My friend Michael Paquin is a fellow of HIMSS, the Health Information Management Systems Society, and an expert in EMR connectivity, Meaningful Use, and the pitfalls of both. Michael shares his thoughts on both in this short video, which is also in transcript form below.
Michael Paquin: I think if we are looking at physicians today and trying to address some of the problems they’re having in their offices and what they’re afraid of in purchasing an Electronic Medical Record, I think we have to start from the beginning and that is service and implementation.
I want to empower all physicians to make vendors give them the service they need. Getting an EMR is just one part of the puzzle in being successful in achieving your Meaningful Use dollar.
The Meaning Use dollars over a five-year period can add up to about $48,000 to $64,000 depending if you’re applying for Medicare or Medicaid. What you really need to think about is that purchase price and negotiate it well, don’t overspend but do overspend if you will, I know that’s contradictory, but do overspend when it comes to implementation and training.
A lot of doctors purchase an Electronic Medical Record and think they can have the training done in 3 days. I’d like you to think about that for just a moment.
If each and every one of you just bought Microsoft Office and brought it into your practice for the first year or first training, could you get trained on PowerPoint, Outlook, Word, Excel all the different features of Microsoft Office in three days while you’re not seeing patients or you are seeing patients? Can you train all 3-4 nurses in your office? What does that mean?
So what I’m suggesting to you is take the time to get trained so that you can use the product correctly. What I’m seeing out in the marketplace is doctors starting to go with their second or third vendor for their Electronic Medical Record software because they have an unsuccessful first brush with Vendor A or Vendor B – they weren’t trained.
All these systems have workflow issues, all of them are trying to address them, and all of them are trying to get better. None of them are going to be perfect but what’s going to make a perfect EMR installation for you is the training.
Make sure you negotiate all the prices.
Make sure you buy from a vendor that is certified by the ONC.
Make sure you’ve got that certification.
Certification means when you get your Meaningful Use dollars you can show your product was certified. So there is a lot to getting ready for purchasing an EMR, there is a lot to choosing the right vendor.
Make sure that you get in touch with an EMR consultant, there are a lot of lessons learned that will pay for a consultant’s time. Anyway in this first video I think we’ve covered enough but feel free to contact me with any questions.
Joe Hage: So I’ll paraphrase. When you’re choosing an EMR partner make sure that it is going to be around and one that can provide you with the level of training you need.
Michael Paquin: And certified.
Joe Hage: And certified, Michael thank you very much.
Today, PhysiciansPractice sponsored a webinar with CMS’s Robert Anthony on the topic of “Meaningful Use Stage 1.” Robert Anthony is a Health Insurance Specialist in the Office of E-Health Standards and Services (OESS) at the Centers for Medicare & Medicaid Services (CMS), where he focuses on the EHR Incentive Programs. Robert had a very pleasant voice to listen to, and he gets my vote for the best CMS Employee Speaker that I’ve heard!
I was not familiar with the OESS before, so I looked it up and found out what they do: Provide the overall leadership for and coordinate the implementation of Title IV of the HITECH Act. (Title IV = Medicare and Medicaid Health Information Technology)
Robert briefly reviewed what has happened to date with the EHR Incentive Program and the terms of the Medicare and Medicaid programs. The three main differences in the two programs are:
The types of providers that are eligible for each program – information here.
The volume of each type of patient needed to participate: no volume needed to participate in the Medicare program and 30% Medicaid patients for all eligible practitioners except pediatricians who only need 20% Medicaid patients.
The tasks in year one in which the certified EHR is adopted. For Medicaid the practice only needs to attest that they have adopted, implemented or upgraded an EHR. In year one for Medicare the practice needs to attest to meaningful use for 90 days, which means data is collected and input into the attestation system.
The majority of the webinar was devoted to FAQs (my favorite part of any CMS-related education session!)
Q: Can entities participate in the Medicare EHR Demonstration Project, and the Medicare or Medicaid EHR Incentive programs too?
A: Yes. The demonstration projects are about to be sunsetted (completed.)
Q: What information must be provided to patients to meet the requirement for a clinical summary at the end of each visit?
A: If system is certified, it will automatically provide the appropriate information for the clinical summary, which includes the patient’s problem list, medication list, medication allergy list, and diagnostic test results.
Robert suggested looking at the answer online at the CMS FAQ which I posted below:
In our final rule, we defined “clinicalsummary” as: an after-visit summary that provides a patient with relevant and actionable information and instructions containing, but not limited to, the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.
