Meaningful Use of Health Information Technology, Part 2

We are at the start of five critical years of electronic health record (EHR) adoption and health information technology (HIT) expansion. $44,000 of federal stimulus money is on the line for qualifying providers with certified EHR systems. Confusion is growing about what a certified EHR is, and chiropractors are wondering where they fit in. Through the HITECH Act, meaningful use of EHRs is now being defined, and its definition will determine who qualifies for incentive payments from CMS.

This is part two of a three-part part series on the meaningful use of health information technology. Last month I explained the eight goals behind HIT standards and how your practice has been primed for these standards. Next month we'll continue with an explanation of how incentives will be paid out over the next five years and what milestones your practice will need to achieve to qualify. Before we get there, however, we need to know how chiropractors are going to accomplish meaningful use of a certified EHR system. For our purposes, I've broken the proposed rule down into three categories encompassing 25 total requirements: (1) improving technology; (2) improving outcomes; and (3) objectives which may not relate to chiropractic practice.

Category 1: Rules to Bring Your Technology Up to Speed

Of the 25 proposed rules or "objectives," a large portion define what kinds of capabilities health care providers or eligible professionals need to have once an EHR system is adopted. CMS and the Office of the National Coordinator for Health Information Technology (ONC) paint with a broad brush, as they're writing both for hospitals and private practice providers. These are the keystones your EHR system is going to need to guarantee if you want to qualify for stimulus funds. Your software provider should handle the ability to perform these items.

How to Use This Article Know that some comments are speculative. CMS and the Office of the National Coordinator for Health Information Technology (ONC) have published a proposed rule for what defines meaningfuluse of EHRs. There are 25 major items in this proposed rule. As I write this article, feedback from public comment to CMS is still being collected. There may be a few details that have changed by now. Refer to the full publication, as this summary and commentary is arranged by specific categories. There is not enough space to offer a valuable commentary on each item of the proposed rule while publishing the rule verbatim. I encourage everyone toread the original language of the document. You can read the entire document and a summary at www.futurehealthsoftware.com/quickFacts.html.

1. Computerized Physician Order Entry (CPOE) is used for management of medications, lab results, imaging, provider referrals, and patient visits. The term CPOE is tech-speak for "a doctor who stores and manages his or her patient orders electronically." If you have a true EHR, then you should have this objective fulfilled. To meet CMS standards, 80 percent of your orders must be fulfilled with such a system. For the DC, these orders will include active care PT/rehab orders, radiology, and lab testing if such testing is ordered in your clinic.

2. Incorporate lab test results into the patient's electronic health record as structured data. Offices able to meet the above objectives should have no problem accepting and storing lab tests with the patient's other data in the EHR. To meet CMS standards, this must be done in 50 percent of patient files with whom you have ordered such tests.

3. Maintain a current patient problem list based on ICD-9 or SNOWMED CT. This isn't anything that you don't already do, but just as in the first objective, you'll be doing it strictly via EHR management. To meet CMS standards, this must be accomplished on 80 percent of unique patient visits.

4. Record patient demographics. This function is easily met through most EHRs. Keep in mind, however, that in-clinic data retrieval and analysis are also going to be important. If you're going to collect this information for the government, then you might as well be able to mine it for insights into your practice. To meet CMS standards, 80 percent of all patients must have demographics recorded. These include race, language preference, gender, ethnicity, and date of birth.

5. To exchange patient health information among providers and authorized third parties. What good is it to have completely digital clinic data if that data isn't portable across multiple systems? Problems lists, and radiology results, etc., all need to be able to be sent out by your clinic, as well as be retrieved by your clinic via your state's health information exchanges. To meet CMS standards, you have to demonstrate this capability for at least one piece of patient health information, with the ability to send and receive information on 80 percent of all patients referred in or referred out.

6. Submit claims electronically to public and private payers for at least 80 percent of all claims filed electronically by the eligible professional.

7. Provide patients with an electronic copy of health information. If you've read any of my columns about personal health records, you will understand the implications of this objective. Patients are finally going to have access to their records like never before. To meet CMS standards, you'll need the ability to deliver secure, encrypted, functional electronic copies of records to at least 80 percent of your patients who request such a record.

8. Offer patients electronic access to health information. Beyond simply providing an electronic copy, which the patient may or may not be able to access on their own, at least 10 percent of your unique patient visits should have access to their personal health information, primarily via the Internet, according to CMS.

9. Protect all patient information through necessary security and best practices. Essentially fulfilling HIPAA, a certified EHR is going to have this capability built in, provided your company stays current with its updates. This includes data encryption, secure off-site storage, unique users and passwords, tracking of deletions and additions to the record, automatic log-outs, and recording of health information disclosures.

