Electronic Health Records

The transition to Electronic Health Records is already under way, but is messy, confusing and challenging for practicing chiropractors. While EHRs are clearly the wave of the future, we are a long way from a simple, accessible, cost-effective way to get there from here. The state of affairs now is similar to where workflow software was 25-30 years ago, with multiple incompatible operating systems, no standard protocols, no imposed guidelines, overpriced systems, and uncertain future of both hardware and software vendors.

The standards and incentive programs are strictly the domain of Medicare as it currently stands, but it is likely that indemnity payers will eventually adopt whatever Medicare imposes.

This leaves the practicing doctor in a decidedly uncomfortable position: should I be an early adopter of this technology and seek some satisfaction and possible financial reward, or should I wait for things to sort themselves out with the larger players and then convert when the choices and the guidelines are clearer?

You are not likely to receive Federal dollars for an EHR without a significant time and money investment on your part.

Rewards for Early Adoption

The one financial take-away is that the federal incentive monies you hear about are not likely to ever see your bank accounts for several reasons (in my humble opinion of course):

1. Your software must be accredited and must stay accredited.
2. You must attest to meaningful use and be able to back that up.
3. You must continue meaningful use indefinitely, or you may be subject to post payment audit and reimbursement demands.
4. The $44K you see advertised is a maximum over 3 years of ongoing meaningful use. This is paid out at roughly 75% of the reimbursable amounts paid by Medicare in a calendar year. At a reimbursement rate of $25/98940, this would be about 200 payable Medicare visits a month to get to the maximum.
5. The maximum quoted is for early adoption in 2012, with a minimum of 3 months of full operation. It goes down to $39K and $24K over the next 2 years.
6. There may be a minimum under which nothing is paid; we don’t know that yet.

Key Features

There are several key features necessary for a fully functional EHR:

1. Full access to health records on indexed database
2. Prescription orders and information
3. Access through multiple care settings or multiple providers in the same setting
4. “smart” decision support, meaning access to other databases
5. Communication pipelines for providers, patients an payers
6. Patient portal for secure access to health records
7. Admin tools including scheduling and billing
8. E-reporting

We are not prescribing meds, but the other 7 features have a bearing on most practices. The EHR would ideally integrate all of these features, with ideally being the key word.

Meaningful Use

There are three areas that would have to be met in order to be considered “meaningful use” and therefore available for incentive pay:

1. Core set objectives: Must meet all 15 except Rx.
2. Menu set objectives: Must meet 5 of 15. Set objectives re largely a function of the way the software is set up and used, not so much about what the patient encounter entails. See downloadable list: https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf
3. Quality Control Measures: must meet 6 of 38 listed. “Measures” are active processes initiated by the doctors office and are generally public health in nature
   • screening for hypertension
   • asthma screening
   • low back use of imaging
   • obesity screening and intervention
   • smoking cessation.

Many of these are outside our scope and not applicable to what most DC’s are doing. These will take time and effort from you and your staff. Remember that you do not have to have any level of success in any of these, you just have to have the measurement system set up. See more detail at https://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf

There is another fundamental decision that has to be made in this arena: should any EHR be housed in the cloud or on a server in the doctor’s office? There are several pro and con features to each; here are a few:

Cloud based: PRO: generally cheaper, automatic upgrades and updates, easier multiple access, certification burden falls more on the vendor, much lower hardware setup cost and maintenance, less risk of data loss through disaster (fire, water, vandalism). Cons: more subject to security breaches, dependent on internet connectivity and speed, dependent on operability and availability of remote servers, greater backup requirements and demands.

The server-based options are essentially the opposite of those listed above.

Phases of Implementation

Another feature to consider is that EHR as written in CMS regulations has two phases.

1. The information listed above largely applies to the initial phase.
2. The second phase, scheduled for 2013 or 2014 (depending on when you start) requires interoperability. This means that EHR data from any system can be read by another system. Since there are currently no standards or guidelines, this requirement cannot currently be met. It’s the VHS/Betamax war gigantically amplified and with much higher stakes.Some of the present EHR’s are written in a language that is older and cannot be made useful for inter-operability. This means that these systems must be re-written in a new language, or they will become decertified and will likely go out of business.

What to do now?

My general recommendations are as follows:

1. The primary purpose of undertaking EHR installation in your office now should be for the purpose of increasing the quality of your care, not in order to achieve incentive payments, or even lower operating costs.
2. clinics that have multiple locations, or multiple providers treating the same patient would benefit from the integration of patient records.
3. If you are using a paper system, there is not an overwhelming, compelling reason to undertake the conversion to EHR now. There are just too many unknowns, risks and variables to feel confident in the time, energy and money investment necessary to make this fully operational.
4. If you are alreaday using an EHR, your pathways are more complex.
   • Is it certified?
   • Is certification, attestation and federal payout something you seek?
   • Is it cloud or server based?
   • Can you easily and securely back up your data both locally and remotely?
   • What is the restoration procedure, cost and time factor necessary to get you running again in case of disaster, either local or remote? A remote disaster is that your software vendor goes under or stops answering support requests. A local disaster is fire, theft, etc. in your office.

Since clients’ situations are varied, this is an important, but largely specific decision for your office just for the near future. Within a few years, this will most likely be a requirement for any insured reimbursement.