Rodney J. Moore

an ambulatory, independent, primary-care practice in northern New England, has been attesting to meaningful use since 2011, the first year it was achievable. David Park, a family medicine doctor and partner of the practice, says a lot of the requirements were already being achieved through their regular practice work flow.

White River was a 2013 HIMSS Davies Ambulatory Award winner - recognized for outstanding achievement of health information technology to improve outcomes. Park credits White River's success in part to its selected EHR vendor, eClinicalWorks. "Any vendor worth their salt should make meaningful use easier - it's a natural selling point for them as a way to easily offset the initial cost of purchase."

Park says it is critical to elect a provider as a champion of meaningful use initiatives and to have buy-in from all staff members. "Having a provider be a part of the 'voice of change' can make buy-in easier for everyone," Park says. "I've heard from other practices whose meaningful use champion was an ancillary staff person, who really was challenged to make changes to the work flow - so necessary changes may be met with prickly resistance by providers who think their work flow is being unnecessarily changed by someone who doesn't understand fully how care is rendered."

For helpful meaningful-use resources, Park often turns to CMS' website and to his EHR vendor support e-mails and forums. "Sometimes, the easiest thing is to just go to the CMS.gov website and get information from the source," Park says. "The rules are there, however, the interpretation of them can be difficult at times. For that, I go to our EHR vendor's users' forum and can usually find answers there."

Fremont Family Care, a small primary-care practice in Fremont, Neb., is also several years into its own meaningful-use journey and has successfully attested to Stage 2. Shortly after the implementation of its EHR system in 2011, Fremont designated a super user and an EHR specialist who became familiar with meaningful use measures.

Beth Belmont, director of primary-care clinics at Fremont Health, says staying on top of the changes is difficult, but not impossible. "Our EHR system helps since we have a dashboard that shows the metrics and performance by physician," Belmont says. "Each year we also educate ourselves on meaningful use and any changes by reviewing information on the CMS website. The EHR implementation team then implements work flow changes as necessary.

Belmont says although Fremont has relied on the CMS website for continuous updates, they've also used their EHR vendor support extensively. "With the changes that occurred with meaningful use Stage 2, our practice paid for one-on-one education by our EHR support vendor," says Belmont. "This allowed us to better understand the metrics, how we could use our EHR to help us with the journey, and develop work flows for staff."

For practices that are still in the early stages of meaningful use, Belmont says it is critical to communicate expectations and optimize work flows. "As much as possible, collaborate with providers and staff to develop work flows that fit into their current routine, as to not disrupt the clinic flow," she says. "Constantly communicate with your staff and physicians about what they are doing well and what needs improvement to meet these metrics."

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A pair of small practices are fully entrenched in the meaningful use journey. Here’s how they’ve succeeded. 

Two Small Practices on Committing to Meaningful Use 

It appears that the EHR Incentive Program is losing some of its early momentum. “At present, we have 52 percent of all of the Medicare Eligible physicians receiving a 1 percent penalty on all of their claims from Medicare because they are not participating in the MU program,” said Steven Stack, president of the American Medical Association. “And we have 10 percent to 11 percent of physicians who are at stage 2 of the MU program.”

According to Stack, one of the main reasons why doctors do not participate in meaningful use is because, “It is designed in such a way that it mandates a number of very specific things be done and be done in ways that doctors do not find helps their patients. It also does not help them be efficient and effective in their patient care. It creates real challenges in the medical practice because the physician is turned into a typist and clerk.”

, three out of four physicians surveyed report that EHRs increase costs and do not save time. “Many organizations, particularly smaller practices, do not have the technical and leadership resources to effectively deploy and optimize EHRs or complete necessary process changes,” said Harry Greenspun, director of Deloitte’s Center for Health Solutions. “They fear they will be unable to maintain productivity or achieve a reasonable return on investment by any measure.”

Once implementation of meaningful use begins, according to the Deloitte survey, few physicians report intentions to stop or abandon moving to the next stage. Of those who have not yet started implementation, most plan to stay put. Out of the 18 percent who had not started meaningful use, 70 percent had no future plans to reach any stage of meaningful use.

