This is an age of disruptive innovation in health care in which the business model is changing. Fee-for-service, volume-based systems are being replaced by fixed-fee, value-based systems. One of the major facilitating forces behind this change has been the development of the electronic health record, which is providing the medical community with the ability to have real-time quality metrics that will drive the development of web-based clinical decision support tools that will transform the current peer-review–based rules of practice with an eclectic fluid environment of continuous quality measurement and improvement.
The development of the electronic medical record (EMR) has been an evolving process over the last 30 years, occurring in phases based on the availability of technology and the changing requirements of payment systems. As a result of the recent changes imposed by the Patient Protection and Affordable Care Act (PPACA), this is an age of disruptive innovation in health care in which the business model is changing from a fee-for-service, volume-based system to a risk-based, fixed payment value system. Although it was written before the PPACA as part of the American Recovery and Reinvestment Act (ARRA), the Electronic Health Record Incentive Program has established new standards for what an EMR will need to be in the future. The changes imposed by the program facilitate the changes that are imposed in the PPACA. This article reviews the regulations imposed by this legislation and describes what the electronic health record (EHR) of the future will look like as a result.
Meaningful use
On February 17, 2009, President Barack Obama signed public law 111-5, the ARRA, a stimulus bill intended to lift the American economy out of recession. An important component of the ARRA is the Health Information Technology for Economic and Clinical Health (HITECH) Act, created in an effort to stimulate the medical community to accept and incorporate EHRs into their practices and to use these applications to promote best practices, with a national health information network as the desired end result. Meaningful use (MU) changes the way clinicians work.
Priorities
The priorities of the HITECH Act are as follows:
- 1.
To improve quality, safety, and efficiency, and to reduce health disparities
- 2.
To engage patients and their families
- 3.
To improve care coordination
- 4.
To improve population and public health
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To ensure privacy and security protections for personal health information (PHI).
Definition of MU
MU is described in the Act as the use of “Certified EHR technology in a meaningful manner”; electronic exchange of health information to improve the quality of care, such as promoting coordination of care; and reporting on clinical quality measures (which will become more stringent over time).
Thus, to comply with MU, an EP must be using a certified EHR that shows the ability to share information with others involved in the care or management of the patient; one that must have the ability to transmit quality data to central registries.
Benefits and penalties
To incentivize providers to comply with MU, the HITECH Act provides financial incentives to eligible providers (EPs) who comply with the standards described in the Act. They are shown in Table 1 . Each EP who complies with MU in the required time period (defined later) will be eligible to receive a total of $44,000. Those who do not comply will ultimately have at least a 3% reduction in their reimbursements that will continue indefinitely.
| Adoption Year | Maximum Payment ($) | PFS Penalty | ||||||
|---|---|---|---|---|---|---|---|---|
| 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | Total | ||
| 2011 | 18,000 | 12,000 | 8000 | 4000 | 2000 | 0 | 44,000 | — |
| 2012 | — | 18,000 | 12,000 | 8000 | 4000 | 2000 | 44,000 | — |
| 2013 | — | — | 15,000 | 12,000 | 8000 | 4000 | 39,000 | — |
| 2014 | — | — | — | 12,000 | 8000 | 4000 | 24,000 | — |
| 2015 | — | — | — | — | — | — | — | −1% |
| 2016 | — | — | — | — | — | — | — | −2% |
| 2017+ | — | — | — | — | — | — | — | −3% |
Stages of MU
A project of this size that requires such a major change in behavior cannot be implemented immediately. Therefore, MU will be introduced in 3 stages. Stage 1, which begins in 2011, is concerned predominantly with EPs capturing clinical data in an electronic format and initiating quality reporting. In 2014, stage 2 expands with the addition of decision support, and, in 2015, stage 3 adds clinical outcomes MU criteria ( Fig. 1 ).
HIE
The second pillar of MU is HIE, which is the ability of each of our MU-certified systems to communicate with another equally certified system. This communication is critical to the success of the program.
HIE is defined as the mobilization of health care information electronically across organizations within a region, community, or hospital system. It provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to, and retrieval of, clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. HIE is also useful to public health authorities to assist in analyses of the health of the population.
