In January 2011, I ventured into solo practice after being in a group practice since completing my residency training in 2004. In group practice, charting was for the most part traditional. I utilized voice dictation very efficiently with pre-set “macros” creating a Word document for each patient visit. The system saved, printed and signed the documents for each visit. The staff placed labs, operative reports, discharge summaries and all other faxes in patient charts. Staff pulled charts and re-filed them each day.
I thought the time to implement an electronic health record (EHR) and go “paperless” would be perfect with starting a new practice. After all, I would avoid a transition and scanning of paper charts to a paperless electronic system. A second advantage of initiating my new paperless venture was that my patient volume would be lower than before and allow more time to concentrate on the implementation of the EHR.
I asked around for some recommendations from colleagues about their likes and dislikes with the software they were using. After several webinars and demonstrations, I decided upon the CareTracker product offered by Ingenix. Ingenix offered an incentive program with reference to payment, which was attractive, especially with me starting a new practice. My start-up cost and monthly fees were not due to Ingenix until I successfully met “Meaningful Use” and received the first year $18,000 (Medicare) financial incentive from the Centers for Medicaid and Medicare Services (CMS). The CMS financial incentive payments differ depending on which program one decides to participate in. Ingenix sets up clients with a bank that offers a no interest loan to pay the start-up and monthly fees until the practice receives the incentive check after successfully meeting Meaningful Use.
I thought it was a no-brainer and signed up. The software offered by Ingenix included practice management and EHR components that communicate seamlessly. After little debate from my practice manager, who also participated in the webinars and demonstrations, the deal was done.
What Is Meaningful Use?
I soon learned the two words, Meaningful Use, were more than just using an EHR to chart patient visits. I was well aware there was an EHR incentive program offered by CMS with using a certified EHR technology but otherwise did not know anything beyond that tidbit of knowledge. How quickly I would learn.
Meaningful Use has three main components:
• using a certified EHR in a meaningful manner like e-prescribing;
• using certified EHR technology for electronic exchange of health information to improve quality of healthcare; and
• using certified EHR technology to submit clinical quality and other measures.
The CMS website (http://go.cms.gov/hq2zGp ) states: “Simply put, ‘meaningful use’ means providers need to show they’re using certified EHR technology in ways that can be measured significantly in quality and in quantity.”
I thought even better than CMS saying this was “simple” was the fact that in 2011 and/or 2012, practices only had to meet Meaningful Use for 90 days. This sounded easy enough so I was off and running. I had a new practice, new EHR and practice management software that my staff and I were learning at breakneck speed, and an amazing implementation specialist.
I was soon introduced to the 25 Meaningful Use objectives. I learned about “core set” objectives, “menu set” objectives, numerators and denominators. The CMS has devised 15 required core objectives while practices may choose the remaining five objectives from a list of 10 menu set objectives.
I became familiar with meeting the measure of an objective and calculating a percentage based on numerators and denominators for each objective. The numerator is the number of patients for whom the practice met the objective. The denominator is the total number of patients for whom the practice could have met the objective. Ultimately, these numbers give a percentage by which one can meet Meaningful Use. Certain percentages for the first year have been preset for each core set and menu set objective. I learned about qualifying for exclusions to objectives and finally a new word (“attestation“) came into play.
Overcoming Implementation Hassles
I began scratching my head and asking why I had to meet certain objectives like taking vital signs and recording height, weight and blood pressures. I quickly realized I had embarked on a very arduous, time-consuming task. What happened to simple? Wasn’t an EHR supposed to make my life easier, more efficient, paperless, get me out of the office earlier, allow me to see more patients and cut down on staffing?
I found it even more entertaining to ask my colleagues, especially from other specialties, what they were doing to meet Meaningful Use and what their game plan was with reference to implementing a certified EHR. Most looked at me like I was from the planet Mars and asked what I was talking about.
Now let me clarify. Utilizing an EHR solely as a functional piece of software for charting is much different than utilizing an EHR and successfully achieving Meaningful Use. This became more and more clear as I began utilizing the EHR in an effort to achieve Meaningful Use. Luckily, the program I chose, CareTracker, has a Meaningful Use “dashboard.” This allowed me to monitor my core set and menu set objectives daily to see if I was meeting the minimum requirements in order to attest and qualify successfully for the year one financial incentive.
Shortly after signing up with Ingenix, I was assigned an implementation team that included separate specialists/trainers for the practice management portion of the program and a specialist for the EHR. I did not realize it at the time but my implementation specialist, Deidre Robinson, would later play a particularly vital role in making this transition as well as attempting to meet Meaningful Use successfully.
Our training initially entailed watching videos online and subsequently participating in webinar training sessions with our implementation specialist. When I say “our,” I am referring to my entire staff from my medical assistant to my practice manager. Prior to this venture, little did I know that not only would I be trained on how to use the program but my staff would become just as important with the utilization of the program, especially with meeting Meaningful Use. I quickly learned that meeting Meaningful Use was a team effort rather than an individual achievement.
So I was off and running and started using CareTracker in February 2011. The first available attestation date was April 2011, so one would have to have been meeting Meaningful Use for the previous 90 days starting in January 2011. I spoke with and at the very minimum e-mailed Deidre daily. She was constantly available and monitored my progress remotely paying close attention to every detail of my utilization of CareTracker. I realized if there is not constant monitoring and you are not meeting a core set objective or menu set objective, it may not be recognized in a timely manner. Several hundred patient visits could go by prior to this being flagged. Certainly, this could negatively impact the numerator and denominator numbers. These numbers are ultimately what are reported during the attestation process to CMS.
I quickly realized meeting the criteria for Meaningful Use was going to be extremely difficult for physicians as a whole. By mid-May, approximately 150 physicians had successfully attested out of roughly 660,000 physicians and surgeons in the U.S.
As I noted earlier, the Meaningful Use “dashboard” with CareTracker provides daily updates and monitors the percentages of successfully meeting the core set and menu set objectives by calculating the numerators and denominators daily. I checked our percentages on the dashboard daily and we would adjust our workflow to meet the core set and menu set objectives in which we were deficient.
By early June, my percentages were all above average and we successfully attested on the CMS website, which immediately gives an answer to the success or failure of attesting.
Meeting Meaningful Use was achievable. It required a team effort that involved my entire staff, a good implementation/training specialist, the right software and a lot of patience.
Dr. Key is in private practice at Connecticut Foot and Ankle Associates in Woodbridge, Conn. He is a Fellow of the American College of Foot and Ankle Surgeons.