Electronic Medical Records

CMS’s Andrew Slavitt talks with MMS about MACRA

Posted in Electronic Medical Records, Health Policy, Health Reform, Payment Reform, Regulation on May 26th, 2016 by MMS Communications – Comments Off on CMS’s Andrew Slavitt talks with MMS about MACRA

Editor’s Note: On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide.  In early May, the Massachusetts Medical Society sat down with Andrew Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services, to talk about the new rule and how it was developed.  More information on the Proposed Rule can be found here.

MMS:  Recently you said that you thought CMS had lost the hearts and minds of America’s doctors, and the new MACRA rule was an opportunity to win them back. Can you tell us how you got to that point and why you think the new proposed rule will change physicians’ perceptions?

CMS Acting Administrator Andrew Slavitt

CMS Acting Administrator Andrew Slavitt

MR. SLAVITT: I want to start with mentioning that the Quality Payment Program that we put out in a proposal comes at a very exciting time in the evolution of Medicare. The implementation of MACRA allows us to take the next transformative step in the Medicare program, by introducing the Quality Payment Program to pay physicians and other clinicians for quality, with a more flexible approach, common-sense approach.  MACRA repealed the SGR and streamlined the patchwork of Medicare programs that currently measure value and quality into a single framework where every physician and clinician has the opportunity to be paid more for providing better care for their patients.  MACRA builds on the important reforms of the Affordable Care Act, which increased the numbers of Medicare clinicians participating in alternative payment models, which are models that reward coordinated, innovative care.

But, there is a lot of fatigue that has come with all the changes over the years. We know it can feel like there are people that sit around thinking of ideas for how to make a physician’s job more difficult; when what is really happening is the accumulation of requirements over time, passed in a series of laws or that come through a series of regulations. If people don’t implement and manage them carefully, we end up in a situation where I think we are now –  where despite all of the best intentions, the burdens add up for those on the front lines where care is given or received.

If people don’t feel like they’re being heard, if they don’t feel like they have a voice, and if they don’t feel like the changes make sense for their practice, it can be incredibly demotivating.

We have approached the implementation of MACRA with the belief that physicians know best how to provide high quality care to our beneficiaries.  And we have taken an unprecedented effort to draft a proposal that is based directly on input from those on the front line of care delivery.  Before drafting the Quality Payment Program proposal, we reached out and listened to over 6,000 stakeholders, including state medical societies, physician groups, and patient groups to understand how the changes we are proposing may positively impact care and how to avoid unintended consequences.

The feedback we received shaped our proposed rule in important ways—and the dialogue is continuing. Based on what we learned, our approach to implementation is being guided by four principles, which I think are also consistent with the goals of the MACRA legislation.

  • One is to keep the patient at the center, always.
  • Two, give physicians more flexibility to control their own destiny and to control what gets measured, how it gets measured and have a little bit more say in how things work, because I think that flexibility is a critical ingredient to some of the issues that we talked about.
  • Three, is simply to do less. Find opportunities wherever we can to reduce the burden. It’s as simple as that.
  • Fourth is simplify, simplify, simplify. That is something we try to take an opportunity to do in every place we could, whether it’s in the use of technology, whether it’s in taking this patchwork of programs and consolidating them and, it will be in how we ultimately implement many of the other components. We have an opportunity to really make a big change. What we’re going to have to do well is continue to listen, provide as much flexibility as possible and simplify.

At the end of the day, after thoughtful and skillful execution, it will be time that tells us how well we have done.

MMS:  You also talk about user-driven policy design. Can you talk about what that means and how it influenced the new Meaningful Use rules now called Advancing Care Information?

MR. SLAVITT: Sure. It’s actually not that radical a concept in the real world. In the real world it might be called “talking to your customers about what they want.” Perhaps in Washington, though, it is a bit of a new concept.

A great example of user-driven policy design would be the visit that you led us on when we were in Massachusetts: Sitting down and listening to what people who deliver care say about the impact of our work at CMS. There is no magic to it: just listen; translate needs into actions; create and deliver; communicate and seek further input; continue to iterate.

In a nutshell the big trap when doing public policy is to do it from your desk. The opportunity we all have – and it’s quite exciting for the people in the agencies – is to really get out there and think about what it feels like at the kitchen table of the American family, what it feels like in the clinics where people get care and how to improve on that. It is a wholesale different way of approaching this work.

When we implemented ICD-10, we used a bit of this approach, I think successfully. We are attempting to roll it out more significantly with the Quality Payment Program. I think you’re exactly right, the Advancing Care Information proponent of MIPS is a critical aspect which we took in a significant amount of input on.

And like I said, continuing to listen and iterate is a very important aspect of user-driven policy design. We are in the phase now of listening to input. And even after we publish the final rule, we will listen and iterate.

MMS:  You’ve also compared the new MACRA proposal to the rollout of an iPhone. So if you’ll forgive me for expanding on that analogy, even in Massachusetts there are physicians who are still using flip phones. You’ve also said, and I’m paraphrasing, that it’s okay to have payment models that aren’t perfect as long as we learn from them. How do you see these perspectives fitting into the implementation of MACRA, e.g., opportunities for physicians who are not used to taking on risk, learning how to bear more risk without fearing that they’re going to lose their practices?