How will HIE change practices? It will bring structured data elements into practices and allow the transmission of similar data to others outside a practice. Examples include the incorporation of structured laboratory data into EMRs. Complete blood counts are no longer presented as faxed documents. The values are instead entered in an EMR for hemoglobin, hematocrit, red blood cells, white blood cells, mean corpuscular volume, and so forth, which allows changes to be charted and patterns of change analyzed for every element.
HIE will also improve the communication of clinical information between providers. Patient visit data will be transmitted in a structured format called Continuity of Care Records (CCRs) and Continuity of Care Documents (CCDs). CCRs and CCDs allow clinical information exchange between and among primary care physician (PCPs) and specialty care physician (SCP). More importantly, because they are in a common format, the information is automatically incorporated into the EMR of the recipient. This process occurs seamlessly between practices even if they use different EMRs.
Quality measures reporting
The third and final component of MU is quality measures reporting, and this is the most revisionary element. For purposes of the requirements under sections 1848(o)(2)(A)(iii) and 1886(n)(3)(iii) of the Act, clinical quality measures are defined to consist of measures of processes, experience, and/or outcomes of patient care, observations, or treatment that relate to 1 or more quality aims for health care, such as effective, safe, efficient, patient-centered, equitable, and timely care. Through this reporting, the Centers for Medicare and Medicaid Services (CMS) is beginning the move to value-based practice. A set of core quality measures has been developed that all providers will be required to report.
MU is expected to accelerate the conversion of the medical records present in all doctor’s offices to digital data that can then be leveraged to improve the quality of medical care and lower its cost.
The EMR and its components
Clarifying the differences between an EHR and EMR is frustrating at times because so many people use the terms interchangeably. The CMS refers to the EHR because it represents the legal record containing confidential health and billing information drawn from the patient record and sent electronically to them for reimbursement. As a result, most federal agencies within the US Department of Health and Human Services, Social Security Administration, Office of People Management, and Veterans’ Administration reference this system as an EHR.
However, vendors consider the software they sell to you to be the electronic version of a paper record that contains not only physician notes but also nursing notes, laboratory results, imaging reports, pathology reports, family and social history, and treatment plans. Therefore, they refer to their software as EMR. To help provide clarity to the discussion, the difference between EMRs and EHRs must be described. The following definitions have been developed by major authorities in health information technology.
EHR
As defined by the Healthcare Information and Management Systems Society (HIMSS), the EHR is a longitudinal electronic record of patient health information generated by 1 or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter (as well as supporting other care-related activities directly or indirectly via interface) including evidence-based decision support, quality management, and outcomes reporting.
Documentation of Patient Encounters
The components of a patient encounter include the following:
- •
Chief complaint
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History of present illness
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Past medical and surgical history
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Endoscopy history
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Family history
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Social history
- •
Review of systems
- •
Physical examination
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Assessment
- •
Plan
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Orders.
All of these elements must be documented on initial visits and must be at least referenced on most return visits. Although most of these elements can be entered into today’s EMRs using picklists and dropdowns, the history of present illness is unique in that it must allow for flexibility in composition. This flexibility is accomplished in multiple ways including typing, voice recognition, use of macros, point-and-click options, and dictation.
The gastrointestinal (GI) EMR has a unique component, the endoscopic history. Clinicians need to know what endoscopic procedures were performed, when and for what reason, and the result.
Order Sets
Current MU-certified EMRs have the ability to create order sets that link a set of orders to a diagnosis, which is not only an efficient way to enter them but also provides for a more uniform style of practice in large groups. This method is essential for quality management and performance improvement and is discussed later. It also allows for the more efficient use of extenders.
The Endoscopy Report Writer
A major proportion of the services provided by gastroenterologists today are in the form of endoscopic procedures. Accordingly, the information produced by these services must be recorded and reported in a uniform fashion. The format of the endoscopy report has been worked out and has been reported by Lieberman.
