Q&A - August 4 Webinar

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• Q1: The MU criteria are very specific as to coding elements. Are there suggestions to guide creation of new EHRs, or do existing EHRs need to recode to conform to the requirements such as those listed on the CCHIT documents?

  
  The meaningful use requirements must be followed by all vendors wishing to receive the certification needed to be a certified vendor. None of the existing CCHIT certifications meet the requirement of a certified EHR product for the meaningful use incentive program. All EHR vendors will need to get a different certification for meaningful use from an ONC-Authorized Testing and Certification Body (ONC-ATCB). Currently no organization(s) have been approved by the ONC as an ONC-ATCB. To a varying extent, EHR’s will need to tweak their systems to comply with the new standards.

• Q2: Providers are scared to share info electronically; the perception is that they are not protected from litigation once the information leaves their domain (Not malpractice covered). Are there any Federal laws that protect EHR/HIE users?

  
  As asked and answered during the webinar
  
  Dr Barr: Dr. Zaroukian, there is one particular question about sharing information electronically. It is concerned about physicians that might feel a little unprotected from litigation once information is shared or exchanged between health care providers. I wondered if you have any comments about that, and whether there are any protections that you are aware of for physicians in practice?
  
  Dr Zaroukian: It’s an interesting question. Speaking as a non-lawyer, I would say that part of the thing to look at here is to look at how non-electronic information was shared and the electronic equivalent of that information. If the question is intended to basically ask once information generated in your practice is shared elsewhere, if and how does that pose a legal risk to you, I think the key issue is that if it’s been provided in the context and the same manner according to the same HIPAA regulations for sharing information, that in and of itself should not represent any increased risk. I think one of the keys is going to relate to the issue of patient permissions and to what degree will patients have the ability to determine and direct the release of their own information for purposes other than direct patient care. I don’t know of any specific federal laws right now that are in the HIE space. I do know that there’s a lot of work being done right now with regard to additional rules and regulations and guidelines around health information exchange as it relates to privacy and security. But to my knowledge, there’s no specific guidance on that yet.

• Q3: Will there be any incentive for Rural Health Clinics beyond what the individual Physicans, Nurse Practitioners and PA earn? Will there be a loan program for small non-profits to help bridge the cost of EHR until the incentive is received?

  
  There is an additional 10% bonus available in the Medicare program for providers practicing in a health professional shortage. There is currently no loan program through the government to help defray the costs though many vendors are offering packages to do so. The Medicaid program allows providers to receive some upfront funds to help with the purchase of an EHR.

• Q4: How and when will the providers get their checks?

  
  According to CMS, they expect to begin issuing payments starting in May 2011 for the Medicare program, remember you will have to collect 90 days of data before submitting attestation. The Medicaid incentives will be paid by the States and will also begin in 2011 but the timing will vary by State. Under the Medicaid EHR Incentive Program, incentives can also be paid for the adoption, implementation, or upgrade of certified EHR technology. Click here for further information

• Q5: Is there any plan to for ONC to engage physicians that are EHR-experienced to serve as "physician-tutors" for other physicians?

  
  The Health IT Journey Stories are an initiative from the ONC which may provide some of the opportunities you are looking for. Click here for further information

• Q6: Does the 20% Medicaid requirement apply to the entire practice as a group or to each individual physician? If based on individual physician, is it based on submitted claims or the insurance list of assigned patients?

  
  There are several different ways that you may be allowed to calculate this number and the final methodologies will be up to your State Medicaid Agency. According to CMS “The Medicaid patient volume methodology will be designated by the State Medicaid Agency and approved by CMS. Note: The final rule describes acceptable methods for estimating patient volume. In determining patient volume thresholds, EPs should include individuals enrolled in Medicaid managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and Medicaid medical home programs or Primary Care Case Management.” Click here for further information

• Q7: What do you see as the role of the QIOs as it pertains to assisting physicians attain Meaningful Use?

  
  As asked and answered during the webinar
  
  Dr. Barr: Dr. Blumenthal, there are a few questions here about support for practices along the lines of whether ONC is going to engage experienced users of the EHRs to be physician tutors. Will the QIOs be helpful to assist physicians attaining meaningful use, and what kind of assistance is available for practices? Perhaps this is an opportunity to talk about regional extension centers and other ideas that the office has regarding support for practices either coming to EHRs new or already using EHRs and wanting to get up to speed on meaningful use.
  
