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In her HIMSS keynote speech, HHS Secretary Kathleen Sebelius said 4 out of 5 hospitals and 2 out of 5 physician practices plan to meet meaningful use criteria by 2015. "If those numbers hold, this will be the fastest-growing health technology we have ever seen in this country or any other country around the globe." Photo by Brian Blanco / AP Images for American Medical News

5 ways meaningful use will change your practice (HIMSS meeting)

Practicing medicine will present new challenges and opportunities after new rules are implemented -- for you and for your patients.

By — Posted March 21, 2011

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Complying with meaningful use rules can earn bonus money for your practice from Medicaid or Medicare -- but it also can shake up the way your office operates and the way you interact with patients.

As hospitals and practices prepare for attestation of having met the requirements, many convened at the 2011 Healthcare Information and Management Systems Society annual conference in February in Orlando, Fla., to learn what they can expect after going electronic.

Meeting meaningful use will involve more than receiving incentive pay up to $44,000 from Medicare or nearly $64,000 from Medicaid for using an EMR. It means a lot of work -- and adjustment by you and your staff.

Those changes are expected to trickle down even to those who have no plans to seek the incentives, said Natalie Berger, PhD, chair of the HIMSS Ambulatory Information Systems Committee. So physicians need to prepare. "Right now it's only Medicaid and Medicare providers ... getting those reimbursements. But eventually [private] payers are going to follow those guidelines. And then I think patients are going to demand it. It's no longer going to be OK to go to a doctor's office that doesn't have your records or doesn't know you are allergic to those medications."

Some of the changes EMRs bring will be for the better, some for the worse, depending on how the change is managed. Much of the 2011 HIMSS conference focused on those changes, and how physician practices and hospitals could prepare for them. Many discussions revolved around five basic themes: patient engagement; reporting; collaboration; efficiencies; and security and privacy.

Patients will be more involved in their care

With more information in their hands because of meaningful use, and more data available to physicians at the time of a visit, patients are going to be more involved in health care decisions, experts said at HIMSS. One way meaningful use rules address this is by granting patients access to medical records, including diagnostic results, problem lists and medication lists.

Many practices and hospitals already provide this access through patient portals, many of which combine data with patient education tools. Some of these organizations offered a glimpse of what other practices can expect when the physician-patient relationship is changed by technology.

Michael Solomon, PhD, is practice lead of eCare Management at the Coral Springs, Fla.-based health information technology consulting firm Point-of-Care Partners. He and researchers from the Carolinas Healthcare System conducted a 12-week controlled randomized study of 220 patients using the portal offered to patients of Carolinas Physician Network, a large medical group operated by CHS. They analyzed the effectiveness of the portal to engage patients and affect patient outcomes.

"If we expect the patient to play a critical role in a patient-centered approach to care, then we need to measure the effect of care intervention on a patient's level of engagement -- that is, how activated they are in their own health care," Solomon said. The group found that the more patients used the portal, the more engaged they were in their health care.

For Miramont Family Medicine, a family medicine practice in Fort Collins, Colo., adopting an EMR meant that patient visits were more meaningful because of the information available and collected at the time of visit. John Bender, MD, a family physician at Miramont, said "value-added time" -- time patients actually spend with doctors as opposed to sitting in waiting rooms -- improved from 64% to 67% after implementation.

"Now that doesn't sound large," he said, "But a 3 [percentage point] improvement across all 10,000 patients we were seeing at the time -- that's huge."

Dr. Bender said this was especially significant, given that the average appointment time increased from 41 to 51 minutes after going electronic. Doctors are documenting several metrics they weren't documenting before, and patients "are getting a lot more time per visit with the physician."

Doctors will find it easier to see how they're doing

Stephen Wagner, PhD, vice president of Carolinas Healthcare System, division of medical education and research, said patients can be engaged, but measures are needed to see how that engagement has affected their outcomes.

"We're very good in health care at finding things that make lots of intuitive sense, and then we find out sometimes too late or way down the road that they really aren't working the way we thought they would," he said. "We need better intermediate markers."

EMRs are expected to make these intermediate markers easier to measure what is and isn't working. Before Miramont installed an EMR, Dr. Bender said, only 42% of diabetic patients had an A1c documented within the past year. Since implementation, the practice improved its metrics reporting to 91%.

"We all think we're doing a good job but had no way of knowing that. We had to find out where we are," he said. "We finally knew how many diabetic patients we had."

"Doctors are Type A. You give them a report card and ... then they start working really hard and they will fix [the problems]. And they will do it on their own without being told," he said.

Physicians will collaborate more with other doctors

When physicians are making decisions about a patient's care, "it's not about the data, it's about the knowledge that you create," said Hal Wolf, senior vice president and chief operating officer of the Permanente Federation, which represents Kaiser Permanente's eight Permanente Medical Groups.

Wolf said elderly, chronically ill patients see, on average, 14 physicians. Those doctors collectively write an average of 50 prescriptions a year during the course of 37 clinical visits.

The interoperability spelled out under meaningful use means that measures of progress physicians have access to also are available to other members of the patient's care team. This interoperability, and the subsequent collaboration of care team members, will help ensure that integrated patient-centered models of care being created because of meaningful use are successful.

EMRs "create a fully integrated approach to an entire effort to take care of a patient," he said. "When you have the information, as you all know, you have turned the magical corner, because every caregiver is looking at one up-to-date record in basic real time as needed. That is a tremendous step forward."

