Brenda asked:
As a private OT clinic that does not contract with medicare/ medicaid, are we required to use electronic medical records? We do submit claims to private insurance companies electronically.

Answer:
The short answer is no.

In fact, NO ONE is REQUIRED to use EMR whether they take Medicare or Medicaid. However, if you take Medicare or Medicaid, then you have to be a “meaningful use” of a “certified EHR” in order to: 1. Get the EHR Incentive money and 2. Avoid the government penalties for not being a meaningful user of an EHR.

Some might argue that the work to show meaningful use is not worth the effort compared to the incentive money you receive. Plus, the penalties for not using an EHR are not that big of an issue (see this post on the EMR penalties ) Although, there are plenty of people arguing on the other side. For example, Meaningful Use is relatively easy (at least in Stage 1) and the penalties are going to be a major issue for their clinic since they have such a large Medicare or Medicaid population.

Then, there are the doctors that are leaving Medicare and Medicaid behind completely (see this doctor as an example). The argument here is that Medicare and Medicaid are the lowest paying payers out there and now they’re going to penalize them even more so they might as well just stop taking them. We’ll see how many adopt this strategy.

One word of Caution…
There’s a possibility that insurance companies will hop on board the requirement of an EHR and Meaningful Use (see this post about private insurance and meaningful use ). I’m sure they’re keeping a keen eye on how well it goes for the government before making any decisions. My gut feeling is still that they won’t wholesale take the governments approach to EHR and meaningful use. Instead, they may require some sort of electronic documentation or reporting requirements which are more easily performed with an EMR. Essentially it will be an extension of their requirement to have claims submitted electronically.

Despite the myth that EMR is a requirement, so far no one can require you to use an EMR. They can only provide incentives and penalties if you don’t (which only the government has done to this point). Although, there’s always the aspirational goal that Bush and Obama have made of Full EHR by 2014.

The longer answer is…EMR is not a Requirement….yet?

Be sure to check out all the EMR Stimulus Questions and Answers posts.

In a recent article at Physicians Practice, James O/’Connor, MD describes well the current EHR climate:

Physicians’ responses are all over the map. A surprising number of our colleagues still don’t know about meaningful use. Some doctors plan to ignore it altogether. (It appears that the fewer the number of years to retirement, the greater the apathy towards meaningful use.) Some practices are optimistically and enthusiastically making plans. Others are revealing their ambivalence, wrestling with the question “should we or shouldn’t we?”

I whole-heartedly support the adoption of electronic health records. I was an early adopter in my own practice and have spent a good deal of time in the industry. I am aware that the majority of my colleagues remain resistant to EHRs.
…
Nonetheless, the pros and cons of meaningful use are not really the problem. The problem is that, once again, we physicians are subject to a mandate over which we have little control and no choice whether to comply. Is this surprising to you?

He then goes on to make the case for why doctors really don’t have much choice but to comply with meaningful use of an EMR system. His reasons are essentially:
1. HITECH EHR penalties
2. Major Insurer adoption of meaningful use
3. ABMS Maintenance of Certification program adoption of meaningful use
4. Board Certification meaningful use requirement

We’ve talked about pretty much all of these reasons in the past on EMR and HIPAA.

1. The EMR Stimulus Medicare penalties don’t amount to a whole lot.
2. I think major insurance companies are in wait and see mode for commercial insurance adoption of meaningful use. They definitely want more data, but I think they’re not sure meaningful use is going to give them that data.
3. I don’t know much about ABMS and how that works for cash only doctors. Maybe someone can tell me why this matters in the comments. I guess you need this certification to practice medicine on a cash basis?
4. I thought I wrote about this before, but I can’t find the article. I guess it’s possible. Isn’t board certification done on a state by state level? I must admit that it just seems weird that to practice medicine you somehow would have to show meaningful use of an EHR. What about recent grads? I don’t know, this just doesn’t make much sense to me.

Dr. O’Connor describes the choice as follows:

OK, so technically, we do have a choice. We could stop taking Medicare and Medicaid patients, accept cash only, give up our board certification (and thus usually hospital privileges), and move to a state (or country) that doesn’t impose EHR requirements. But is that really a choice? No.

He does then encourage active participation in the discussions of meaningful use so that you can affect it for good. I agree this is a good thing and an important act. I believe Meaningful Use stage 2 will be greatly impacted by 1. public comment and 2. experience in meaningful use stage 1. It’s important that doctors are part of this conversation or I think they’re going to be unhappy with MU stage 2.

I recently got an email from someone who told of a practice manager that was concerned with the insurance companies demeanor when it came to EMR. Here’s a short description of their concern:

He [A practice manager] mentioned he’s noticed and heard from many physician colleagues that the insurance payers really seem to be getting more of a caustic demeanor and approach with their subscribers. In particular, they don’t seem to care that an EMR is being used. If anything, they seem to challenge the notes saying the physicians are just using a template and not doing what they say. My caller wanted to know if we were seeing more of this. I think some payers are changing demeanor in preparation for upcoming cuts due to health reform.

This type of reaction is something to definitely be concerned about. Back in Feburary of this year I posted about the difference in an EMR that does Documentation by Exception versus Documentation by Veracity. In that post, Matt Chase from Medtuity does a great job describing the difference in documentation methods.

It’s really kind of interesting to see that the insurance companies becoming caustic towards this template based EMR notes that basically post a bunch of junk in the note that may or may not have been done. I don’t know a single doctor who likes those types of notes. In fact, most people hate them. Well, I guess I have seen many doctors who liked this type of note because it allowed them to bill the insurance companies at a higher level than they were documenting previously.

As I write that last line, I guess it’s no wonder that the insurance companies are kicking against this type of documentation. Especially since they’re always looking for ways to save money. Although this spells trouble for many of the large EMR vendors that are designed to document using this type of method.

I guess we can give credit to the insurance payers for something if they can help to end the long, useless, hard to read, templated based notes that are just designed for reimbursement and not better patient care.