MR. SLAVITT: It’s really important to put in context what payment model and incentives are supposed to do. I have never met a physician, nor do I hope to meet a physician, who makes decisions on patient care based upon how they’re going to get paid. I don’t think that’s how physicians are wired.

The role of payment models and incentives is simply to reinforce what the clinician believes to be the right way to deliver care. If incentives are done well and done right, clinicians will get reinforcement financially; and the payment system gives them the opportunity and the dollars to invest and reinvest in the kinds of things that they believe are right for their practice and for their patients. We have to make sure it is clear that we know it is the clinical and cultural leadership that improves quality, not public policy.

The point I was making about the iPhone is that we are in early generations of some of these payment models. The clinicians who participate should be aware that models are meant to reinforce the good practice of medicine, but the models are not going to be perfect. The models are going to have to get better over time based upon how they get used in the real world and improved upon. For instance, in our second generation models we have made changes, like adding telemedicine or adding patient incentives to make sure that the patient is aligned with their physician in staying healthy.

And where did the changes come from?  They came from listening to physicians and patients. The physicians tell us this model would be better if it could do this, if it could do that. And that’s the thinking that has to continue. So, like any other good, user-driven program, we want an ongoing dialogue so that year over year the program improves for patients and clinicians.

MMS:  So on to interoperability, which I know is one of your concerns. You know it’s one of the physicians’ greatest frustrations. Secretary Burwell has said 90 percent of EMR vendors are committed to interoperability, which is great. I think I can hear physicians nationally groaning because they think they’ve heard this before. So what is it that CMS can do and HHS can do to make it real?

MR. SLAVITT: Let’s talk about what interoperability really is. This is such an important ingredient to improving health care. But interoperability in some respects needs to just be as simple as this: how can we collaborate for the best outcomes when a patient is going to experience different parts of our fragmented health care system? What we want out of interoperability is simple: having a patient referred for other care and understanding what happens at that visit; or communicating with the physician when a patient is discharged from the hospital to make sure they are taken care of and are healing at home.

As you mentioned, Secretary Burwell announced that companies representing 90 percent of EHRs are committing to three vital steps to real interoperability. I thank the many who have made this commitment. It has the potential to set us on a new course, but we all need to be more committed than ever to making sure that the substance of this pledge translates to reality.

And you’re exactly right about physicians groaning; we are not talking sending a man to the moon. We are actually expecting technology to do the things that it already does for us every day. So there must be other reasons why technology and information aren’t flowing in ways that match patient care.

Partly, I believe some of the reasons are actually due to bad business practices. But, I think some of the technology will improve through the better use of standards and compliance. And I think we’ll make significant progress through the implementation of API’s in the next version of EHR’s which will spur innovation by allowing for plug and play capability. But the reason that the pledge is important is because the private sector has to essentially change or evolve their business practices so that they don’t subvert this intent.

In some respects, you can look at me and you can look at the government and say, “Why don’t you just mandate that people do this?”  We have very few higher priorities, but the reality is that if we really want change, we need everybody to put pressure on people in the system to make the technology work. So, if you are a customer of a piece of technology that doesn’t do what you want, it’s time to raise your voice. We’re doing everything we can to make sure that the technology vendors stop focusing on meeting the regulations, so they can start focusing on their customers and their users, and design around the physicians’ needs, the caretakers’ needs, the patients’ needs.

MMS:  We reached out to other medical societies nationally to get some questions for this interview, and they’re all interested in MACRA’s Quality Payment Program, including MIPS and APMs. Many of the questions had a pretty common theme: Physicians are willing to be held accountable for what they’re doing and they know they’re going to be graded on it, so to speak, but they’re concerned about being held accountable for things that are not under their control, whether it’s care that’s not under their control or let’s say a non-compliant patient for whatever reason. The other part of it was registries; how can the medical community be more involved and engaged with CMS in the development of these registries. So your thoughts on those two issues?

MR. SLAVITT: They’re very good questions. First, I’ll just go back to my earlier comment, which is that these payment models are intended to be strong signals about the kind of activities that improve patient care. And so, yes, a physician will feel like there are some things that they’ve got to really influence and pieces of the puzzle that they don’t control; we are interested in hearing about those and making sure that those make sense.

However, patient compliance is a tough but critical part of the process, and efforts to communicate to patients and so forth are obviously part of what physicians do and have been doing for a number of years. At the same time, we’re hearing amazing stories from physicians in small practices and rural, underserved communities.  Motivated and driven with a passion for patient care, they are redesigning their care teams around their patient needs in ways that are having dramatic impacts in patient compliance and health outcomes.  Meaningful impacts, such as significantly improving A1C levels – even as practices expanded to take on sicker, under-insured patients – and significant increases on follow through for referrals on behavioral health and addition referrals.  These are improvements that matter in our communities and in our homes.  And we’re hearing physicians say, “This is incredible! We’re practicing medicine again!”

We work very hard to create what we call a core set of measures, which means that we want to be on the same page with every other payer that’s in a physician’s office so that a physician can focus on one way of doing things.

