Making Wound Care More Meaningful: Understanding Incentive-based Programs

  In today’s fiscal healthcare climate, remaining financially secure can be as imperative to clinicians as it is to provide optimal care — a standard that continues to be redefined by federal programs and professionals seeking to improve care delivery across the healthcare spectrum. The federal government’s program to promote “Meaningful Use” of electronic health records (EHRs) in an effort to establish secure, confidential exchange of health information across the care continuum, is paramount and has become a household name among providers and hospitals.   But many clinicians have yet to qualify for the financial rewards associated with EHR implementation set forth by guidelines initiated by the Centers for Medicare & Medicaid Services’ (CMS) EHR Incentive Programs, which provide payments to eligible professionals (EPs) and hospitals as they demonstrate meaningful use of certified EHR technology. (Ambulatory practice-based physicians, designated as “eligible professionals” by CMS, can receive up to $44,000 through Medicare incentives and up to $63,750 through Medicaid if they attest [qualify] by Oct. 4, 2012. Those who first qualify next year and in 2014 will be eligible to receive lesser amounts.)   Why haven’t more specialist physicians qualified at this point? Cost and financing are issues. Some physicians have said the incentives are not large enough to compensate them for costs associated with installation of an EHR system. Another factor is basic uncertainty about the future of their businesses. A recent survey by the Physicians Foundation found that 92 percent of practicing physicians said they were “unsure” where the US health system would be or how they would fit into it 3-5 years from now. Other providers may be waiting to see if new legislation ends the program (an unlikely event, since the program has bipartisan support).   What’s more, for clinicians running wound care centers, concerns regarding EHR Meaningful Use are closely tied to Medicare’s Physician Quality Reporting Initiative, now known as the Physician Quality Reporting System (PQRS). Both EHR Meaningful Use and PQRS take the “carrot and stick” approach, with incentives given to early adopters and penalties on the horizon for non-adopters.   The time to adapt is now.

Conforming to Meaningful Use

  Under current rules, all physicians who do not meet EHR Meaningful Use standards by October 2014 will face Medicare payment cuts of 1 percent in 2015 and 2 percent in 2016. There is quite a bit of overlap between the PQRS and Meaningful Use programs, since both require using an EHR to record and report clinical measures to CMS. It is currently possible to receive both Meaningful Use incentives and meet PQRS requirements; however, separate filing is required. CMS officials have said they will align the two programs in 2014 so that physicians can file once and get credit for both programs.   There are several important facts physicians working in wound care clinics need to know about EHR Meaningful Use:     • Ambulatory surgery centers and most other types of freestanding clinics do not qualify as eligible hospitals, and thus can’t collect stimulus payments as organizations. The individual physicians may qualify, but they must file on their own as “EPs.”     • The requirements state that 50 percent of an EP’s patient encounters during the reporting period must be at one or more practices that are equipped with a certified EHR system. This allows EPs to participate in the program even if they work at multiple locations with varying levels of Meaningful Use adoption. For example, if a physician treated the majority of his/her patients at a clinic with an EHR, but also treated some patients in a private office without an EHR, he/she could still qualify.

Definition of EP

  Under Medicare’s EHR Meaningful Use, EPs include: doctor of medicine (MD), osteopathy (DO), podiatric medicine (DPM), optometry (OD), or chiropractic (DC), and dentist or dental surgeon (DDS or DMD). Medicaid has a slightly broader definition of eligible professionals, including nurse practitioner (NP), certified nurse midwife (CNM), and physician assistant (PA; if employed at a federally qualified health center or rural health clinic). Note that one cannot collect incentives from both programs.   Stage I of Meaningful Use took effect in January 2011. As of Aug. 1, 2012, 66,883 physicians overall had qualified for the Medicare Meaningful Use while another 50,887 had qualified through Medicaid. This represents 18 percent of all physicians who participate in that program and are eligible for Meaningful Use, according to CMS officials.   To date, some 25,000 family practice and internal medicine physicians have attested, comprising almost 50 percent of all those who have qualified. The attestation rates for specialist physicians are significantly lower. For example, only 2,137 general surgeons and 2,500 orthopedic surgeons have qualified so far — low rates for technologically advanced physicians.   What are the specific barriers that wound care physicians and other specialists report facing in qualifying for these incentives?   ChartLogic Inc., a national EHR vendor based in Salt Lake City, UT, recently conducted a survey of about 100 specialist physicians who had successfully qualified for Stage I. This survey found the most difficult challenge reported was “distributing clinical summaries to patients,” cited by 38 percent of those reporting.   The Stage I attestation guidelines require the medical office to make available clinical summaries, either paper or electronic, to patients within 3 business days after a physician’s examination. The survey also found the second major difficulty was in “collecting patients’ vital signs” (height, weight, blood pressure, body mass index). This requirement was cited by 14 percent of specialist practices as their most difficult challenge.   A third specific challenge of “collecting patient demographics” was reported by 8 percent of practices to be most difficult. Stage I requirements state that practices must collect demographics as structured data, including preferred language, gender, race, ethnicity, and date of birth. Note that all the practices responding to the survey had successfully qualified for Stage I incentives, so they were able to meet these challenges successfully.

Qualifying for Payments

  The days of simple reimbursement through fee-for-service medicine are coming to an end. Both the federal government and private payers are requiring new measures of accountability — measures that require the use of EHRs. The selection and implementation of an EHR should be viewed in terms of a sound business investment that will generate a positive return of investment and improve patient care. While the clock is ticking, there is time to plan for EHR implementation in a careful manner. Medical group leaders who wait too long may find themselves rushed into hasty decisions and without time for effective training.   Below are some tips that may prove helpful:     1. Select an EHR designed for specialist care. Data collection can be more burdensome to wound care clinicians in a busy clinic than for primary care physicians, who generally see 20-25 patients per day, many of whom are returning patients, according to the American Academy of Family Practitioners. In contrast, most wound care physicians see many first-time patients each day. While vital signs can be collected by nurses or medical assistants, physicians will need to document each patient evaluation. Busy clinicians should look for an EHR system that has customized templates and multiple ways of entering information. Advanced EHR systems enable physicians to input data via keyboard, point and click, and touch screen.     2. Ask patients to self-report demographics. Patients are accustomed to self-reporting personal information in many situations, so it’s feasible to have them do this in the waiting room when possible. Many medical offices provide check-in kiosks or tablets to patients to facilitate data entry. If a clinic serves many elderly patients, consider staying with a paper solution. One option is to collect the needed demographic with “bubble-in” forms that can be fed into optical mark readers, which will then load the data to the EHR system. Before purchasing the forms or optical scanners, check EHR compatibility.     3. Use a patient portal for clinical summaries. Printing and mailing a patient summary (within 3 days per Meaningful Use standards) is an option, but can be costly and time consuming. One cost-effective alternative is to install a patient portal, a web-based application that allows patients to interact with providers. Many, but not all, certified EHRs come with patient portals. When a clinic or medical practice has installed a portal, staff can quickly upload the clinical summary to a web site to be viewed by the patient. Note that current Stage I Meaningful Use standards do not require patients to read or to download a clinical summary; it just needs to be “available.” Vendors can demonstrate the process of ensuring a portal is compatible with an EHR. If it takes numerous clicks of the mouse to send or upload a patient summary and 50 patients are seen per day, extra work each day for all involved can be expected. Zubin Emsley is chief executive officer of ChartLogic Inc. For more information, visit www.chartlogic.com.