The EP must include all of the above that can be populated into the clinicalsummary by certified EHR technology. If the EP’s certified EHR technology cannot populate all of the above fields, then at a minimum the EP must provide in a clinicalsummary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)):
Diagnostic Test Results
Medication Allergy List
Q: How and when are incentive payments made?
A: After the online attestation is made (attestation thresholds must be attained), provider information is verified, then in 6 to 8 weeks a payment is generated. Payments are made in whatever way the entity typically gets CMS payments.
Q: What if patients do not routinely receive prescriptions during an office visit? How can the threshold be met? (Referring to computerized provider order entry (CPOE) for medication orders.)
A: For attestation, practices need to do this for 30% or more of all unique patients with at least one medication in their medication list. Note that patients with no medications in their medication list are excluded, so CMS believes this core initiative is realistic.
Q: For the Medicaid program, do you count the patient visit or the number of services (e.g. patient visit plus two tests equals three patient ticks) during the visit?
A: This question needs follow-up and if you send an email to email@example.com, they will be sent to CMS for the answer. Here is additional information from the CMS FAQ:
When calculating Medicaid patient volume or needy patient volume for the Medicaid EHR Incentive Program, are eligible professionals (EPs) required to use visits, or unique patients?
There are multiple definitions of encounter in terms of how it applies to the various requirements for patient volume. Generally stated, a patient encounter is any one day where Medicaid paid for all or part of the service or Medicaid paid the co-pays, cost-sharing, or premiums for the service. The requirements differ for EPs and hospitals. In general, the same concept applies to needy individuals. Please contact your State Medicaid agency for more information on which types of encounters qualify as Medicaid/needy individual patient volume.
Q: We are a new practice and plan on getting an EMR in the next 3 months. Can you walk me through the time lines?
A: If you haven’t chosen an EMR yet, your first year in either program will probably be 2012. In the first year of Medicare participation, you will need to use the EMR meaningfully for 90 days during calendar year 2012, and you have up to 60 days after the close of the calendar year to attest to your use. In the first year of Medicaid participation, you will need to adopt (acquire, install), implement (commence utilization of EHR such as train, data entry), or upgrade (expand) a certified EHR and attest to your activity at any time during the calendar year.
Q: What validation or oversight will CMS provide for the attestation process?
A: Before any payment is made, checks of provider eligibility and information will be done. Keep in mind that attestation is a legal process. Random audits will be put in place in the near future.
Q: Should a practice register if we don’t know which program we are going to use?
A: You can register at any time, and you can change from one program to the other prior to attesting, so you can register for one program and change before you begin the attestation.
Q: If your first year of attestation is in 2012, can you get the full 44K over the course of the program?
Q: Can you verify if Physician Assistants are eligible for one of the programs?
A: Physician Assistants (PAs) are only eligible under the Medicaid program and must be the lead provider for a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) to qualify.
Q: Does a radiology practice have to provide a clinical summary for patients?
A: No practice type is excluded from clinical summary mandate. CMS has not heard of any practice type having a problem with this so far. Remember, to achieve meaningful use, you must provide clinical summaries to patients for more than 50 percent of office visits within three business days. Exclusion: Any EP who has no office visits during the period of EHR reporting.
Q: Is the problem list supposed to be related to the chief compliant of the office visit?
A: Not necessarily. Practices are required to maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) codes. To comply, at least 80 percent of all unique patients seen by eligible providers must have at least one entry (or an indication of none) recorded as structured data.
Q: What if questions were not able to be answered during the webinar?
A: Please e-mail Physicians Practice and we’ll get your answers from CMS. This could take several days, so please be patient. We will post your answers and all post-webinar questions at http://www.physicianspractice.com and notify you via e-mail as well.
A great list of additional resources were provided by Robert Anthony and Physicians Practice:
Note: See my latest post on registering and attesting for the EHR Incentive Program here.
CMS has announced two national calls for attestation.
Tue May 3, 2-3:30pm ET (for Eligible Hospitals)
Thu May 5, 1:30-3pm ET (for Eligible Professionals)
CMS is holding conference calls for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare Electronic Health Record (EHR) Incentive Program to provide information on the attestation process. Mark your calendars for one of the calls below.
Tuesday, May 3, 2:00 – 3:30 p.m. ET – Register to join this call if you are an eligible hospital or CAH who wants to learn more about the attestation process for the Medicare EHR Incentive Program.