For specialists, we’ve done a lot of work and a lot of collaboration.  Eighty percent of our measure sets are specialty specific, and the vast majority of those measures come from physician leadership outside of CMS where people are saying this is the evidence-based state of practice, this is what we want. We spent a lot of time engaging the clinical community – medical societies and front-line physicians – to design a program that’s equally meaningful to a wide range of specialties that practice in very different settings.  There’s plenty of ways to be successful within the Quality Payment Program. In addition, for small practices, we’ve designed our proposed rule to provide support and flexibility that match their circumstances, including increased technical assistance, exemptions for small volume practices, allowances for medical home models, and a continued focus on reducing reporting burden.  Our teams are set up to evolve these rules and the clinical community needs to continue to be a strong partner in this process.

MMS:  You are in charge of the most powerful agency in the nation to effect changes in health care in this country at the time of greatest change in health care. So what do you see as your role in this position and the role of CMS in helping shape the future of health care?

MR. SLAVITT: I think it’s really to listen to and absorb the voice of the people that are doing great care every day. We have 140 million consumers that are a part of Medicare, Medicaid and the Children’s Health Insurance Program, and the Marketplace.

If you start with that, let’s talk about what their life is like. They’re increasingly mobile. They’re connecting to an often fragmented system where they’re not anchored. Many of these 140 million, the vast majority are on modest incomes or fixed incomes. They may have family-care needs, both with parents and with children. They worry about how they’re going to pay for the next prescription drug or about missing their bus to their next dialysis appointment. They worry about whether health care is going to become too expensive to manage.

So if you keep it at that fundamental level, it makes, I think, our job pretty clear: represent the needs of the people we serve and to make sure those needs are getting met. CMS will continue to shape health care by making sure these programs are preserved, as well as evolve to meet the needs of the patients.

The wrong way to do that is to put a bunch of policy ideas together in a black box and try to implement them.

The best way – and it is very exciting – is to manage these programs by capturing both the voice of the patients and of the voice of the clinicians, represent those the best we can, and drive towards the delivery of high quality care.

MMS:  Is there anything else you want to say?

MR. SLAVITT: I want to thank you all at the Mass. Medical Society for the visit we had in Boston in the physician’s office. It is so important that we figure out how to connect public policy to what happens on the ground and in the real world. It’s invaluable. And we have to keep it up. It’s not one-off. It must be a cultural commitment. In fact, in the month of May alone, we have 35 scheduled events to hear from a wide range of stakeholders and this outreach will remain an important ongoing part of our work. I personally have been meeting regularly with physician groups, including smaller and rural practices, and have spoken to thousands of physicians in different parts of the country about their work, the opportunities and challenges they face, and what this proposal means for them and their patients.

The second thing I’d say is for physicians who are looking at these new regulations, to please get engaged. There is no possible way, for all the thinking our team can do, that we can anticipate every consequence of what we are working on. And as we aim to provide you with meaningful flexibilities, reduce your burden, and simplify how things get done, please help us think about how these programs can fairly and objectively reward you for the quality of care you delivery.

With all of the work that went into the proposal, it is critical that we receive direct feedback from physicians and other stakeholders. We rely heavily on the feedback for people to say, “I see your intent but what is happening is there’s an unintended consequence or there is a better way to lead us.” If physicians don’t get engaged, then consequentially they will feel the impact of things that they really could have influenced, and we want them to see that we are listening.

I know Washington can feel so distant, policy-making can feel so distant, and I think people are just, sheer exhausted for good reason, so sending in feedback can feel too difficult or pointless. But if this is truly able to be moved forward with all the input of the people who take care of all the beneficiaries (who I like to think actually run Medicare every day), then these new improvements will go so much better, and the Medicare program, the patients in these programs, and the practice of medicine will be the better for it.

I recognize that it’s not the talk, but how we act together, that moves things forward. Which is why I think the change from Meaningful Use to this new, much simpler, much more flexible program of Advancing Care Information is so important because it’s intended to be, among other things, a proof point that we’re not just talk. We are willing to look at things that aren’t working and fix them because it’s for the good of our patients, your patients and for the good of the practice of medicine.

 

The President’s Podium: A Renewed Effort on HIT

Posted in Electronic health records, Electronic Medical Records, Health IT, meaningful use on May 20th, 2016 by MMS Communications – 1 Comment

by James S. Gessner, M.D., President, Massachusetts Medical Society

Physicians well know the rapid advance of information technology in medicine over the last Gessner Cropdecade.  Pushed by federal and state regulations and requirements, the adoption of electronic medical records has been swift. Today, some 90 percent of physicians in Massachusetts use some form of electronic medical records.

While health information technology (HIT) arrived with great promise and adoption has been quick, widespread acceptance has lagged, and EHRs remain a major concern among physicians of all specialties. Among the most contentious issues: interoperability, clinical workflow efficiency, and the myriad demands of reporting patient data as required by Meaningful Use and the Physician Quality Reporting System, among others.

Some physicians have embraced HIT; they see it as a way to reduce medical errors, streamline workloads, and offer a path to improved outcomes.  Others view it as an impediment to the physician-patient relationship, a huge expense, a tool that consumes too much time, and a source of immense frustration.  Some have even stopped practicing medicine because they found the rules and regulations and operations too onerous.

