Some physicians—most notably, surgeons and pain-management specialists—have expressed concern that they will be unfairly subject to the 2012 ePrescribing penalties, based on the fact that their opportunities to ePrescribe are limited by the nature of their practices. The Proposed ePrescribing Rule published in the Federal Register on June 1 offers a potential remedy for these providers.

 The rule, which amends the (MIPPA) 2011 ePrescribing rule, affords providers several new arguments they can use to request a “hardship exemption” from the 2012 penalties. (These are in addition to the already existing reasons, i.e., rural areas that lack high speed internet access and/or rural areas that lack pharmacies that accept ePrescriptions.) The new justifications include:

      1)   Inability to ePrescribe due to local, State, or Federal law, (i.e., providers who predominantly prescribe controlled substances).

      2)   Inability to count the ePrescriptions towards the Medicare incentive program, (i.e., providers who predominantly prescribe post-surgery—visits that are not included in the specified CPT denominator codes.

How does this relate to Meaningful Use Monday? The rule also reconciles the EHR (meaningful use) incentives and the Medicare ePrescribing incentives to some extent, in an attempt to harmonize the differing ePrescribing requirements and eliminate duplicate work for providers. (See “Meaningful Use, ePrescribing, and PQRS: Need for Harmonization” and “Meaningful Use Measures: ePrescribing.”) The Proposed Rule accomplishes this through two provisions:

      1)   Providers who successfully demonstrate meaningful use in 2011, which includes ePrescribing, would be exempt from the 2012 ePrescribing penalties. (Note, however, that these providers will be trading the 1% 2011 ePrescribing bonus for avoidance of the 1% 2012 penalty.)

      2)   ePrescribing software that is ONC-certified would be deemed also certified for the purpose of the Medicare ePrescribing program.

If you’d like to submit a comment to CMS on this proposed rule (file code CMS-3248-P), you can do so by July 25.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

You know on the weekends I love to through in a little round up of some interesting things said about healthcare IT, EMR and other topics on Twitter. Hopefully, they’ll educate, entertain and inform. If not, tomorrow’s another edition of Meaningful Use Monday.

T2: I used to read 4 newsletters, now I don’t. I’ve chg’d to read tweets & blog post – so much more current. #hcsm

April 24, 2011 6:26 pm via TweetDeckReplyRetweetFavorite

@Colin_Hung

Colin Hung

I’ve been talking about this quite a bit lately on this blog (see my post about social media EMR information). However, I love how the described their shift from newsletters to tweets and blog posts since they’re more current. I obviously agree. Although, if you subscribe to the EMR and HIPAA email you can enjoy the convenience of an email newsletter with the current info of a blog.

Rock Health Launches –The First Seed Accelerator to Promote Interactive Health http://dlvr.it/PZc58

April 24, 2011 12:37 pm via dlvr.itReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

I saw this announcement a while ago. I’m really excited to see what Rock Health is able to do. They definitely have a number of big names. I wish that I was some way involved with them since I love their approach. Plus, I’m really excited to have my brother, David, participating with me on the Smart Phone Healthcare website I recently launched. Mobile healthcare is a really hot area of the market and I think together we’re going to bring some interesting perspectives to the mobile area of healthcare.

E-Prescribing Incentive Program Comparison: http://bit.ly/hAjVe5 #healthit #medicare #meaningfuluse

April 23, 2011 7:22 am via webReplyRetweetFavorite

@richelmore

HealthcareTechNews

I usually hate PDF’s and a tweet in a blog post that leads to a PDF is probably even worse. Although, it has an interesting format for considering the multiple e-Prescribing incentive programs. Of course, if you’re a regular reader of the site, then you already have started ePrescribing right?

LOL! RT @WilIFerrell: Facebook is like jail, you sit around & waste time, you write on walls & you get poked by people you don’t know.

April 23, 2011 6:17 pm via webReplyRetweetFavorite

@Colin_Hung

Colin Hung

This just made me laugh and so I had to share it. Although, if you Like EMR and HIPAA on Facebook, then it will be so much better than prison. Well, maybe not much better, but it will make me smile.

To continue last Monday’s post regarding the differences between participation under Medicare and Medicaid, the Medicaid program imposes no penalties (or as Medicare euphemistically calls them, “adjustments”) for not being a successful meaningful user. Medicare adjustments are scheduled to begin in 2015. Upon discovering this discrepancy, one (somewhat devious-minded) physician suggested to me that this provided a loophole: declare as a Medicaid participant, begin participating (successfully or unsuccessfully) in 2015, and insulate yourself from any penalties. I’m sorry to report that, as creative as this strategy seemed, non-meaningful use Medicaid participants will still be subject to adjustments to their Medicare fee schedules when those penalties begin.

Two other noteworthy differences between the programs:

• The Medicare payment schedule is front-loaded, with more money available in the first years of a provider’s participation. Medicaid incentives remain constant after the first year’s $21,250 for adoption, implementation, or upgrade of an EHR.
• The Medicaid programs are run by individual states, so requirements and processes may vary somewhat from the Medicare program and from each other.