Thursday, May 5, 1:30 – 3:00 p.m. ET– Register to join this call if you are an EP who wants to learn more about the attestation process for the Medicare EHR Incentive Program.
What the Calls Will Cover
Path to Payment – Highlighting the steps you need to take to receive your incentive payment
Walkthrough of the Attestation Process – Guiding you through CMS’ web-based attestation system
Troubleshooting – Helping you successfully attest through CMS’ system
Helpful Resources – Reviewing CMS’ resources available on the EHR website
Q&A – Answering your questions about the attestation process
Instructions on How to Register for a Call
To register for these calls, take the following steps:
The registration site for the Tuesday, May 3 eligible hospital and CAH call. Registration closes Monday, May 2 , 2:00 p.m. ET.
The registration site for the Thursday, May 5 EP call. Registration closes Wednesday, May 4, 1:30 p.m. ET.
Fill in all required information and click “Register.”
You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter. Please save this page in case your server blocks the confirmation email. (If you do not receive the confirmation email, check your spam/junk mail filter as it may have been directed there.)
If assistance for hearing impaired services is needed, please email firstname.lastname@example.org later than 3 business days before the call.
Prior to each call, presentation materials will be available in the Upcoming Events section of the Spotlight Page on the CMS EHR website.
Registration closes when all available space has been filled, or 24 hours before each call; no exceptions will be made, so please register early.
How will I attest for the Medicare and Medicaid Incentive Programs?
Medicare eligible professionals, eligible hospitals and critical access hospitals will have to demonstrate meaningful use through CMS’ web-based Registration and Attestation System. In the Medicare & Medicaid EHR Incentive Program Registration and Attestation System, providers will fill in numerators and denominators for the meaningful use objectives and clinical quality measures, indicate if they qualify for exclusions to specific objectives, and legally attest that they have successfully demonstrated meaningful use. A complete EHR system will provide a report of the numerators, denominators and other information. Then you will need to enter that data into our online Attestation System. Providers will qualify for a Medicare EHR incentive payment upon completing a successful online submission through the Attestation System—immediately after you submit your results you will see a summary of your attestation, and whether or not it was successful. The Attestation System for the Medicare EHR Incentive Program will open on April 18, 2011.
For the Medicaid EHR Incentive Program, providers will follow a similar process using their state’s Attestation System. Check here to see states’ scheduled launch dates for their Medicaid EHR Incentive Programs.
Do you have questions about the EHR Incentive Programs? Do you want to find out if you are eligible, how much of an incentive payment you can earn, and learn more details about the program and what you need to do to qualify?
To attest for the Medicare EHR Incentive Program in your first year of participation, you will need to have met meaningful use for a consecutive 90-day reporting period. If your initial attestation fails, you can select a different 90-day reporting period that may partially overlap with a previously reported 90-day period. To attest for the Medicare EHR Incentive Program in subsequent years, you will need to have met meaningful use for a full year. Please note the reporting period for eligible professionals must fall within the calendar year, while the reporting period for eligible hospitals and critical access hospitals must fall during the Federal fiscal year.
April 18, 2011, is the earliest an eligible professional, eligible hospital or critical access hospital can attest that they have demonstrated meaningful use of certified EHR technology under the Medicare EHR Incentive Program.
Under the Medicaid EHR Incentive Program, providers can attest that they have adopted, implemented or upgraded certified EHR technology in their first year of participation to receive an incentive payment. Medicaid EHR Incentive Program participants should check with their state to find out when they can begin participation.
What can I do now to prepare for attestation?
Visit the Registration page and get registered for the EHR Incentive Programs right now. If you haven’t previously registered, you can complete the registration and attestation process at the same time.
Also, review the Attestation User Guides, which provide step-by-step instructions for login and completing attestation. You can find separate Attestation User Guides for eligible professionals and eligible hospitals in the Resources section below.
Finally, you can enter your information in our Meaningful Use Attestation Calculator prior to submitting your attestation to see if you would be able to meet all of the necessary measures to successfully demonstrate meaningful use and qualify for an EHR incentive payment.
What will I need to login to the Attestation System?