Health information technology has been a major focus of the Massachusetts Medical Society since the establishment of the MMS Committee on Information Technology (CIT) some 20 years ago. The Committee’s Guide to Health Information Technology has provided useful information and direction for physicians as we struggle through the obstacle courses of HIT and EHRs.

The last year has seen a renewed effort by physicians nationally and locally, to share our concerns about the impact of HIT on physician practices and how we deliver patient care.

In September, MMS hosted an AMA Break the Red Tape Town Hall, to voice concerns about Meaningful Use.  More than 100 physicians attended, and the collective message was clear: EHRs are cumbersome, time-consuming, and hurting productivity.

MMS officials have also met with CMS Acting Administrator Andrew Slavitt on multiple occasions, including a visit last fall, at our suggestion, to Massachusetts and the office of a local family physician.  The visit provided Mr. Slavitt with a first-hand, real-world look at the issues affecting physicians as they work with electronic health records and wrestle with interoperability.  The encounter influenced his thinking about Meaningful Use; Mr. Slavitt has made it clear that EHRs should be patient-centered, physician-focused, and simple.

Our most recent effort was the adoption of a new set of principles governing health information technology.  Proposed by the CIT, the principles were adopted unanimously by the House of Delegates at our May annual meeting.

The essence of the new policy is contained in seven statements. It states that information technology available to physicians should accomplish the following:

  • support the physician’s obligation to put the interests of the patient first;
  • support the patient’s autonomy by providing access to that individual’s data;
  • be safe, effective, and efficient;
  • have no institutional or administrative barriers between physicians and their patients’ health data;
  • promote the elimination of health care disparities;
  • support the integrity and autonomy of physicians; and
  • give physicians direct control over choice and management of the information technology used in their practices.

MMS members may read the complete report of the CIT on these new principles here.

Guided by these principles, MMS will continue to work on health information technology issues and how these tools can improve the practice of medicine – and that means first and foremost a focus on patient care.  HIT does indeed hold promise, but its priority should not be on data collection, but on how it can raise the level of patient care – a goal shared by each of us as physicians.

The President’s Podium appears periodically on the MMS Blog, offering commentary on a range of issues in health and medicine.

 

 

 

Your EHR in 2016: Interoperability is Key Trend

Posted in Electronic health records, Electronic Medical Records, Health IT on December 18th, 2015 by Erica Noonan – Comments Off on Your EHR in 2016: Interoperability is Key Trend

Interoperability is expected be a key focus for EHR systems and the physicians who use them in 2016. We asked Micky Tripathi, founding president and CEO of the Massachusetts eHealth Collaborative, about the latest important developments on EHR interoperability and how they may impact your practice.


MMS: Tell us what the recent “KLAS” agreement means for physicians?

MT: The recent summit meeting (hosted by KLAS, the independent health information technology review organization) was a unique private sector initiative to establish objective “Consumer Reports” style measurements of interoperability performance across EHR systems. The summit brought together 10 major EHR vendors as well as 30 large provider organizations from the around the country. Over an intensive two days, the group achieved consensus on a measurement approach and process to be conducted by a credible, neutral organization. The measurement process will be the first comprehensive measurement of nationwide interoperability capturing both provider and vendor attributes. In other industries, the private sector comes together to hold itself accountable by working collaboratively on transparent measures of progress.  The KLAS agreement represents a significant step forward in the maturity of the health IT industry.

Micky Tripathi

Micky Tripathi

MMS: How will we know when interoperability is working?

MT:  When people stop complaining about it! Just joking. Interoperability isn’t a single thing – it’s a general term that describes different types of information exchange appropriate to a particular purpose. For example, email is very good for certain types of communication, but is a very poor substitute for those times when only a phone call will suffice. Similarly, sometimes a provider wants to have a complete medical summary sent to them, in which case they would want to receive a continuity-of-care document, whereas at other times they may just want to check on a medication allergy, in which case a “magic button” single-sign on viewer would be most important. Both types of exchange are important, each is appropriate to the specific clinical need.

Interoperability is already working very well in some areas — as (the science fiction author) William Gibson reportedly said, “the future is already here, it’s just not very evenly distributed.”  Take electronic prescribing, for example — a huge success across the country. Similarly, lab results delivery is very widely available in most health care delivery areas across the country.  EHR-to-EHR exchange has been harder to accomplish because it relies on coordination of many different vendors as well as many different providers. Even here we’re seeing tremendous progress though. The Massachusetts Health Information Highway has over 500 provider organizations connected and conducts over 2 million secure health information exchange transactions per month.

However, interoperability will never be “done.” As information technology gets better and medical advances continue, our expectations will grow as well.  We’ve seen with computers and smart phones that the more they do, the more we want. The same is true for interoperability as well.

MMS: What timeline do you expect in terms of seeing widespread improvements in interoperability?

MT:  We’re already seeing them. It’s important for us to have some perspective though. Just like you can’t have a good telephone network until most people have a telephone, you can’t have good interoperability until most providers have an EHR. A short 5 years ago, less than 10% of physicians had an EHR. That number is now over 75%, and for hospitals it is now over 90%.  So, why do we think that we should have universal interoperability already, when just a couple of years ago most physicians didn’t even have an EHR? No other industry has achieved it that fast, and yet, no other industry is as complex as health care.

