malpractice claims, independent of EHR adoption; these early adopters contribute a disproportionate amount of time in our analyses, favoring an effect of EHRs on reducing malpractice claims," the group explained. Centers may also have implemented other practice changes around the time of EHR adoption as well, they noted.

Other limitations were the fact that data from a single group of physicians in one state covered by one malpractice insurer may have had an impact on generalizability and that it covered a relatively short period after EHR adoption, which may have precluded looking at the influence on missed or delayed diagnosis-type claims. "While this study includes only a small number of post-EHR claims, it suggests that implementation of EHRs may reduce malpractice claims and, at the least, appears not to increase claims as providers adapt to using EHRs," the group concluded.

Is a 'Cloud'-Based EHR for You?

Which Electronic Health Record system should I select?Among physicians and managers in small-group practices today, there is no more common question.But lately, another vexing question has emerged: Whether to install EHR software on servers in your office, or subscribe to an Internet-based system maintained in "the cloud."

What Is "the Cloud"?
When EHR vendors began offering their products via the cloud, many physicians were puzzled. Some think that the cloud is simply techie parlance for the Internet.In fact, it refers to a method of computing whereby the critical applications are housed in remote locations -- "hosted remotely" in tech jargon -- and accessed by end users via the Internet.Physicians have long been accustomed to "hosting" critical software applications on servers in the office. That is how they've accessed practice management systems -- the information technology (IT) backbone of medical practices -- for 20 years or more.Having all the practice's data hosted remotely -- on the cloud -- raises questions about data access and security.Some of those fears may be eased if you consider how much you are already doing in the cloud.For instance, many people conduct much of their banking via secure websites that allow them to access all of their private financial information, transfer funds, check investment accounts, and pay bills. Millions have used Web-based email systems such as Gmail for all manner of personal and professional correspondence for many years.These services live in the cloud.You do not have any software loaded and running on your computer to use these tools.So, the cloud is really just a giant client-server model: a distributed application structure that partitions tasks between the providers of a service (called servers) and the clients. A client (a user workstation or PC) initiates communication sessions with the server by requesting a service function.In the cloud, the server providing the service -- for example, an EHR service -- is hosted remotely. Your Web browser is the client.

Why the Cloud Is Gaining in Popularity
Cloud computing represents a paradigm shift in IT management. The cloud makes it possible for you to grow and expand rapidly and generate efficiencies and cost savings by paying as you go for the services you use.Cloud-based EHR services are typically offered as complete software packages provided over the Internet, eliminating the need to install and run an application on your own computers and simplifying maintenance and support.Sometimes this is referred to as "software as a service," or SaaS.For many practices the cloud-based solution is a good choice for several reasons:

• Generally, there are no retained earnings in a medical practice, so any new investments must be financed externally or the physicians take a hit against their current earnings. Low up-front costs are more palatable and less complicated.
• IT expertise and resources may be nonexistent or retained on a project-by-project basis. The cloud model does not require sophisticated technology infrastructure that must be built and maintained by expert, costly IT staff.
• A cloud-based EHR does not require a special facility or environmental considerations because on-site servers are unnecessary. Backup and disaster recovery services are central and inclusive in the cloud model.

But fear of losing control over critical data is often a stumbling block in cloud adoption. Actually, though, cloud computing can give you more control over your data than you get with a client-server EHR.Cloud providers offer many options for protecting the data entrusted to them -- often more than your in-house IT staff or budget could make possible. In all situations, however, data sovereignty should belong to you.Other benefits of cloud computing:

• An encrypted high-speed Internet connection provides your practice with access to data and applications without having to manage software changes or invest in server hardware.
• Updates are automatic and managed by the vendor so you won't need staff to work over a weekend to install software, migrate files, or test data conversions.
• And you'll always be on the most current version, without requiring additional infrastructure investment.