Dept. of Health and Human Services Secretary Kathleen Sebelius said in her keynote address to HIMSS attendees that, on a national level, having this integration will make it easier for doctors to compare treatments quickly and cheaply to see what works. "Those same records connected together can help spread the knowledge at the speed of light throughout our health care system. In the Obama administration, we look at health IT not just as an opportunity to grow our economy but also as a powerful tool to help improve the health of our nation."

Physicians will pinpoint practice inefficiencies

Despite all the promises of improved efficiencies and quality of care, experts are quick to warn that practices need to identify inefficiencies before even looking at an EMR. They must know how an EMR system will help solve those inefficiencies. Otherwise, they could be made worse by going electronic.

You must build a foundation before you implement and have a clear plan for execution, said Paul Kleeberg, MD, clinical director of REACH, the federally funded regional extension center serving Minnesota and North Dakota. The execution plan needs to address work flow and process problems that, if not addressed, will plague EMR adoption.

"Turning on the [EMR] will be like shining the flashlight in the corner. You get to see all the cockroaches," Dr. Kleeberg said.

"That which was bad before gets worse," said Tina Buop, chief information officer of Muir Medical Group in Walnut Creek, Calif. When a practice goes electronic, there will be a "beacon light" shining on poor work practices.

She used the example of physicians taking patient files home at the end of the day. "It's now a beacon light, because everyone will now know they didn't finish charting that day."

Buop said the importance of training and work flow tracking during implementation cannot be overstated, because work flow changes when a new technology is introduced.

After implementation, physicians might discover new data that come to doctors electronically. But a lot of the work of charting that data can be delegated to medical assistants or nurses. Otherwise, physicians may find that the workday has gotten longer, she said.

Physicians will need a firmer grip on data security

One area that is a relatively minor provision in the stage 1 meaningful use requirements, but needs to be a major focus of any adoption plan, is patient privacy and security, Buop said.

The stage 1 requirements include only one line on security and privacy, she said. "And it's a shame, because privacy and security, honestly, can be one of the biggest nemeses of the success of stage 2 and stage 3" meaningful use criteria.

Under stage 1, a gap risk assessment needs to be conducted that will identify security and privacy vulnerabilities. Stages 2 and 3 have not yet been finalized but will focus on an increased use of data, which could create more vulnerabilities.

The confidentiality, integrity and availability of data is part of the Health Information Portability and Accountability Act, which is separate from meaningful use, Buop said.

"If you are a solo practitioner with your own EMR and are trying to qualify for meaningful use, you are responsible for the information for privacy and security," she added. That means you need processes in writing that ensure confidentiality, integrity and availability of data.

Pittsford, N.Y., pediatrician Alice Loveys, MD, is the chief medical information officer for the Monroe County Medical Society Health Information Technology Service Bureau, which assists physicians in technology issues. She strongly suggests that practices have a HIPAA security manual in place at the start of implementation. The manual is something a practice develops and writes itself that details how it ensures the security of patient information.

She said developing the manual is no small feat, and something that the RECs cannot do for a practice, because each one is unique to that practice. But the REC can help direct doctors to other resources that can help.

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Health IT challenges

Each year, HIMSS conducts a survey of health IT professionals to identify the priorities and challenges they face. Respondents continued to list meeting meaningful use criteria as a high priority.

Top IT priorities over the next two years
Achieving meaningful use42%49%
Focus on clinical systems27%23%
Optimizing current systems8%11%
Leveraging information9%9%
Focus on ambulatory systems7%2%
Demonstrating ability to exchange informationn/a1%
Providing patient-centric solutions2%1%
Integration of IT and medical devices1%0%
Barriers to achieving meaningful use
Lack of data metricsn/a26%
Achieving end user acceptance24%22%
Lack of adequate staffing resources37%18%
Lack of fundingn/a8%
Inability to complete requirements on timen/a6%
Lack of adequate technology17%5%
Don't understand requirementsn/a5%
Don't know7%3%
No barriers2%1%

Source: 22nd Annual HIMSS Leadership Survey, released Feb. 21

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So you can't meet meaningful use. Now what?

A December 2010 study by the New York-based market research firm Black Book Rankings found that 90% of health care professionals who bought an electronic medical record would not meet meaningful use requirements by the 2011 deadline. Ninety-three percent said lack of vendor support was among the reasons why.

Doctors Hospital in Pontiac, Mich., found itself in such a situation when its EMR vendor said it had no plans to make the upgrades to ensure that the hospital's system would be certified.

Clarence Sevillian III, president and CEO of Doctors, and Kay Patterson, director of information service, shared the hospital's story at HIMSS to educate others about available options. Doctors Hospitals figured it had four: develop its own hybrid system; implement a commercial solution with another vendor; employ an open-source, or nonproprietary, EMR solution; or merge with another health system.

Physician practices not ready to meet stage 1 criteria probably would face similar options -- the last of which would be to sell the practice to a hospital system. Which path practices pursue would depend on the pros and cons of all options, Sevillian said.

For Doctors Hospital, it decided to pursue a merger but didn't want to hedge all its bets on one path. So in addition to its merger plans, the hospital implemented an open-source, Web-based EMR system, which was the most viable option in case merger plans fell through. The open-source solution cost $3.5 million compared with $7 million for a commercial system.

"One of the reasons we decided to pursue a dual path," Sevillian said, "is because you could get all the way through that process of saying you want to integrate [with another hospital system], but that could fall through." In fact, the merger did fall through, leaving the hospital to focus on adopting an open-source EMR model.

Patterson said she doesn't yet know when the hospital will meet meaningful use. The open-source system it implemented is being certified.

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