The biggest barrier to interoperability until now has been lack of demand — physicians weren’t asking for interoperability because they didn’t have EHRs and because prevailing models of care and payment didn’t require interoperability. The world is different now, and physicians are demanding interoperability from each other and from their vendors, and we’re seeing the market respond.  Within the next few years I think we’ll see close to nationwide ability to send clinical documents to any provider in the country, and we’ll see the maturation of nationwide health information networks that also enable query and retrieve capabilities as well.

These networks are already emerging rapidly – like Epic’s Care Everywhere, Surescripts, CommonWell, the MA HIway, etc – and in the next few years we’ll see the building of “bridges” across these networks in the same way that phone networks and ATM networks are stitched together to provide universal coverage.

MMS: Do you think some regulation or a government mandate is inevitable down the road?

MT: I hope not. It would be a terrible mistake, and I guarantee that most physicians will be very unhappy with any kind of government mandate for interoperability, whether at the state or federal level.  Health care and IT are too complex to expect that the government can get it right or keep up with it. The best prescription for getting more interoperability is to expand value-based purchasing through Medicare and Medicaid that pays for better care and improved outcomes. That will create more demand for interoperability but will allow providers and their vendors to come up with the best ways to accomplish it.

— Erica Noonan

Physicians Speak Out: Stop Meaningful Use Stage 3

Posted in Electronic Medical Records, meaningful use on October 1st, 2015 by Erica Noonan – 1 Comment

By Erica Noonan, Vital Signs Editor

WALTHAM — Physicians are typically first in line when it comes to technology that can help them treat patients.

As early adopters of electronic health records and enthusiastic supporters of the earliest stages of Meaningful Use, typical physicians are eager to try new things and work with new tools.

“Doctors are digital omnivores,” AMA President Steve Stack, MD, an emergency department physician. “We adopt technology at a blistering pace when we work, and when it helps us take care of patients.”

That is why the physician-led movement to delay the implementation of Meaningful Use Stage 3 is so relevant, he said.  With only 12% percent of eligible physicians and 38% of eligible hospitals nationwide able to meet the requirements of MU Stage 2, the move to the next stage is untenable and the pressures are driving physicians out of practice.

More than 100 physicians attended the AMA’s Break the Red Tape town hall meeting Sept. 29, hosted by MMS Vice President Henry Dorkin, MD, at MMS Headquarters in Waltham, to describe how misguided federal regulations had profoundly impacted their practices.

Most had stories of lost productivity, useful patient health initiatives put aside for lack of time and resources, and tens of thousands of dollars spent per practice annually on information technology fees in attempts to meet Meaningful Use requirements. Many questioned why physicians are held responsible and penalized when software programs from outside vendors fail to work properly.

“We treat the patient and save the lives. We shouldn’t have to write the software code for the EHR and be told we are a failure because the EHRs can’t talk to each other. The penalty programs are on us, not the vendors,” said Dr. Stack.

Matthew Gold, MD, a Massachusetts neurologist asked: “In what other system are the end users penalized? Quality measures need to be specialty specific and relate to patient care. Too much time is taken for things that are irrelevant and take away from patient care.”

Several participants mentioned colleagues who have stopped practicing medicine because of Meaningful Use rules, leaving thousands of Massachusetts patients — many senior or disabled in western Massachusetts — struggling to find a primary care provider.

Past MMS President Ronald Dunlap, MD, estimated imposed meaningful use requirements had slowed his staff  down by 30 percent. “Our productivity has been hammered by this,” he said.

MMS Secretary-Treasurer Alain Chaoui, MD, a family physician, described himself as an “early and enthusiastic” EHR adopter. “I thought Meaningful Use was in best interest of patients in 2011 and I did everything I could to comply with Meaningful Use stages 1 and 2,” said Dr. Chaoui.  “Even with my best intentions to take care of my patients, the pressures have landed only the medical profession. I don’t see pressures on the vendors to make them compliant and interoperable.”

Lloyd Fisher, MD, a pediatrician and director of infomatics for Reliant Medical Group, said Meaningful Use Stage 2 failed to take into account practice demographics, penalizing physicians with large numbers of Medicare and Medicaid patients. “We don’t need a disincentive to treat the neediest patients. They need to change the rules,” he said.

The AMA’s campaign pushes for delay for Stage 3 rules until at least 2017, and major improvements in EHR interoperability. “This is the wrong time for Meaningful Use Stage 3,” said Dr. Stack.  “We need to take time to learn from the stages we already have and do Stage 3 right.”

Interoperability is New Focus for Health IT

Posted in Electronic health records, Electronic Medical Records, meaningful use on February 13th, 2015 by Erica Noonan – Comments Off on Interoperability is New Focus for Health IT

By Leon Barzin

MMS Director of Health Information Technologykeyboard 1

Barriers to interoperability continue to be main challenges to moving the nation’s health care system beyond simply making electronic silos of information from paper ones, according to experts at the recent annual meeting of the eHealth Initiative.

