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
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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:
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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
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Review of systems
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Physical examination
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Assessment
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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:
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Patient demographics and history
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Assessment of patient risk and comorbidity
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Procedure indication(s)
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Procedure: technical description
- •
Findings
- •
Assessment
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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.
Related posts:
Impact of Health Care Reform on the Independent GI Practice
A Letter to Fellows: Transitioning From Training into Practice in Uncertain Times
Medical Practice Integration: Going Big in Private Practice
Gastroenterologists and the Triple Aim: How to Become Accountable
Demonstrating Value: Registries and Beyond
Gastroenterologists and Accountable Care Organizations
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