  David Blumenthal: Thanks for that question. The Office of the National Coordinator has set up 60 of these regional extension centers. They cover the entire geographic expanse of the United States. They are by grant requirement focusing on primary care physicians in small practices and in underserved areas, also in community health centers and on critical access hospitals. Their goal is to help physicians decide which system to purchase, to help them install it, to help them run it, and to help them become meaningful users, and then to help them get value for their practice and their patients. The different regional extension centers—there are 60 of them—are taking different approaches. I do expect that some will engage physician opinion leaders and tutors. Some may actually get medical students working with them since a lot of medical students learn these records pretty fast. Others will make resources available through webinars like this, through materials online. There is going a variety of approaches. Some of them are quality improvement organizations. About a third of those 60 are already quality improvement organizations who applied for and got funding.
  
  I think the way to start with the planning—planning is a critical part of this and it’s a great thing to emphasize—is to go to http://healthit.hhs.gov and find out who is your regional extension center. Give them a little time to get set up, because they’ve just been funded and they’re getting going. Some may not be ready to go at a gallop. Contact them, get registered with them, and find out what they have to offer. If you don’t like what they have to offer, let us know. By the way, there will be, I’m sure, other sources of support. They won’t probably be quite as affordable, but there are lots of consulting companies and lots of vendors who are getting into this business of supporting physician adoption and meaningful use as well.

• Q8: What kind of assistance is available for practices that have already begun working with EMR?

  
  There are many options out there. If you are a primary care provider you should investigate ONC’s Health Information Technology Extension Program (REC) in your area. You should also reach out to your vendor to see what help they can provide. Click here for further information

• Q9: Can Nurse Practitioners qualify for the Medicare incentive?

  
  They do not qualify for the Medicare incentives just the Medicaid incentives.

• Q10: Does an EMR have to be CCHIT certified to apply for meaningful use certification?

  
  Q10: The EHR must be certified by an ONC-Authorized Testing and Certification Body (ONC-ATCB) as meeting certain criteria that have just been released by ONC. Unfortunately, ONC has yet to approve any organization as ONC-ATCB so products have not yet been certified for the incentive program. CCHIT has applied to be an ONC-ATCB and most individuals expect will receive ONC-ATCB status however regardless of their status as an ONC-ATCB none of their current certifications will count as a valid certification for meaningful use. You can find more information on certification at AmericanEHR and the Centers for Medicare & Medicaid Services

• Q11: When will it be the earliest to apply and qualify for MU and the first Incentive? What is the breakdown of Incentives per year and how many years?

  
  You should be able to submit your attestation to the meaningful use measures starting in April of 2010 for the Medicare program. You must have 90 days of information in your system to qualify for stage one meaningful use. Click here for more information on the Medicare program and the breakdown of the incentive payments. The Medicaid program has a different structure and can vary by state. Click here for further information

• Q12: Does the program start 2010 or 2011? If I install and correctly use EHR now do I get first reimbursement payment any earlier than if I start using it Jan 2011, for example? Or Oct. 2011?

  
  The incentive program does not officially start until 2011. However, it can take a substantial amount of time to select implement and then become a meaningful user of an EHR system. It generally takes practices at least 3 months to return to normal productivity after “go live” (when you start using your EHR for patient care) and to start to attempt the tasks required for meaningful use. Additionally most EHR vendors already have long waiting lists on when they can actually begin the installation of your EHR system; some are scheduling installations over 6 months out.

• Q13: When can you apply for Medicaid incentive, if you have already implemented an EHR?

  
  You should be able to register your intention to participate in the program starting in January 2011 and then be able to submit your attestation starting in April 2011. However before you submit your attestation you must be using an EHR system that has received a certification for meaningful use by an ONC-ATCB. Currently no EHR products have received this certification. You will also need to be collecting all the data required to meet the meaningful use requirements for at least 90 days before you submit your attestation to CMS. That being said you are ahead of the curve you will just need to update your system when and if your vendor has tweaked their system to meet meaningful certification requirements.

• Q14: I would like to know how ONC plans to make all this work in a solo practice..any examples?

  
  ONC has set up a number of programs to help doctors in small practice the most important of which is the Health Information Technology Extension Program. Click here for further information
  
  As asked and answered in the call
  
  Dr. Barr: Dr. Zaroukian, how do you think meaningful use could work in a smaller, solo practice? Is it feasible, and have you seen any examples?
  