The recent Meaningful Use Program started with three goals for the identified stages: Stage 1: data capture and sharing; Stage 2: advance clinical processes; and Stage 3: improve outcomes.

Stage 1 of Meaningful Use, as painful as it has been to some independent practices, is generally considered quite successful in fostering electronic data capture.  It has moved the use of electronic medical records from single digits in the pre-Meaningful Use period to an estimated 70 percent nationwide today.

Unfortunately, it appears that both Stages 1 and 2 have largely failed in the primary objective of “sharing,” moving health data security to the right place at the right time – especially among dissimilar systems.

In January 2015, the U.S. Department of Health and Human Services released the document, A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure.

If improved interoperability can be achieved via this federal roadmap, such a system would support more efficient and effective healthcare and lead to a continuously improving health system that empowers individuals, customizes treatment, and accelerates cure of disease.

On the heels of the release of the government’s document, the eHealth Initiative held its yearly meeting last week, bringing together physicians, administrators and other national experts to focus on how this plan could be implemented in real clinical environments.

Several consensus items among attendees were clear:

  • EHR vendors and providers can no longer ignore interoperability.
  • New secure interoperability software is on the near horizon and mobile devices will be the focus.
  • Patients will soon be included as active partners in their healthcare and possess some or all of their records on their smartphones.
  • Wearable sensor devices like Fitbit will become more clinically connected and able to provide useful clinical information.
  • Early pilots in telemedicine are moving toward standard operation, especially chronic disease management, benefiting from advances in sharing technology.

Although there seems to be little impetus for additional “checkbox” Meaningful Use requirements, it appears efforts will shift throughout the industry, within provider communities, and at CMS to push forward with interoperability improvements.

Board of Registration in Medicine Gives Final Approval to EHR Proficiency Regulations; New Rules Effective Jan. 2

Posted in Electronic health records, Electronic Medical Records, Uncategorized on December 17th, 2014 by Erica Noonan – 1 Comment

 

The Board of Registration in Medicine today gave its final approval to new regulations, strongly supported by the MMS, interpreting that law in a way that allows physicians many options in how they demonstrate proficiency in the use of electronic medical records.

The new regulations will go into effect January 2, 2015, but all physicians renewing their licenses before March 31, 2015 will receive a one-time waiver from the requirements.

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In addition, physicians with renewal dates up to 60 days after March 31 could submit a renewal application prior to March 31, and be within the window for an automatic waiver.

The regulations establish multiple ways in which physicians would be in compliance with the requirement. There are also a broad set of exemptions for certain license categories, where electronic health record use is intrinsic or not relevant.   Read full details of  state’s new EHR proficiency requirement and exemptions here.

Today’s action successfully culminates a two-year effort to work with the Board to interpret the state legislature’s 2012 law connecting federal Meaningful Use and a Massachusetts medical license in a way that did not disenfranchise thousands of physicians.

“The Massachusetts Medical Society believes that electronic health records have enormous potential for patient care, and the Society’s extensive policy on EMRs declares support for them and a desire to work toward improving them,” said MMS President Richard Pieters, MD.  We are grateful that the Board of Registration in Medicine has taken a reasonable approach on this issue, exhibiting utmost concerns for patient safety and access to care.”

 

–Erica Noonan

The President’s Podium: Common Sense on EHRs

Posted in Board of Medicine, Electronic health records, Electronic Medical Records, Health IT, meaningful use on September 26th, 2014 by MMS Communications – 1 Comment

By Richard Pieters, M.D., President, Massachusetts Medical Society

In its landmark 2001 report,  Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine recognized the “enormous potential” of technology to improve health care.  Indeed, of all the changes sweeping throughout healthcare in recent years, perhaps the most revolutionary has been health information technology (HIT).

One area of explosive growth within HIT has been electronic health records (EHRs). The U.S. Department of Health and Human Services noted in May of 2013 that the use of EHRs by doctors and hospitals more than doubled from the previous year, with Massachusetts one of the heaviest adopters.  Statistics from the Office of the National Coordinator for Health IT show that 71 percent of physicians and 80 percent of hospitals in the Commonwealth have adopted EHRs.

Yet, 14 years after the IOM’s report, after billions of dollars spent in federal incentives, and despite skyrocketing adoption, physician acceptance of EHRs appears at best, a mixed bag, at worst, a struggle. Recent efforts are instructive.

In its 2014 Survey of America’s Physicians released this month, The Physicians Foundation found that nearly half of respondents (45.8%) felt that EHRs “detracted from efficiency” and slightly more (47.1%) thought it “detracted from patient interaction.”  More than half (50.5%) believe EHRs “pose a risk to patient privacy.”

Separately, on September 16, the American Medical Association called for an overhaul of EHR systems. “Today’s current EHR products,” said AMA President-Elect Steven J. Sack, M.D., “are immature, costly, and are not well designed to improve clinical care…. The usability of EHRs is a significant driver of physician professional dissatisfaction and a challenge to practice sustainability.” AMA then outlined eight priorities for improving EHR usability to benefit caregivers and patients.