10. Other capabilities include: being able to check insurance eligibility electronically from public and private payers on 80 percent or more of unique patients and being able to submit claims electronically.

Category 2: Objectives Meant to Improve Outcomes

11. Create lists of patients identified by conditions. Storing patient demographics and maintaining an electronic problem list make this objective possible. As I said in last month's column, the goal of HIT isn't to wow our patients with computers, but to get patient data within health information exchanges. We expect mining this data will help us improve outcomes and as a side effect prove the effectiveness of chiropractic care with more reliable data sets. In order to meet CMS standards, your office is going to have to generate one patient list based on a condition.

12. Electronically record vital signs, including BMI, and growth and development charts (for patients ages 2 through 20).The benefits of this requirement should be obvious, especially in our increasingly overweight society. Rather than just weighing in, EHRs offer an interactive component to the patient, whereby they can see their body mass index tabulated immediately. As research continues to refine morbidity risks based on BMI percentages, patients will be able to see just how their weight is increasing their risk for chronic disease.

13. Provide summary care record for each transition of care and referral for at least 80 percent of the transitions.

14. Record smoking status for patients ages 13 and older. In order to meet CMS standards, you'll need smoking status data on at least 80 percent of patients. With a qualifying EHR, this task is simple and unobtrusive. As smoking is closely linked to increased morbidity and mortality, there is going to be a new emphasis on smoking cessation in primary care settings, and that includes chiropractic offices.

15. Send care reminders to patients ages 50 and older according to patient preference. CMS requires reminders for preventive and follow-up care for any patient age 50 and older. Although the reminder itself may not be electronic, your EHR should be able to generate a list of patients who are 50 or older, their schedule of visits, and how they want to be reminded. To meet CMS standards, this must be accomplished on at least 50 percent of such patients. Clearly, the goal is to limit the amount of forgotten patient care milestones and increase preventive testing. Better compliance delivers better health care outcomes.

16. Provide clinical summaries to patients after an office visit. While offering patients digital access to their record may improve outcomes, this objective will probably do the most to clarify patient instructions and summarize what happened in the office - two factors that may improve patient compliance. To meet CMS standards, summaries must be offered at 80 percent of all patient visits.

17. Report ambulatory quality measures to CMS. Improved reimbursement for care of Medicare patients has been available for providers offering voluntary reports of quality outcomes in their offices according to published care guidelines. Participants would have to calculate and submit their data electronically to meet CMS standards. These can be calculated automatically by the software.

18. Implement and respond to five clinical decision-making support rules. This is as close as the CMS document gets to speaking about evidence-based care. Specialties within health care are encouraged to use their own particular care guidelines during the clinical decision-making process, which should appear in the EHR as care alerts. The practitioner's agreement or disagreement with the alert is recorded in that particular case. Chiropractors, for example, may see use of care alerts based on NCQA LBP or CAD guidelines for neck trauma.

19. Maintain an active medication list.

20. Maintain an active medication allergy list.

21. Perform one test of EHR's ability to submit data to vaccine registries.

22. Alert public health surveillance systems for disease. While you might be asked to make sure your system can communicate with state registries, chiropractors don't offer vaccinations or often provide primary care for infectious disease, so these two objectives may not be seen as critical and are only required if you perform them.

Category 3: Objectives With Unknown Application in Chiropractic Practice

As the CMS and ONC document is meant for all providers and for hospitals, there are a number of objectives chiropractors may be exempt from complying with, or that have less importance in the chiropractic practice. As stated, at the time of this writing, leaders in the profession are providing feedback on these items. CMS has acknowledged that certain provider types will be exempt from such things, but the final rule has not yet been published regarding the exemptions.

23. Generate and transmit prescription medications electronically in 75 percent of cases. As chiropractors don't prescribe in 47 states, we will most likely be exempt from this objective.

24. Perform medication reconciliation at care transitions. No doubt you want to know what medications your patient is on in order to understand how the medications might be affecting their problem list. However, the breadth of these three objectives may be limited, as advising on medications other providers have prescribed is outside our scope of practice in most states.

25. The eligible professional has enabled functionality to implement drug-drug, drug-allergy, and drug-formulary checks.

Putting It All Together

Last month we covered the why behind health information technology expansion, and now we've covered 25 meaningful use items that will determine whether your use of EHR will be considered meaningful, and therefore eligible for stimulus funds. Please join us for part 3 next month [May 20 issue], when I outline what milestones you'll need to achieve in order to get the highest incentive payments. I'll explain how you get paid and the formula for your incentive monies to adopt an EHR. Adopting EHR is something we'll all be doing with or without incentive monies over the next few years, so we might as well get paid for it.

The key is to achieve better outcomes for our patients through meaningful use. Your software will do most of the reporting for you. You simply need to capture the data. This leads to higher-quality management of care and incentive payments for doing so.