  Mike Zaroukian: Yes. In some ways it will be easier because there will be fewer individuals to coordinate to achieve meaningful use and less need to, if you will, to deal with the compromises that occur in any larger practice where a one person solution may not be optimal for another. The key issue I think, as Dr. Blumenthal pointed out, is smaller and more rural, less connected practices will have a greater difficulty amassing the expertise necessarily to set up the technology and change management and other parts of this. This is where the regional extension centers and other types of resources, hospital affiliations or beacon communities, etcetera, where those are available to a solo practice they can be a big help allowing you to stand on their shoulders and use their expertise to get it done. But from the perspective of is it achievable within that practice, a solo or a small group practice, the answer is absolutely, yes. In some ways there’ll be fewer barriers of certain kinds that make the biggest difference which is people and processes.

• Q15: Can one of the panelist clarify the definition of "encounter" in the context of a physician needing >30% of encounters paid by Medicaid to be able to apply for that incentive payment?

  
  According to CMS “The Medicaid patient volume methodology will be designated by the State Medicaid Agency and approved by CMS. Note: The final rule describes acceptable methods for estimating patient volume. In determining patient volume thresholds, EPs should include individuals enrolled in Medicaid managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and Medicaid medical home programs or Primary Care Case Management.”Click here for further information

• Q16: Will physicians that work in the office & in Nursing homes qualify for the Medicare & Medicaid incentives?

  
  Yes, physicians that work in a nursing home part of the time and in the office part of the time should be able to qualify for the incentive. CMS has put together a helpful chart to determine if you are eligible and to determine which programs you are eligible for. Click here for further information

• Q17: Where can we find DETAILED, EXPLICIT definitions of the meaningful use tasks, in a concise display? The HIT.hhs.gov site does not have such a display readily available. There lots of generalities, e.g. reference to the 25 tasks, but no explicit list.

  
  You can find a list on the AmericanEHR blog and there is a very good article in the New England Journal of Medicine by Dr David Blumenthal, that is free to everyone and which includes a very good table outline of the requirements. You can find the list of the clinical quality measures to pick from (you will need to a total of six to report on list) starting on the 32nd slide of this presentation. Note that a denominator of 0 can be used if you are a specialist and to not have any data on the measure in your system.

• Q18: Where do we find the vendors that are recommended by Medicare and which ones are recommended for small practices in particular?

  
  As answered during the webinar
  
  Dr. Barr: There is a question about where to find vendors recommended by Medicare and I don’t think that Medicare’s going recommend any vendors, but what Dr. Blumenthal and Dr. Zaroukian talked about was the certified EHR technology and that process, and for those of you who are looking for EHRs, that’s one of the main purposes of the AmericanEHR Partners site where there is a comparison tool. Not every EHR is on there. As soon as the certification process described by our speakers is underway and there are products certified, we’ll be making certain that the site identifies those and you’ll be able to compare and contrast information about the EHRs that are participating in the site, as well as satisfaction data about those EHRs when we have sufficient data, more than 10 raters for any of those products.
  
  I would encourage you to look at the site, and you can also filter by the size of practice and other demographics. As further data is added, that will become more meaningful.

• Q19: Is there a resource that compares all EMRs in terms of meaningful use?

  
  AmericanEHR Partners will be providing this information as EHR vendors complete the meaningful use certifications.

• Q20: When you say that the Regional Extension Centers by grant will be focusing on primary care physicians, does this means that specialists can take advantage of these services?

  
  As asked and answered during the webinar
  
  Dr. Barr: In the regional extension centers there seems to be a focus on primary care physicians. Can specialists still take advantage of the services? Are they available to such specialists for example?
  
  David Blumenthal: They are available. No one will be turned away, but the regional extension centers will allocate their resources first to primary care physicians. There are many kinds of resources that they may make available: Help with purchasing records, with choosing records, with installing records, materials on websites that are provided at very low marginal costs to physicians who call and ask for them. But in terms of the really intensive person-to-person assistance, I think that that’s likely to go primarily to primary care physicians.

• Q21: Are any EMRs able or required to allow you to transition to another EMR?

  
  Vendors are not required to allow you to transition to another EMR. However, in many cases if you decide to transition to a new EMR vendor you can work with them to migrate your existing data to the new system, though this can be costly.

• Q22: If the states are not ready for some of the data to come from the EHRs will that be held against the practice for meeting the goal?

  
  Practices that are located in a state that cannot receive this type of data can receive an exemption on this measure so it will not be counted against them.