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EHRs and the new health care game


Most of us have now conceded that the transformation of health care is here to stay. Yet, we aren’t entirely sure where it is taking us, or why we should play ball.

Healthcare reform, as we call the new game, is indeed here to stay. In fact, reform-type changes have been around for more than 20 years. Many professionals -media professionals included -have mistakenly confused healthcare reform with health insurance reform. As long as Obamacare was in question, we thought healthcare reform was also up for grabs. Not so, but it meant that many of us fell behind the change curve.

Some eyecare providers (ECPs) faced another dilemma: the Medicare question. Many ECPs asked, “If I don’t see many Medicare patients and my business is more refract-and-refer, am I really in the healthcare game? Do the EHR incentives even apply or matter to me?”

In every case, health reform matters for eye care. However, it is not about the stimulus money. Reform matters with or without incentive grants, regardless of either carrots or sticks.

The ECP continuum

There is an end game in healthcare reform. It is wrapped around key tenets such as portability, interoperability, and transparency. Those concepts are rolling out before our eyes under the guise of the HIPAA Omnibus Rule, new laws concerning the exchange of Protected Health Information (PHI), and the appearance of hospital-compare and physician-compare Web sites, not to mention the advent of various patient portals and big-data platforms.

What does this mean for ECPs? The following 5-step continuum helps us see the big picture, one that only begins with EHRs.

Step 1: Implement and use certified EHRs. Electronic health records are where it all starts. Health care is forsaking paper charts; electronic records are the new de facto standard. Despite their shortcomings and ongoing evolution, EHRs signal an adapt-to-survive game. If you are hanging on to paper ways, tell yourself, “no EHRs, no patients.”

Why certified EHRs? While only certified EHRs can guide you through the Meaningful Use process, the certification criteria also spell out what we may call the future survival standards, the rules of the new game. These are the capabilities you will need in order to remain relevant in the business of health care.

Step 2: Communicate electronically. EHRs are not about your handwriting; they are about the secure electronic exchange of health data. Call it exchange, call it secure messaging, or direct transport, this is portability and interoperability being fleshed out in real time. This is what Stage 2 of Meaningful Use is all about. Stage 1 was about laying a foundation of EHRs. Stage 2 is about moving beyond EHRs.

As a side note on electronic communications, patient messaging should not be confused with secure messaging. Several industry partners today offer practice-management interfaces for patient-facing marketing communications: appointment reminders, recalls, product offerings, and patient education. They may use e-mail, text-messages, or automated phone messages. Patient messaging platforms do not deal with PHI and are not subject to the HIPAA laws, nor do the vendors want them to be. Such offerings do not constitute secure messaging, which is set apart by its clinical nature.

Secure messaging integrates with EHRs and applies specifically to the transport of PHI, the most obvious form of which is the Continuity of Care Document in Stage 1 Meaningful Use, also known as a Summary of Care, or a transition/referral of care formatted to the Consolidated Clinical Document Architecture standard in Stage 2 Meaningful Use.

Step 3: Position your practice for team delivery of care. Why exchange patient data? Another big play in the new healthcare game is a move away from silos of care to team-based delivery of care, or care teams. It could be said that HMOs have tried and failed at this already, but remember that HMOs did not have the benefit of the HITECH Act or a federally-funded Nationwide Health Information Network.

One CMS Innovations pilot program worthy of your attention is the Comprehensive Primary Care Initiative (CPCI)1. The CPCI is taking the Medical Home concept into the offices of your local primary care physicians (PCPs), equipping and incentivizing them to establish care teams for the complete care-including eye care-of chronic patients. Note that most patients will quickly qualify for complete care coordination.

Inherent in positioning your practice for team-based care is a business culture transformation. A transition is needed not only for technology, but also for people. It will not suffice simply to upgrade your IT infrastructure. Work to prepare your staff as well. The work under way by TransforMED2 for the American Academy of Family Physicians is instructive, a mature model of how PCPs are converting their practices to a patient-centered medical home model.