According to this guideline, the report must include the following fields:
- •
Patient demographics and history
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Assessment of patient risk and comorbidity
- •
Procedure indication(s)
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Procedure: technical description
- •
Findings
- •
Assessment
- •
Interventions
- •
Unplanned events
- •
Follow-up plan
- •
Pathology.
These essential components should be incorporated in all endoscopy reports. Endoscopy reports have traditionally been documents that record the details of the procedure that was performed. Through the use of a uniform set of formatted fields, these reports can be the tool that is used to refine the performance of procedures. Registries like the American Gastroenterological Association (AGA) Digestive Health Registry have been created by the societies to host and compile these metrics. Like all physicians, gastroenterologists will eventually be profiled based on the reporting of quality outcome metrics, the results of which will then drive reimbursement for their services.
Endoscopic Images
Most endoscopy reports also either include or reference endoscopic images that are obtained during the procedure. These images are captured and usually stored on a separate server. The EMR then must hold a script that allows it to access these images and incorporate them into the report. This access requires interfaces to be created from the endoscopy software and the EMR.
Pathology Modules
GI endoscopists also have a need for access to pathology reports. If the practice uses a commercial pathology company, then an interface is necessary that will send demographic information to the pathology company and receive report fields in return. If the practice has its own captive pathology company, it may or may not use a separate laboratory information system, which will require an interface as well. If the EMR is used for processing the pathology, then templates can be created within the EMR itself. Regardless of the structure, structured pathology data are essential for quality monitoring of issues like adenomatous polyp capture rates.
Patient Portals
A patient portal is a tool that allows a secure tunnel in the Internet to provide an interactive continuum of care between the patient and the physician, facilitating effective electronic communication and clinical data exchange.
Most portals contain standard features such as appointment requests, prescription renewals, and transmission of documents and forms. Other features of portals include importing referral documentation, and automated interviews that allow patients to complete their own history before the physician encounter. Customized disease and health management plans are also facilitated, based on the patient’s input to the provider, who can then track, measure, and adjust plans. A portal integrates real-time clinical and administrative workflow among providers, hospitals, and patients.
In addition, a message can be sent to a group of patients identified for a medication recall, for a new service to help a chronic condition, or those due for tests or follow-up visits. Through a patient portal, messages are automatically addressed, encrypted for security, and sent to the targeted patients.
This is the future of physician-patient communication.
Mobility
Most gastroenterologists see patients in a variety of locations including hospitals and ambulatory surgical centers (ASCs). However, these locations are usually away from the physician’s main office where the patient management system (PMS) and EHR are located, which creates issues in everyday practice. Every procedure performed in an ASC requires a timely history and physical examination. Clinicians therefore need access to their EMRs to accomplish this. The management of hospital inpatients often requires access to the clinical information stored in EMRs. Likewise, when clinicians are on call and have patient interactions, these must be recorded in EMRs for clinical as well as medical-legal purposes. These interactions all require real-time access.
The solution for this is to make use of Web-based tools either on personal computers (PCs) or handheld devices like smartphones or pads.
The major issues here include:
- 1.
Real-time access to the data
- 2.
Security of the communication
- 3.
The ability to enter as well as receive data
- 4.
Access to additional tools (eg, Performance Quality Rating Scale [PQRS]).
Real-time Access
Today, every communication between a physician or the nursing staff and the patient must be recorded. This requirement means that clinicians need to have the ability to connect to EMRs whenever it is required. This ability is especially critical in the group practice setting where one physician may be covering another, on call for another. Web-based access to EMRs allows for this type of communication.
Security
The security of the communication is critical. The Internet itself does not provide the level of security necessary for secure communication. One of the solutions for this is a connection called the Virtual Private Network (VPN), which creates a secure tunnel within the Internet that is password protected and encrypted. This protection adds the security necessary but requires an extra login and password that the user is required to enter.
Another means of safe communication is through the use of terminal server (TS) technology. The Microsoft Windows TS is a server program running on its Windows NT 4.0 (or higher) operating system that provides the graphical user interface of the Windows desktop to user terminals that do not have this capability themselves. Such terminals include the low-cost NetPC or thin client that some companies are purchasing as alternatives to the autonomous and more expensive PC with its own operating system and applications. The reserves a part of the server for each licensed user who then only needs to use a remote desktop application to access the full functionality of the EMR from wherever it is being accessed. Security is maintained and access is complete.
