The Train has Left the Station: National EHR Incentives & Developments

Chairperson: Laura J Fochtmann, MD

Fochtmann explained the objectives of this session as the allowing attendees to be able to better “describethe current status and major initiativesof the national EHR movement; considerationsin EHR selection, such as software certification; potential advantages and pitfalls of electronicprescribing; potential advantages of EHRuse, including facilitated communication with primarycare.

More than $17 billion in incentives for physicians who demonstrate “meaningful use” of EHRs, starting in 2011, was included in the American Recovery and Reinvestment Act (ARRA) of 2009, noted the speaker, adding that Medicare reimbursement rates will be reduced in 2015 for those who don’t meet this requirement. The incentives, and penalties, are expected to accelerate adoption, which has been limited to date.

National Health Information Technology Incentives

RobertPlovnick, MD, MS

Plovnick first reviewed the incentives and penalty plans laid out under ARRA for meaningful use of EHRs, stating that the “proposed rule lists 25 technical requirements spanning several areas,” including:

Demographics, problem and medication lists, integrated clinical decision support, e-prescribing, CPOE, clinical quality measures, basic exchange of clinical information with external entities, providing patients an electronic copy of their information, and privacy and security requirements, which are “moving targets.”

He next stated that the logistics of the meaningful use requirements (eg, how many and how they are reported) are not finalized.

When looking at certification, Plovnick explained that “using a certified EHR system is a requirement for obtaining the incentives, certification will be of a single-solution software as well as modules that can be combined to meet the requirements, and currently CCHIT is the only group that certifies EHR software at national level current.” He did add that other entities are in the process of joining CCHIT.

Providing an abridged timeline of meaningful use incentives, the speaker reviewed that the proposed rules were released on December 30, 2009; the final rules should be in place by late June 2010; the program beings January 1, 2011; and the definition of meaningful use will change in 2013 and 2015 to become more stringent.

Plovnick next reviewed the break down throughout the years of the financial incentives, which add up, over 5 years, to $44,000, if a physician starts meeting the criteria by 2012. He added that the “incentives are based on a percentage of overall charges billed to Medicare per year,” also noting that Medicaid incentives follow similar rules but with a larger incentive: up to $63,750 over 6 years, if at least 30% of a physicians patient population is on Medicaid.

Other HIT incentives the presenter touched up were the e-prescribing incentive (2% Medicare bonus for doctors who send at least 25 e-prescriptions in 2010 (www.cms.gov/erxincentive), HIT regional extension centers, state HIEs, and federal HIT efforts (www.healthhit.hhs.gov).

“Many details are yet to be finalized,” he concluded, so check the APA site for updated information at www.psych.org/ehrincentive and more EHR resources (www.psych.org/ehr)

Certification Comission for Health Information Technology (CCHIT) Behavioral Health Work Group

Steven Daviss, MD

“Providers and hospitals that wait until Fall 2010 to choose EHR technology will experience a high risk of failing to achieve meaningful use in time for the 2011-2012 incentives,” began Daviss.

The speaker then provided a brief history of the behavioral health work group, explaining that it was tasked to “come up with real-world criteria, not necessarily ideal criteria, for a psychiatry-specific EHR so that EHR vendors could meet them.” Challenges in doing so included developer-clinician tension, designing an EHR how clinicians will like it but that is able to be produced by vendors, knowing the target type of provider (physicians, nurses, other mental health providers, or a mix) and their different needs, knowing the target setting (clinic, hospital, small or big office, multi-specialty office), mission creep, meaningful use issues, physician needs, state laws of behavioral health documentation that vary, a lack of behavioral health measures in meaningful use, the need for co-signatures for treatment plans, deciding whether to go with status quo of the current EHR landscape or the ideal, issues of interoperability, and integration between behavioral health and other providers.

The group, Daviss explained, came up with 310 criteria for a behavioral health EHR, 165 of which are the same as ambulatory EHR criteria, 92 of which are new or revised (part of an add-on product to an existing certified EHR), and a set of 53 core criteria that all CCHIT-certified EHRs must have.

Criteria include access control, advance directives, case load, assessments, audit, order medication, documentation, confidentiality, data retention, clinical decision support, inter-domain, general ordering requirements, medication management, treatment plan, problem list, scheduling, technical services. For the add-on product, criteria include referrals, report generation, assessment, treatment plan, security and access, manage terminology and codes, legal information, clinical decision support, problem list, provider management, reporting/data exporting, and mange clinical documents and notes.

Daviss closed, noting that the group is “looking to launch a behavioral health CCHIT-certified comprehensive certification in June 2010, when vendors will be able to apply for certification.”

Electronic Prescribing

Zebulon Taintor, MD

Taintor began by reviewing the results of a 2006 Institute of Medicine report on preventing mediation errors that shows there were 4 billion prescriptions written in 2006, that four out of every five physician visits include the writing of a prescription, that we can save $2.9 billion with e-prescribing, and that e-prescribing is legible, fast, and allows you to make sure you know the medication is available at the pharmacy (instead of the patient going there and finding out they’re out of the drug or having to wait 2 hours for it to be filled).