Stack said the incentive program is less attractive to physicians who haven’t yet attempted meaningful use since, “It’s an all or none paradigm, so you have to successfully complete the entire meaningful use program as defined by the government or else you fail. So if you get 19 of the 20 elements correct, you’ll get a penalty and you’ll be deemed to be a failure in the program, which really seems fundamentally unreasonable and certainly does not encourage people to incur the great cost and expense necessary to fulfill the program when the likelihood of success is uncertain and the possibility of failure is substantial.”

Stack said the complexity of the measures and the stringent requirements to meet specific measures actually acts as a deterrent for many physicians. “It [meaningful use] is overly complex, it’s overly proscriptive, and it has an unreasonable threshold to determine success or failure that actually serves as something of a disincentive to participate,” said Stack.

Another significant detractor for physicians who have chosen not to participate in meaningful use is the overall cost involved can be substantial, often approaching tens of thousands of dollars. “This is going out and buying an expensive software program, installing it and then you have to pay for extra work to be done to make it communicate and connect with other electronic health records,” said Stack. “So this is not plug and play.”

Many physicians and practices are finding that the cost of entry simply doesn’t add up. “A lot of smaller practices aren’t financially motivated to continue with meaningful use after stage one,” said Shaun Conrad, manager in the healthcare advisory practice at Ernst & Young. “With additional incentives difficult to obtain and penalties being low, smaller practices don’t believe the juice is worth the squeeze in continuing with meaningful use. The implementation, practice effort, and administrative costs are outweighing the overall financial gain.”

Conrad said some physicians are taking a cautious approach to their meaningful use strategy because frustration levels remain high for those who’ve already committed. “Doctors are frustrated with meaningful use and the frequent changes in direction,” Conrad said. “The path from stage to stage continues to evolve and many are waiting until the dust settles before committing to a direction and meaningful use strategy. Having patients involved in meaningful use and getting them engaged with a patient portal and electronic messaging has proven too difficult for doctors.”

Rodney J. Moore is a healthcare writer, ghostwriter and medical copywriter based in Nashville, Tenn.

Why is the dropout rate of the EHR Incentive Program getting higher and higher? Experts say there are multiple reasons. 

Why Doctors are Declining Meaningful Use

The shift from volume- to value-based reimbursement is well underway and physicians are likely finding it challenging to keep up with the changes and various emerging payment models.

According to Allison Brennan, senior advocacy advisor, and Sara Brown, government affairs representative, for the Medical Group Management Association (MGMA) government affairs office, practices will continue to be affected since there is a significant increase in enrollees in Medicare. Every eight seconds, according to U.S. Census data, someone ages into the Medicare program since approximately 10,000 baby boomers turn 65 every day. This is driving up costs, since naturally more enrollees means more expense.

As a result, last January, for the first time in the history of the Medicare program, HHS set explicit goals for alternative payment models and value-based payments. Among other targets, HHS Secretary Sylvia Burwell announced the goal of tying 50 percent of payments to alternative payment models, such as accountable care organizations or bundled payment arrangements, by the end of 2018.

One of the payment models with the potential to affect physicians immediately is the Value-Based Payment Modifier (VBPM). The VBPM provides for differential payment to a physician or physician group under the Medicare Physician Fee Schedule (PFS) based on the quality of care compared to cost of care over a performance period. The program will be phased in over the course of three years based on physician group size, beginning with groups of 100 or more EPs or physicians this year and affecting all physicians by 2017. And that data for all physicians under scrutiny in 2017 comes from this year.

Under the VBPM, physicians' score is split 50 percent / 50 percent through:

•Outcomes measures: Three composite measures on acute and chronic prevention quality indicators; all-cause readmission

• Cost measures: Total per capita cost (includes Medicare Part A and Part B spending), and per capita cost for four chronic conditions (COPD, coronary artery disease, diabetes, heart failure)

Another emerging payment model for physicians are accountable care organizations (ACOs), which are not new, but continue to evolve. There are 338 current ACOs in the Medicare Shared Savings Program participating in two payment models: a one-sided model where providers share in savings only, and a two-sided model with shared savings and losses.