Although there are start-up costs with the SaaS cloud model, typically around $13,000, there is no up-front software license to purchase or lease. With a client-server setup, those usually run more than $60,000.And although you won't be paying a software maintenance or upgrade fee, you will be paying a monthly subscription or service fee, typically about $500.For organizations that have the wherewithal and staff to maintain a data center (multiple servers, perform regular data backups, manage software upgrades, and attend to the details of technical troubleshooting) a client-server model is a viable choice, but may still be cost-prohibitive.Practices that find startup investment in a data center daunting, or do not have adequate IT support, will find clarity in the cloud.

'Meaningful Use' Compliance Slow

The medical system is undeniably morphing into a more electronic one, but many clinicians are still not ready for it, according to current and former government officials.

Although more than 30,000 clinicians qualified for bonus payments for using electronic health records in 2011, many others are unaware of how to prove they're meaningful users of the technology, wrote Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services, and current National Coordinator for Health IT, Farzad Mostashari, MD, along with several others, in a special article in the May 14th issue of Archives of Internal Medicine.

In the article, the authors provide a "Guide for Physicians to the EHR Incentive Programs" that explains how to register for, report, and attest to meaningful use of health IT.

"Meaningful Use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records (EHRs) in a meaningful way that significantly improves clinical care.

Broadly, in order to be eligible for bonus payments, clinicians must show their EHR is capable of e-prescribing; exchanging health information with other doctors, patients, and the Centers for Medicare and Medicaid Services (CMS); and submitting clinical quality and other measures for analysis.

There will be three different stages of meaningful use requirements under which providers will have to progressively increase their use of EHRs. Stage 1 criteria, which focused on the basic requirements to create a health IT foundation, are already finalized.

In order to be eligible for bonuses under Stage 1, clinicians must meet at least 15 objectives from a list that includes generating and transmitting e-prescriptions; recording patient demographics; recording smoking status; providing clinical summaries of each visit; and having the ability to submit immunization data.

Stage 2 criteria, which is in the rule-making process, delves deeper and focuses on e-prescribing, incorporating lab results into EHRs, and allowing data to be accessed by patients, among other things.

Stage 3 criteria will be released in 2014 and will concentrate on measuring outcomes and making self-management tools available to patients.

Most U.S. physicians are eligible for incentive programs, but there are some exceptions. Physicians and other clinicians can determine if they're eligible by checking on the CMS web site, the article's authors said.

After determining whether a clinician qualifies, the next step is certification, where physicians must prove they are using certified EHR technology. There are over 900 certified health IT products, and clinicians can view the list here.

As of Dec. 31, 2011, more than 172,000 clinicians were registered for the EHR Incentive Programs, according to the authors of the Archives article.

The next step is attestation, which differs depending on whether it's Medicare's EHR incentive program, or Medicaid's EHR incentive program that the clinician is attesting to.

In order to receive incentive payments from the Medicare program, a clinician must attest to meeting all of the required objectives using certified EHR technology during 90 days in the first payment year and a full year beginning the second payment year. Attestation user guides and an attestation calculator are available here. Clinicians are eligible to receive up to $44,000 over five years under the Medicare incentive program, but will be subject to a 1% penalty if they are not using EHR in a meaningful way in 2015.

Registration for Medicaid's EHR incentive program occurs with CMS, but each state will establish its own system for determining whether doctors and others are using EHR for Medicaid patients, and to determine bonus payments, which could total a maximum of $63,750 over six years. Unlike the Medicare EHR incentive program, clinicians participating in the Medicaid program won't be penalized for failing to adopt EHRs.

The authors said they understand the move away from a paper medical system and to an electronic one isn't easy.

"Even the strongest enthusiasts for EHRs recognize that their adoption involves significant changes for physicians, with attendant dislocations in workflows, investments, and habits of practice," the authors wrote. "Although the ultimate benefits for both practice management and health care almost certainly make this transition worthwhile, the discomfort for physicians during the transition ought not to be underestimated."

They said the first years of meaningful use will likely be the most difficult, but the transition should become smoother once sectors of healthcare embrace an increasingly electronic medical system, and as medical students learn how to manage patient care electronically.