If you are an eligible professional, you’ll need:
Your Type 1 National Provider Identifier (NPI)
The same user ID and password you used to register
If you are working on behalf of an eligible hospital or critical access hospital, you’ll need:
An active National Provider Identifier (NPI)
The same user ID and password you used to register
If you did not register the facility, you’ll need an Identity and Access Management system (I&A) Web user account (User ID/Password) and be associated to the organization NPI, if you’re a user working on behalf of an eligible hospital or critical access hospital.Create a login in the I&A System if you’re working on behalf of an eligible hospital or Critical Access Hospital and don’t have an I&A web user account.
What is the CMS EHR Certification Number?
During attestation, CMS requires each eligible professional, eligible hospital and critical access hospital to provide a CMS EHR Certification ID or Number that identifies the certified EHR technology being used to demonstrate meaningful use. This unique CMS EHR Certification ID or Number can be obtained by entering the certified EHR technology product information at the Certified Health IT Product List (CHPL) on the ONC website here.
NOTE: The ONC CHPL Product Number issued to your vendor for each certified technology is different than the CMS EHR Certification ID. Only a CMS EHR Certification ID obtained through the CHPL will be accepted at attestation.
Eligible professionals, eligible hospitals and critical access hospitals can obtain a CMS EHR Certification ID or Number by following these steps:
Select your practice type by selecting the Ambulatory or Inpatient buttons.
Search for EHR Products by browsing all products, searching by product name or searching by criteria met.
Add product(s) to your cart to determine if your product(s) meet 100% of the CMS required criteria.
Request a CMS EHR Certification ID for CMS attestation.NOTE: The “Get CMS EHR Certification ID” button will not be activated until the products in your cart meet 100% of the CMS required criteria. If the EHR product(s) do not meet 100% of the CMS required criteria to demonstrate Meaningful Use, a CMS EHR Certification ID will not be issued.
The CMS EHR Certification ID contains 15 alphanumeric characters.
I’m an Eligible Professional (EP). Can I designate a third party to register and/or attest on my behalf?
In April 2011, CMS implemented functionality that allows an EP to designate a third party to register and attest on his or her behalf. To do so, users working on behalf of an EP must have an Identity and Access Management System (I&A) web user account (User ID/Password), and be associated to the EP’s NPI. If you are working on behalf of an EP(s), and do not have an I&A web user account, please visit I&A Security Check to create one. States will not necessarily offer the same functionality for attestation in the Medicaid EHR Incentive Program. Check with your State to see what functionality will be offered.
When will I get paid?
Incentive payments for the Medicare EHR Incentive Program will be made approximately four to six weeks after an eligible professional, eligible hospital or critical access hospital meets the program requirements and successfully attests they have demonstrated meaningful use of certified EHR technology. CMS expects that Medicare incentive payments will begin in May 2011. Payments will be held for eligible professionals until the eligible professional meets the $24,000 threshold in allowed charges.
Eligible hospitals and critical access hospitals attesting in April 2011 could receive their initial payments as early as May 2011. Final payment will be determined at the time of settling the hospital Medicare cost report.
Medicaid incentives will be paid by the states and are expected also to begin in 2011. States are required to issue incentive payments within 45 days of providers successfully attesting to having adopted, implemented or upgraded certified EHR technology during their first year of participation in the Medicaid EHR Incentive Program. Launch date for the Medicaid EHR Incentive Program varies by state, so the earliest date attestation can begin also varies by state. Several states have disbursed incentive payments as early as April 2011.
How will I get paid?
Payments to Medicare providers will be made to the taxpayer identification number (TIN) you selected at the time you registered for the Medicare EHR Incentive Program.
CMS will deposit payment in the first bank account on file. It will appear on your bank statement as “EHR Incentive Payment”
If you receive payments for Medicare services via electronic funds transfer, you will receive Medicare EHR Incentive Program payment the same way. If you currently receive Medicare payments by paper check, you will also receive your first Medicare EHR Incentive Program payment by paper check.
IMPORTANT: Medicare Administrative Contractors (MACs), carriers and fiscal intermediaries will not be making these payments. CMS has contracted with a Payment File Development Contractor to make these payments.
Have questions about your EHR incentive payment?
DON’T: Call your MAC/carrier/fiscal intermediary with questions
DO: Call the EHR Information Center
1-888-734-6433. TTY users should call 1-888-734-6563
Hours of Operation: 7:30 a.m. – 6:30 p.m. (Central Time) Monday through Friday, except federal holidays
Why the payment amount may be less than you thought: The Medicare & Medicaid EHR Incentive Program Registration and Attestation System contains a Status tab at the top which will contain the amount of the incentive payment, the amount of tax or nontax offsets applied, and the remittance advice reason code containing the reason for any reduction.