All of these features can be accessed using Web-based smart phones or pads. Data are in real time and security is maintained as long as the network is secure.
Another popular means of establishing secure real-time communications is through the use of active server pages (ASP), which create an application that sits on a Web server and communicates with 1 or more databases. ASP brings an application to the user that is accessible wherever there is Web access, and allows a safe, secure access to the databases that communicate with the ASP application. ASP applications are common in online services like banking. This technology is the basis of the so-called cloud where applications no longer reside in PCs but exist on a Web-based server. Once there, they can communicate with databases that are located elsewhere; this is the future of computing.
Choosing an EMR
The selection of an EMR can be a daunting task. Currently there are more than 250 companies that sell EMRs. This number will undoubtedly decrease over time as consolidation occurs in the industry. How does the user choose? The first essential issue to consider is whether the software is MU certified. Only certified EHRs should be considered as viable choices. Once the field has been narrowed in this fashion, the other essential features for a GI practice need to be considered, such as GI-specific templates and an endoscopy report writer. Whether the software can be customized is a critical feature because clinicians need to customize the templates to their specific needs. What is the company’s capability for service? Will they be responsive?
One of the most important steps in choosing an EMR is to find a champion within the practice, usually a physician, who will embrace the process and advise the rest of the physicians in the practice. Demonstrations of each EMR are critical. These demonstrations take time and focus, so a champion is essential.
Quality improvement
As discussed earlier, HIT can build a foundation for quality improvement (QI). CMS considers that the QI produced through the HITECH Act and MU will be an essential factor in the future control in the cost of Medicare and Medicaid. The success of health care reform relies on limiting the variation in the care that is provided. By limiting variation in care and promoting better adherence to evidence-based medicine, the overall cost of health care will be easier to control.
Most clinicians practice with a knowledge base that has been built in medical school and in postgraduate training, but continually refined through continuing medical education either in the form of journal articles or educational sessions. However, the fields in which clinicians practice are continually expanding the requirements of their knowledge base. In addition, this is a period of shared outcomes in which clinicians are expected to report results into registries that are large databases composed of fields of clinical data. The hope is that, by accumulating this data, it can be leveraged to improve decision making.
Registries
In order for this to be accomplished, the data has to be transmitted to the registries in real time and seamlessly so that it does not interfere with the provision of medical care. To do this, common formats are required. With the marked heterogeneity in EMR data structure, this is difficult. In time, these common fields will be formatted and data will be transmitted unencumbered.
Once there are large clinical data repositories, it will be possible to create standards for performance and then benchmark providers against these standards. The main goal of benchmarking is not to identify outliers but to provide a means for providers to conform to the standards by showing them how they compare with their peers.
Clinical Decision Support Tools
The essential next step after registries is the creation of clinical decision support (CDS) tools, which are vehicles to feed back assistance in decisions to providers. They will not only assist physicians who are outliers to conform to standards, but will also assist even the best physicians to improve the value of their work. Ultimately, standards will tighten and the bell curve of performance will tighten. Levels like 6 σ may never be reached, but medical practice will become less variable.
Real-time CDS tools will supplement and potentially replace some of the previous tools of continuing medical education because they will be in real time and narrowly focused on the specific clinical situation in which the physician is practicing.
These tools will be even more useful to the less trained physician like the PCP or the physician extender like the Nurse Practitioner or Physician Assistant. CDS tools will allow care for certain conditions (eg, IBS) to be provided by the less trained professionals and still maintain the same level of quality, which will be essential to cost control.
Order Sets
Originally referred to as cookbook medicine, order sets have become an essential component of the implementation of EMRs. They allow us to create a standard set of orders for each clinical diagnosis that is encountered. They not only improve quality, they enhance efficiency and help control cost. In addition, they help define the state of the art.
Order sets are integrated with knowledge databases so that clinical references can be accessed in real time to confirm the accuracy of each component of the order set.