Accountable care organizations have also been identified as an alternative payment model for practices to implement to avoid scrutiny through the Merit-Based Incentive Payment System (MIPS) coming in 2019.

According to Brennan, “with smaller margins and greater risk, practices will have to closely evaluate the services they provide.” In addition, Brennan pointed out that practices with a sophisticated understanding of financial and clinical analytics will be best positioned for these evolving payment models. 

She also urged practices to stay ahead of the curve and thoughtfully consider if certain voluntary programs are right for their practice.  Those practices that can be ready to adapt to mandated payment changes will be more likely to succeed, she added.

The decisions your practice makes and the steps it takes toward value-based care today will have a big impact tomorrow. Here's what you need to know.

The Road to Value-Based Payments is Now Open

At this year’s Medical Group Management Association (MGMA) Annual Conference, healthcare consultant Rosemarie Nelson provided compelling evidence about the promise of patient portals and their potential to make physician operations more efficient.

“I think the best way to get into an EHR is to start with portal technology,” Nelson said. “Practices should engage patients and get them to start registering and submitting ‘PMFSHx’ (or past medical, family, social history) online."

Patients often tire of giving the same information over and over to different providers, so the portal can offer a central place for gathering information.  “Another place to search for a portal is with [a practice's] practice management system vendor …  to register and bill patients and for appointment scheduling," she said. "…That is data the practice will want integrated with the portal. Why re-enter information the patient has already entered?”

Nelson identified kiosks as being a particularly attractive option for patients to access portals during their visit. “First, kiosks range in costs from very low to several thousand [dollars] with monthly fees,” Nelson said. “Practices haven't calculated their existing costs; they don't know the cost of the process for something as simple as patient registration. Add the cost of re-processing insurance claims due to ineligible insurance at $25 to $40 per claim and the ‘costs’ are easily offset by reduced operational costs and improved collections.”

In one example Nelson provided at her educational session in Nashville, Tenn., kiosks at the West Boca Diagnostic Imaging Center in Boca Raton, Fla., allowed providers to see 15 to20 more patients per day than with traditional front desk check-ins.

Nelson said during the due diligence purchase process, a practice can start with the vendor's cost-benefit analysis and then apply their own specific patient data (usually a vendor will assist with a justification presentation). “Of course, that is easily said, but practice managers wear many hats and may not have the time, but getting a few hours of consultative help may give them the assessment that can support a purchase (or clearly indicate why not to go forward with implementation).”

The portal is also an ideal place to deliver practice content, frequently asked questions, and physician-authored, peer-reviewed content for patients, Nelson said. In addition, one simple but effective way to pump up a patient portal is to make sure it is mobile friendly in a growing environment of smartphone-enabled patients.

Nelson expects more development and integration of mobile apps with portals in the future. “Why not make it so easy that the patient could download a free app and try it right there in the waiting room?” she asked

“For the most part, many practices are not patient-friendly or consumer-friendly and I see that changing as our reimbursement model evolves,” said Nelson.

You likely have a patient portal to meet meaningful use, but here's how to put it into practice to really help your practice staff and your patients.

Patient Portals: From Implementation to Maximizing Use

The current environment of meaningful use of EHRs might best be described as both good news and bad news.

“The goal of the meaningful use program I think was achieved of getting EPs to buy the EHR technology and start using it,” said Robert Tennant, director of health information technology policy for the Medical Group Management Association's (MGMA's) government affairs office. “That’s the good news.”

Tennant spoke on the recent rule announcements to the EHR Incentive Programs at this year's MGMA Annual Conference in Nashville, Tenn., on Tuesday (Oct. 13).

“The bad news is as the industry shifted to Stage 2 there was a drop-off of significant proportions and very quickly the incentives are going away,” Tennant said. “Only 60,000 have attested so far and CMS has closed the attestation website so there will be no new attestations for Stage two this year.”