For those receiving paper checks, there will be a tear-off pay stub which identifies offsets made to the incentive payment.
Where you can find more information about the offsets: For more information about tax offsets, call the Internal Revenue Service (IRS) at 1-800-829-3903.
For more information about non tax offsets, call the Department of the Treasury, Financial Management Service (FMS) at 1-800-304-3107.
Will CMS conduct audits?
Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program potentially may be subject to an audit. Here’s what you need to know to make sure you’re prepared:
Overview of the CMS EHR Incentive Programs Audits
All providers attesting to receive an EHR incentive payment for either Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses). Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers.
States, and their contractors, will perform audits on Medicaid providers.
CMS and states will also manage appeals processes.
Preparing for an Audit
To ensure you are prepared for a potential audit, save the supporting electronic or paper documentation that support your attestation. Also save the documentation to support your Clinical Quality Measures (CQMs). Hospitals should also maintain documentation to support their payment calculations.
Upon audit, the documentation will be used to validate that the provided accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.
Details of the Audits
There are numerous pre-payment edit checks built into the EHR Incentive Programs’ systems to detect inaccuracies in eligibility, reporting and payment.
Post-payment audits will also be completed during the course of the EHR Incentive Programs.
If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped.
CMS will be implementing an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare EHR Incentive Program. More information about this process will be posted to the CMS Web site soon.
States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.
Where can I find user guides and other resources?
Below are step-by-step Attestation User Guides to help you attest for the Medicare EHR Incentive Program. You can also use our Attestation Worksheet, Meaningful Use Attestation Calculator, and educational webinar to help you prepare for and complete the attestation process:
Steps to digging under the meaning of EMR certification:
Image via Wikipedia
Click to see the most recent alphabetical list (by product name not company) of all products certified here.
Find the company or companies you are using or are considering using.
Check that the exact name of the product is what you have or might purchase.
Check to find out if a module or part of the product is certified or if the complete product is certified.
Check to make sure the version of the product is the version you have or will have.
If you have questions about each company’s exact criteria met, you are in luck! On the ONC site here, you can click on each company’s detail (“View Criteria”) on the far right column labeled “Certification Status” to see what they have and don’t have. Compare this to how you are anticipating using your EMR to meet meaningful use. The more check marks a company has, the better-equipped they are (and more flexible) to meet your practice needs and to qualify for the stimulus money.
The ONC site with the Certified Health IT Product List (CHPL) is Version 1.0. Version 2.0 is now being developed and will provide the Clinical Quality Measures each product was tested on, and the capability to query and sort the data for viewing. The next version will also provide the reporting number that will be accepted by CMS for purposes of attestation under the EHR (“meaningful use”) incentives programs.
You can tell ONC what you think would be helpful in the new version by emailing your ideas to ONC.email@example.com, with “CHPL” in the subject line.
If you’d like a list of just outpatient/medical practice EMR products or just inpatient / hospital products, I’ve split the big list into two smaller printable lists here:
Remember that meeting meaningful use does not tell the whole story – if you are shopping for an EMR be prepared to go beyond a product’s certification status to consider:
Flexibility – does it make the practice conform to it or can it conform to the practice? How?
Templates and best practices – are you starting from scratch in developing protocols, templates and cheat sheets for your practice, or does it have a storehouse of examples to choose from or tweak?
Built for the physician, or the billing office, or the nurses, but doesn’t really meet the needs of all three? Make sure the functionality is not too skewed to one user group, but if it is, it should be somewhat skewed to the provider.
Interface and integration with your practice management system. Does the information flow both ways? Do you ever have to re-enter information because one side doesn’t speak to the other?
Interface with other inside and outside systems: Labs, imaging, hospital systems, ambulatory surgical center systems?
Built-in Resources: annual upgrade of HCPCS and ICD codes, drug compendium (Epocrates), comparative effectiveness prompting?
Mobile applications – EMR on your providers’ phones?
Data entry systems – laptops, notebooks, tablets, iPads, smartphones, voice recognition?
Hosting – in your office? at the hospital? at the vendor’s data center? in the cloud of your choice?
What’s the plan for ICD-10? Will they provide practice support and education for the change or will they just change the number of characters in the diagnosis code field?
Price, including annual maintenance and additional costs for training, implementation, on-site support during go-live, and additional licenses for providers or staff.