Step 4: Acceptance on care teams. Is there any question that you need to be part of those care teams? Your eligibility to play begins with EHRs.

There is a secure communications requirement here, which some eye care EHRs have already met or will soon meet. By October 2014, Stage 2 Certification will require all EHRs to demonstrate health information exchange capability for care coordination.

Your use of EHRs that meet these and other new survival requirements  has nothing to do with whether or not you attested to Meaningful Use or received incentive grants. The standards apply to all providers with or without the stimulus money. I call these survival requirements because, without them, your business cannot survive the demands of the new healthcare game.

Step 5: Access to patients and payments. The final step in the ECP continuum is to ensure you do what it takes to retain access to your patients, and also to the reimbursements you deserve for the improved patient outcomes you help deliver.

Lest I blow a whistle too early in the game, let me re-emphasize that this is a continuum-we are looking ahead to the end of the continuum, and there is yet time to play.

Access to patients is a serious matter, of course. We must not assume, once a patient always a patient, or that nothing can happen to steal away your patients. The new game has new rules. At issue here is your technology, not your professionalism. You need the right equipment to stay connected and play the game.

As for payments, another fundamental shift is in the works, a shift away from fee-for-service toward pay-for-performance (P4P). This shift was signaled in July 2007 by the Physician Quality Reporting Initiative (PQRI), essentially a pay-for-reporting pilot program. Today, the program has evolved into the Physician Quality Reporting System (PQRS) and dovetails with the Meaningful Use requirement to report Clinical Quality Measures (CQMs).

CQMs, in turn, are the stuff of registries that collect and curate condition-specific health data at the patient population level. One goal of registries is to enable the development of performance measures and best-practice protocols that, in turn, help improve patient outcomes. It is such advances-again, all fueled by EHRs-that will give rise to P4P reimbursement models.

Expect P4P reimbursement models to be well contested. Yet, they provide hope against a paper-based fee-for-service model that has proved incapable of recognizing and rewarding providers whose care is exemplary. Mediocre, duplicate, and even fraudulent care have been rewarded equally. Advances in health IT will change that, improving reimbursements for those who deserve them, and improving outcomes for all patients.

Beyond EHRs

So, where are we today regarding EHRs? Across the optometry profession, we are seeing continuous adoption of EHRs. The December 2012 EHR Incentive Program report from CMS tells us that 3,934 optometrists have been paid to date, while 10,943 have been registered to date. Those are encouraging numbers, but there is also see a sizeable gap to be closed.

EHRs are Step 1. Step 2 and more take us beyond EHRs. Just as we cannot understand healthcare reform by looking only inside eye care, we cannot understand the end game of reform by focusing our gaze on EHRs. EHRs will remain a constant for providers in their day-to-day work of improving patient outcomes, but there is so much more as well.

To play or not to play?

As a profession, we must know that we belong in the healthcare game. Physicians from all walks of health care want to know what ECPs know and can contribute to the care team. As providers at the preventive end of the eye care spectrum, optometrists must embrace their unique place in providing higher quality at lower cost, another mantra and key tenet of healthcare reform. Let’s play!ODT


1.         Comprehensive Primary Care Initiative. CMS.gov. http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/index.html. Accessed May 15, 2013.

2.         Resources: Health Information Technology. TransforMED. http://www.transformed.com. Accessed May 15, 2013.



5 steps to EHR and beyond…

Meaningful Use (MU) Stage 1 was about the rise of EHRs. Stage 2 journeys beyond EHRs. This 5-step continuum outline helps show the big picture that only began with EHRs.

Step 1: Implement and use certified EHRs. Electronic records are the new standard for relevancy in the healthcare business.

Step 2: Communicate electronically. This includes the secure electronic exchange of health data.

Step 3: Position your practice for team delivery of care. Healthcare has moved to the care team model-a team-based delivery of care.

Step 4: Acceptance on care teams. You need to be part of those care teams

Step 5: Access to patients and payments. Do what it takes to retain your patients, and the reimbursements you deserve.







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