According to CMS, as many as 250,000 EPs will receive financial penalties due to meaningful use program requirements.

 announced Oct. 6 means practices can begin to work with their vendors to identify a pathway forward to attestation. “They [EPs] will still need to deploy a portal and secure messaging, but the lowered measure thresholds will reduce the administrative burden and increase the likelihood of success,” he said. 

“The challenge for a lot of groups have been the public health reporting measures,” Tennant said. “This was one measure where CMS deviated in the proposal from the original [rules] and they deviated in the final rule from both the proposal and the original [rule]. They’re saying all that you need to is be actively engaged with a public health agency, so all that you need to do is register.”

Tennant said risk analysis is also an overlooked component of meaningful use. In fact, he said, the leading cause of failing a meaningful use audit is not having a security risk analysis completed. “What CMS is saying is you must do a security analysis and you must address encryption,” he noted.

Another hindrance that has affected practices is many EHR vendors haven’t spent a lot of time on usability, Tennant said. “There’s been a lot of backlash about the fact that a lot of EHR vendors in their efforts to try to meet meaningful use have maybe not spent as much time on the interface side of the technology. So, physicians get the technology and it meets the meaningful use requirements, but they’re cumbersome and not any fun to use. So there is a lot of discussion about the technology not really helping.”

Moving forward, Tennant recommends that physicians get as many of the free or low-cost resources available on optimizing EHRs and leverage their colleagues about best practices.

“Practices should focus on identifying, implementing, and optimizing EHR technology that not only meets the minimum government standards for meaningful use but, more importantly, is a system that effectively and efficiently supports the clinical and administrative work flow of the practice,” Tennant said.

While the latest rule clarification for CMS on the use of EHRs answers some questions for physicians, there are plenty remaining.

The Current and Future Environment of Meaningful Use

There really is innovation in healthcare. And it's not just being driven by reform.

One example is Rushika Fernandopulle, founder and chief executive officer for Cambridge, Mass.-based Iora Health, who started from scratch in 2012 to rework the primary care experience.

At this year's Medical Group Management Association (MGMA) Conference in Nashville, Tenn., Fernandopulle said he spent three months writing a business plan before he launched his practice, Renaissance Health, which later became Iora. You could say his mantra is: First, break all of the rules. Rather than using today's fee-for-service system of copays and billing codes, Iora charges patients a monthly flat fee of about $150, often covered by insurance. The concept is designed to save consumers in the long run by cutting down on ER visits and long-term care for chronic conditions. Iora raised over $42 million in venture capital since its inception and has 11 clinics in seven states with an additional 30 locations planned for 2016.

Iora's approach is more bottom up than top down, meaning the approach doesn't try changing laws but working around them, according to Fernandopulle. For example, Iora earns their money by taking care of their patients, not by billing for every service they provide, which is how the vast majority of primary-care doctors are paid. Fernandopulle said he wasn't sure his new approach would work, but he did know the current system wasn't working well, so he needed to simply try new things. Fernandopulle admits Iora hasn't gotten it all right, but the only reason it has progressed is that the health system is learning along the way. 

"The problem with healthcare in this country is we have turned it into a series of transactions," Fernandopulle said.  Instead, he said, Iora rebuilds the healthcare system on the only thing that matters - the patient-provider relationship.

Outside of its care approach, Fernandopulle said that what also fascinates people about Iora is the technology behind what they do, which gets away from the traditional vendor-created EHR associated with most medical practices and health systems, and instead focuses on a "true collaborative care platform for improving health" through the uniquely created Iora Clinical Intelligence System. The system combines the traditional EHR data with other patient information, such as claims, to engage patients and drive proactive care to narrow physician attention.

Fernandopulle said the takeaway from his successful approach for other medical practices is that there are better ways to practice, and the current system isn't the only way.

"By changing the payment model, delivery system, and IT platforms we can make things better both for patients and ourselves, and create better economics," he said.

By bucking the traditional system, Iora Health is providing a new approach to primary care.