He next review the multiple ways of implementing e-prescribing into a practice, saying it could be a stand-alone product, part of an EHR system, part of a joined EHR and practice management system (PMS), separate to both an EHR and PMS, or part of a PMS. Taintor noted that “the joined systems seem to be more robust,” with separate EHRs tending to be less robust, adding that a less robust EHR isn’t necessarily a bad thing. “How much do you really need?”

Although a stand-alone e-prescribing program may be free, one must ask if it is subject to mining, said Taintor, adding that such a program won’t meet meaningful use, and that it would take a lot of work to integrate it with an EHR and/or PMS.

Further, according the speaker, “Medicaid initiatives vary by state, state Medicaid medical directors are not happy with stand-alone EHRs, New York state says to use a certified EHR, identification will probably be required for e-prescribers, and you can expect to get 80 cents per e-prescription.”

“Are controlled substances a dealbreaker?” he asked rhetorically. The interim final rule is out for comment and due June 30. Taintor then asked another rhetorical question: “Does the DEA want e-prescribing? There’s serious doubt because they’re making it really hard.”

There are incentives, but one question Taintor is asking is whether there will be incentives for private insurance carriers? Aetna is currently providing them, but almost all others are trying to integrate legacy computer systems, he says. “United, Magellan, and Oxford have separate systems that don’t talk to each other and are not ready for prime time now, but this could be something to watch.”

Secure Patient Messaging

Marc Graff, MD

Graff sought out to “examine whether the EHR changes the relationship between primary care physicians and psychiatrists. The easy answer is ‘sometimes,’” he said. To demonstrate his expertise in the area of HIT, Graff provided background information on Kaiser Permanente, his employer.

• Kaiser is the largest civilian integrated health system in US, with 14,000 physicians covering 8.6 million people, but it is not country-wide; “in fact, it’s somewhat spotty,” he said.
• Kaiser has 24 of the 39 hospitals that are level 7 (HIMMS)-compliant in the US. Only Tricare is bigger.
• There were more than 59.2 million visits to the Kaiser Website in 2009, with an average 162,192 visit per day; visitors are mostly looking for test results, e-mailing their physician, and looking to refill requests.
• 2 million refills were made through the site in Q4 2009, up 26% since the previous year.
• 3 million members were singed up on site as of March 2010, more than half of the total Kaiser members.
• Messages sent to providers equaled 837,393 in 2009, versus 1,268 sent to advice nurses.

An attendee asked Graff how he keeps up with the e-mailing while still providing care. “It’s not easy,” he said. “But it’s just a new way to do it, instead of phone calls like in the past.”

“Office visits are slowly dropping, phone messages are barely changing, and e-mail messages are going up quickly,” the speaker noted, in regards to communication with patients at Kaiser. He added that 100% of the messages sent from him to patients are encrypted and that patients have to unlock them to read them.

In April, Graff’s department received 451 e-mails; responded to 84% in 2 days or less, 1% in 3-5 days, and 14% never; and read 100%. Specifically, 86% of e-mails were responded to via e-mail. “The Psychiatrist is doing about 90% of this, and rest is done by the nurse, because the secure messaging is linked to them,” he added.

“Use of secure messaging varies by area (northwest vs. southern cal), scope of practice (MD vs. PhD, LCSW, MFT), knowledge base, what the PCP expects (eg, do they know you’re ordering labs, are they prescribing psychiatric meds), and patient expectations and satisfaction,” continued the speaker.

“E-mail iss becoming more important as another way to improve communication between primary care providers and psychiatrists,” concluded Graff, “but just because you build it, doesn’t mean it’ll work. You have to ask if you can meet the fast turnarounds that patients expect and handle the calls on top of the e-mails.”

Following Graff’s presentation was a Q&A session that included the following:

How do you handle using the keyboard while meeting with patient?

“Some are sensitive to this,” said Graff, “so I don’t use keyboard with those patients, but I have to go back and do that later. Otherwise, I am able to type while keeping eye contact with patients.”

How do you keep e-mails safe?

“We use a site-based system that keeps it all encrypted; the patient and physician have to log on,” said Graff. “If their system doesn’t encrypt it, I can send it encrypted.”

Do you set a limit on how many e-mails you’ll accept from patients?

“It hasn’t been an issue,” explained Graff, who said he does get e-mails from patients that have nothing to do with care, but that it’s OK. He doesn’t detail it in the patient record, but will write something to the effect of “patient sent cat video e-mail or daily words of encouragement to me, along with 100 other people.”

What percentage of psychiatrists use EHRs, and what if the APA hosted an EHR on its server?

Daviss said he has heard 6-10% of psychiatrists use an EHR, but that he doesn’t know if that’s right; “I would be surprised if it’s more,” he said. The idea of the APA being involved in an EHR system for members has come up, he added, saying that the idea is interesting. “The APA would have control so it couldn’t be mined, and it’s unlikely that the APA would sell the info without permission of users,” he stated.

For additional information, Fochtmann directed attendees to http://content.nejm.org/cgi/content/full/360/15/1477 and www.psych.theclinics.com/article/S0193-953X%2807%2900120-7/abstract.