Putting it all together around risk and value
The age of risk-based value-driven reimbursement has begun. This age will create a myriad of challenges, starting with a change in the drivers of income. Traditionally, physicians have been reimbursed for volume, not value, but this has now been reversed. One of the most significant challenges in moving to value is to find/create the metrics for quality. These metrics have not yet been adequately defined. The metrics must satisfy the following equation:
Because Quality = Service + Outcome, value can now be defined as:
Metrics for service can easily be developed through patient satisfaction surveys. Cost is easy to calculate as well. The challenge is in metricizing the outcomes. Values for this need to be developed over time. CMS is working in this space in conjunction with the National Quality Forum (NQF). As they endorse and implement measures for PQRS, the ratio of encounters that meet the standards can be used as a metric.
Fee-for-service medicine is being replaced by value-based medicine, which will create an environment of reimbursement based on fixed salaries combined with bonuses driven by scores on a balanced scorecard of production, financial, patient satisfaction, and quality reports.
How will EHRs help? See Fig. 2 .
In order for providers to control risk, cost needs to be controlled. This control requires transforming specialty shop (SS) services like complex consultations into value-added processes (VAPs).
With VAPs, protocols and guidelines will guide the provider. EMRs will pull data from registries and drive the creation of detailed practice guidelines that will then support the development of CDS tools. These tools will allow less trained health care participants to participate in the care model at higher levels than they do today. Thus, intuitive medicine will move toward more precision-based services. The disruptive innovations of the PPACA and MU will facilitate the movement of services from high-price specialists to PCPs and midlevel providers, thereby lowering cost and maintaining quality.
Without the data management and CDS tools provided by the EHR, this will not be possible.
Summary
HIT has gone through a long maturation process driven by changes in technology and payment systems. This is an age of disruptive innovation in health care in which the business model is changing. Fee-for-service, volume-based systems are being replaced by fixed-fee, value-based systems. One of the major facilitating forces behind this change has been the development of the EHR, which is providing the medical community with the ability to have real-time quality metrics. These metrics will drive the development of Web-based CDS tools that will transform the current peer-review–based rules of practice with an eclectic fluid environment of continuous quality measurement and improvement. It will be challenging, but the result will be a health care system that is high quality, efficient, and positioned for the future.
The author has nothing to disclose.
References
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- 2. Patient Protection and Affordable Care Act (‘‘PPACA’’; Public Law 111–148).
- 3. Pub L No. 111–5. American Recovery and Reinvestment Act of 2009. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/content-detail.html. Accessed February, 2009.
- 4. Department of Health and Human Services: Centers for Medicare & Medicaid Services. 42 CFR Parts 412, 413, 422, and 495, CMS-0033-F, RIN 0938-AP78.
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- 7. Federal Register/Vol. 76, No. 5/Friday, January 7, 2011/Rules and Regulations.
- 8. American Society for Testing and Materials (ASTM) E2369 – 05e1 Standard Specification for Continuity of Care Record (CCR).
- 9. The Continuity of Care Document: Changing the Landscape of Healthcare Information Exchange. Corepoint Health, 2011.
- 10. EHR – Based Quality Measurement & Reporting: Critical for meaningful use and health care improvement. Chicago (IL): Health Information and Management Systems Society, 2010.
- 11. Lieberman D.A., Faigel D.O., Logan J., et al: Assessment of quality of colonoscopy reports: results from a multi-center consortium. Gastrointest Endosc 2009; 69: pp. 645-653
- 12. AGA Field Guide: Selecting and Implementing Electronic Medical Records for your GI Practice. AGA Institute Press, 2009.
- 13. National Quality Forum (NQF), Driving Quality and Performance Measurement—A Foundation for Clinical Decision Support: A Consensus Report. Washington, DC: National Quality Forum, 2010.
Related posts:
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Gastroenterologists and the Triple Aim: How to Become Accountable
The Impact of Health Care Reform on Innovation and New Technology
Demonstrating Value: Registries and Beyond
Gastroenterologists and Accountable Care Organizations
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