Frustration and dissatisfaction with electronic health records among physicians had surfaced well before the AMA pronouncement, and complaints about EHRs have been increasing as well. The inability of different systems to communicate easily with one another – the “interoperability” issue – remains a drawback.  Perhaps most unsettling, however, is the reality that hazards and risks remain, as the promise of widespread and reproducible gains in patient safety has yet to be fulfilled.

Here in Massachusetts, electronic health records have captured physicians’ attention for quite another reason.  Chapter 224, a law passed in August 2012 that outlined phase two of health care reform for the Commonwealth, included a provision that required physicians to demonstrate “meaningful use” proficiency (which only applies to Medicare and Medicaid) with EHRs as a condition of licensure.  That mandate is to become effective on January 1 of next year.  Without proper interpretation, the law as written could have had severe unintended consequences by disenfranchising over half of the state’s licensed physicians.

Now here’s the good news: The Board of Registration in Medicine has proposed regulations that include a broad set of exemptions for certain license categories.  The Board’s proposal also establishes multiple ways in which physicians could comply with the requirement.

The Board has posted its draft regulations and is accepting comments on them through Friday, October 3 at 5 p.m. MMS offered testimony in strong support of the proposals at the public hearing on Monday, September 29, and I encourage members to add their comments as well. Comments may be submitted via email to Eileen.Prebensen@state.ma.us All comments become public records and will be posted to the state’s website.

MMS has advocated on this issue since the law was passed two years ago, raising the specter of severe disruptions in physician practice and patient access to care.  We are now near a resolution that is advantageous to both physicians and patients.

The Board’s proposal, which addresses all of our major concerns, represents a reasonable, prudent approach to complying with the law, easing physician concerns, and maintaining access to care for patients.

While physician frustration with EHRs is high, it is important to distinguish between problems of technology and problems of policy.  Technological issues are likely to be worked out over time, if only by continued physician persistence and outcry for solutions, as demonstrated by the AMA.

Policy issues, as shown by the Board of Registration in Medicine’s common sense approach to fulfilling the requirements of Chapter 224, are more readily capable of resolution.

MMS, like the IOM, believes that electronic health records do indeed have “enormous potential” for patient care. Our extensive policy on EHRs declares support for them and a desire to work toward improving them, to capture “an opportunity for dramatic benefits to patients in clinical care, research, and the delivery of health care.”

Reaching that potential, however, will require the strong voice of physicians. Whether the issue is one of technology or policy, our local experience has shown how important it is that physicians participate in the conversation.  I urge you once again to review the draft regulations and send in your comments.

The President’s Podium appears periodically on the MMS Blog, offering Dr. Pieters’ commentary on a range of issues in health and medicine. 

EHR Next Chapter: A “Tool” in the MD’s Medical Arsenal

Posted in Electronic health records, Electronic Medical Records, Health IT on May 5th, 2014 by Erica Noonan – 2 Comments

data 2By Debra Beaulieu-Volk

Some of the Commonwealth’s premier experts in health information technology and electronic health records gathered recently at MMS headquarters to take part in the day-long continuing education event, Electronic Health Records Next Chapter: Best Practices, Checklists, and Guidelines.

“The EHR revolution is not new,” said Jeff Loughlin, project director of the Massachusetts eHealth Collaborative, while opening the morning session about EHR best practices and pitfalls. “Along the way, we have seen a lot of failures, primarily because a lot of expectations were put on the EHR to solve the problems of the medical practice,” he said, “rather than using the EHR as one other tool in your arsenal to improve work flow and provide better care.”

To help attendees make the most of this tool, physicians representing small, medium, and large practices weighed in on lessons learned from their EHR experience to date:

Don’t Fear Switching

Today, many physicians are deeply worried that the EHRs they adopted a decade ago no longer suit their needs, said Eugenia Marcus, MD, FAAP, pediatrician and chair of MMS Committee on Information Technology. She can relate, having learned and implemented three different EHR systems since beginning her quest for the paperless office in 1996. “Switching is not that hard,” she said. “Every word of the record does not need to carry over.”

During Marcus’ transitions, staff were responsible for making sure critical information, such as demographics and medication lists, was transferred immediately. But high school students to copy over the rest of the material over a long time period.

Use EHR to Improve Patient Satisfaction

EHRs do far more than simply house patient records, noted Hugh Taylor, MD, a family physician at an 11-doctor practice with three sites throughout the North Shore. In fact, out of the 17 functions Taylor listed that his EHR performed, the last four had little to do with practicing medicine.

“The EHR does many things that don’t affect the clinician so directly but are extremely important to how the office runs,” he said. Examples of these functions included scheduling, confirming insurance coverage, coding and billing, and tracking patient flow. That last item pulls double duty in Taylor’s offices, he said, by helping the practice inform patients when doctors are running behind and of how long they may have to wait. This data is also used to help the practice strive to improve its Press Ganey patient satisfaction scores, he said.

MDs Need Not Do All Documenting

Larry Garber, MD, and his team at Reliant Medical Group, where he serves as Medical Director of Informatics, pulled together a list of which individuals should do the documenting in the medical record, in order of preference, to promote optimal efficiency. “It doesn’t have to be just one person; it can be a combination of people,” he said.