CMS Releases Stage 2 Meaningful Use Proposals

Officials with the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) announced proposed requirements for Stage 2 Meaningful Use and 2014 certification of electronic health records. The Stage 2 Meaningful Use rules and EHR certification standards largely reflect the recommendations made last year. The proposed regulations emphasize the need for greater interoperability among systems and health information exchange. On the Meaningful Use side, this means that organizations will have to exchange data across organizational boundaries and disparate EHRs. The proposed Stage 2 regulations will keep some Stage 1 criteria unchanged, revise others, and include new requirements. Some highlights include:

• Patients must be given the opportunity to view, download and transmit their medical records online.
• The number of decision support elements that must be used will increase.
• Data must be submitted to public health agencies, where possible.Viewing of images will be on the optional menu of criteria.
• Clinical quality measures for Meaningful Use will be aligned with those in other programs that involve quality reporting, including Medicare's Physician Quality Reporting System, the shared savings program for accountable care organizations, medical homes and the Joint Commission's quality program.
• Eligible professionals will be able to report data in batches.
• Physician groups of a certain size can report quality data for their groups.
• Connections to registries will be required, including cancer registries.
• CMS will do prospective reporting of "payment adjustments" for those who don't show Meaningful Use by 2015.

On the EHR certification side, some of the proposals include:

• EHRs must include the direct protocol for secure clinical messaging.
• Vendors will have to begin incorporating standard clinical terminologies into their products. Mostashari cited SNOMED, LOINC, and RXNorm, as examples, but it was unclear whether EHRs must have all of those for 2014 certification. RXNorm for medications must be included, said Steve Posnak, the director of ONC's federal policy division.
• There will be new vendor requirements for usability, partly to give more flexibility to specialists who need "scope of practice" exclusions to meet the Meaningful Use criteria.
• The definition of a certified EHR no longer will be based on meeting 100 percent of a set list of criteria. Instead, the criteria will be revised so that they enable providers to meet the requirements they have chosen to meet for Meaningful Use. That means that specialists who don't use certain aspects of primary care EHRs can qualify for Meaningful Use by using EHRs that are certified to meet the needs of their specialties.
• Beyond satisfying "base EHR" requirements, such as patient demographics, problems, clinical decision support, and computerized physician order entry, EHRs or EHR modules can be certified if they have the capability to help providers achieve the core criteria for their stage of Meaningful Use (with exclusions for specialists) and only those optional menu items that the providers who use those applications have chosen.

Start Using EMR Today and Get $44K  

2011 was the year of “meaningful use”. EMR vendors had to meet certification criteria for the EHR Incentive Programs, and urgent care practitioners had to learn how to be meaningful users of their EMRs in order to qualify for incentive payments. 2012 is the year to jump on board meaningful use and get your share of the stimulus! 

Physicians who begin participating in the program in 2012 are still eligible to receive full incentive payments – up to 75% of their Medicare allowable charges. Remember: the program is about the “meaningful use” of an EMR, so you don’t qualify by just using an EMR; you have to prove you are using the EMR in a meaningful way based on criteria set by the government.  

What does “meaningful use” mean? The idea is that accelerating the use of EMRs will result in healthcare that is focused on evidence-based preventative care through the use of electronic health technology. The government is committed to accelerating the transition from paper to electronic, and health experts expect tangible changes in the U.S. healthcare system to manifest as early as this year as a result of meaningful use.  

Are you a physician who is eligible for the Medicare EHR Incentive Program? Unless you meet all of the exemptions to the meaningful use criteria, you MUST become a meaningful user of an EMR by 2015. Failure to do so will result in payment adjustments to your Medicare reimbursements that start at 1% each year, up to a maximum of a 5% annual adjustment. The Medicare EHR Incentive Program provides incentive payments to eligible professionals, eligible hospitals, and CAHs that demonstrate meaningful use of certified EHR technology. Eligible professionals can receive up to $44,000 over five years under the Medicare EHR Incentive Program. There's an additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HSPA). To get the maximum incentive payment, Medicare eligible professionals must begin participation by 2012.

Medicare and Medicaid EHR Incentive Program Basics