The top choice of documenter, however, isn’t a person at all, but the computer itself. “Whenever possible, reuse data that you’ve already got,” he said. “Let the computer do as much work as it can.” (As a caveat to the pitfalls of copying and pasting, Garber noted that it’s a practice policy that physicians are responsible to review and update any information in notes they create.)

Next, Garber recommended letting patients populate some of their own data. Even triage nurses speaking with patients on the phone can contribute to the record, placing them in the third spot of preference. “What a great place to take history without tying up an exam room,” he said.

Rounding out the list of preferred documenters were medical assistants, doctors assisted by speech recognition, doctors assisted by transcriptionists, doctors typing, and scribes typing. When it comes to accuracy, Garber noted that physicians who use a combination of typing and speech recognition tend to produce the highest-quality notes.

More information about the event and links to faculty presentations are available online.

Free white paper for MMS members: “MMS Guide to Health Information Technology”

EHR Conference Speaker Emphasizes Importance of Protecting Patients’ Information

Posted in Electronic health records, Electronic Medical Records, Health IT, HIPAA on May 2nd, 2014 by MMS – Comments Off on EHR Conference Speaker Emphasizes Importance of Protecting Patients’ Information

By Vicki Ritterband

Ali Pabrai

Ali Pabrai

Encryption. Encryption. Encryption.

Those are the “three” most important activities doctors should do to protect the security of their patients’ electronic protected health information (ePHI), says cybersecurity expert Ali Pabrai, a  presenter at MMS’s recent conference, Electronic Health Records Next Chapter: Best Practices, Checklists and Guidelines.

Encryption is the conversion of data into a form that cannot be understood unless the reader has a key or password to unscramble the information. All sorts of electronic transmissions should be encrypted—including texts and emails—no matter what the device, said Pabrai. If data is encrypted, even if you have a security breach, it is protected.

“Unfortunately, application vendors in the healthcare industry have been lethargic about embedding encryption capabilities,” said Pabrai. “That makes it difficult for a practice or a healthcare organization to implement encryption.”

As more and health information moves between the cloud and mobile devices, organizations will increasingly need to focus their security efforts on those two areas, according to Pabrai. Healthcare data fetches a high price on the black market because it is so rich in identity information.

Cyber security attacks to all types of businesses are occurring at a breathtaking pace: the average organization experiences 1,400 attacks per week and of those attacks, approximately two accomplish their purpose, said Pabrai.  HIPAA fines for information security breaches can run into the hundreds of thousands and even millions of dollars. “Physician practices are more vulnerable to HIPAA fines than ever before,” said Pabrai. Often, organizations don’t know their systems have been broken into until months after the thieves have left the premises.

So what’s a practice to do? Here are the seven steps Pabrai suggests physicians take to ensure that their patients’ electronic protected health information (ePHI) is secure and complies with HIPAA regulations:

  • Assign someone in your practice to be the security or compliance officer. Make sure they have access to the appropriate resources to do their job.
  • Conduct risk analyses regularly, ideally on an annual basis.
  • Develop a security strategy and policies and document them. If HHS’s Office for Civil Rights investigates a security breach, the first thing they will ask is to look at your policies, said Pabrai.
  • Remediate when necessary: address any deficiencies in your protection strategy
  • Secure third parties: make sure your business associates are protecting your patients’ ePHI to the same degree you are.
  • Train your staff so they comply with your cyber security rules and regulations.
  • Evaluate your performance.

For an overview of what’s required from healthcare providers to comply with various aspects of the HIPAA Privacy and Security rules, the U.S. Department of Health & Services offers six free, CME-eligible online educational programs.

More information about the event and links to faculty presentations are available online.

Free white paper for MMS members: “MMS Guide to Health Information Technology”

House Approves Critically Needed Changes to Physician EHR Requirement

Posted in Electronic health records, Electronic Medical Records, Mass. Legislature on February 13th, 2014 by MMS – 10 Comments

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UPDATED: March 20, 2014

Read an update about this issue here.

The Massachusetts House this week approved changes in state law that would disconnect medical licensure from a physician’s use of electronic health records. The issue has been a major focus of the MMS’ advocacy efforts this year.

Under current law, effective Jan. 2015, physicians who wish to renew their license must demonstrate that they utilize EHRs that are at the level of the federal government’s meaningful use program.

MMS President Ronald W. Dunlap, MD, has met several times this year with legislative leaders, and cautioned that if the requirement is enforced, more than 10,000 physicians could lose their license, most of whom cannot, under law, qualify for Meaningful Use incentives. The resulting impact on the health care system would be devastating.

The House language would instead require practicing physicians to demonstrate that they use “digitized patient-specific clinical information.” Practicing physicians who don’t use digitized health records would be given the opportunity to demonstrate that they know how to use such records, by a method to be determined by the Board of Registration in Medicine.

Following a recent meeting between MMS President Ronald W. Dunlap and House Ways and Means Chairman Brian Dempsey (D-Haverhill), the House approved the language Wednesday by a very wide margin.

Unfortunately, the Senate’s supplemental budget bill did contain not such language, so the matter now heads to conference committee, where Chairman Dempsey has indicated will be a strong advocate for the substitute language.

We’d like to extend a big thank you to Chairman Dempsey and the House of Representatives for their actions this week.