For information specific to the EHR incentives under Medicaid, the following resources are available: CMS Medicaid State Information and Medicaid FAQ.

For anyone who wants to see how much they really know about meaningful use, take the fun and educational Meaningful Use IQ Test on EMR Straight Talk.

Lynn Scheps is Vice President, Government Affairs at EMR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

Physicians who are eligible for both programs will likely find participation under Medicaid to be a preferable option because the incentives are higher, the first year rewards adoption/purchase, (without requiring demonstration of meaningful use depending on the state); and the program offers more flexibility in terms of time frames. To participate under Medicaid, a provider must have a practice that is 30% Medicaid (20% for pediatricians), based on number of patient encounters (as opposed to revenue). Some providers are only eligible under Medicaid—nurse practitioners; certified nurse-midwives; dentists; and physician assistants who practice in a Federally Qualified Health Center or rural health clinic that is led by a physician assistant.

Not all states have their EHR incentive programs ready to go yet. 14 states will launch in either January or February; others are expected later in the year.

The major differences between the Medicare and Medicaid incentive programs that providers should take into consideration when making their choice at registration include the following:

Next Monday’s post will highlight some other differences between the two programs that are interesting, but less influential.

Lynn Scheps is Vice President, Government Affairs at EMR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

In the weirdest news I’ve seen in a while, SureScripts has become an ONC-ATCB. Here’s the details from Health Data Management:

In a Dec. 23 announcement, the Office for the National Coordinator for Health IT said that Arlington, Va.-based Surescripts can verify that e-prescribing, privacy and security modules meet the standards laid out in the meaningful use requirements. Surescripts is the sixth authorizer to be approved by ONCHIT, but it’s the only one with limited certification abilities—the five others have ONCHIT’s blessing to certify Complete EHRs and EHR modules.

Doesn’t this scream conflict of interest? They run a nationwide e-Prescribing network, and yet they can certify ePrescribing for ONC. I guess you could make the argument that they know ePrescribing well and so they are qualified to do it. Although, it is just weird and awkward to consider them as an ATCB. I wonder which ePrescribing companies will actually use them. Why did SureScripts even go to the effort to become an ATCB?

One of the challenges of this blog is writing content that will be interesting and useful to a wide variety of readers. At times I think I assume that those visiting EMR and HIPAA have read my 770 previous posts and should have a good understanding about the EMR world.

Of course, the reality is that many of the people visiting this site might only read a couple different posts. Even more significant is that they might only have a remedial understanding of EMR and in particular the EMR stimulus money. This leaves me with the challenge of keeping the long time readers interested and benefiting from the content I create while still helping the EMR newbies understand what they need to know.

In that vein, here’s some questions that I got in an email about meaningful use and the EMR stimulus. Those of you well versed in the EMR stimulus can go and enjoy EMR and EHR or add some content to the EMR wiki while I do what I can to answer.

Are there governing bodies that have been set up to “certify” EMR/EHR software vendors?
Not yet. The government hasn’t recognized any bodies that will certify EMR/EHR per the ARRA requirements. They’ve published some guidelines and rules for those bodies, but HHS has yet to recognize any of them as official ARRA EMR Stimulus certifying bodies. I expect by end of summer we’ll have a couple to choose from. The Drummond Group and CCHIT are both planning to be EHR certifying bodies, but neither has been officially recognized yet.

Do EMR/EHR software vendors have to be “certified”? If they are not “certified”, does this prevent their customers from receiving federal money?
In most cases the EMR/EHR software vendor is the one that will be certified. There has been some provisions and discussions about allowing for 2 other EHR certification options beyond just using a “fully certified EHR” software.

The first is that you could use a combination of certified software vendors. For example, you might use one certified EMR vendor for everything but ePrescribing and then you’ll choose another software vendor who is only certified for the ePrescribing portion. It seems that this type of combo certification will be allowed.

The second is what’s been called a site certification. This would essentially be where a specific site (or location) would be certified against the EHR certification criteria. This is best illustrated by a hospital or clinic which has their own home grown EMR software. This EHR site certification would allow them to certify their site and give them access to the EMR stimulus money. It’s possible that an option like this won’t be available, but from what I can tell it’s looking like it will happen.

Do you think that it is possible to satisfy the Stage 1 objectives?
This is a loaded question. The short answer is that everything is possible. Whether it’s possible or not is not as important as whether doctors will do it or not. This question is hard to answer right now. Mostly because we’re missing a lot of the practical meaningful use details which doctors need to know in order to make a decision.

My gut feeling tells me that it will go about like PQRI stimulus money. Some will get the EMR stimulus and be happy. The same number will try for it and be really disappointed by the whole process. More will say it’s just not worth my time right now. That’s not to say that many of these doctors won’t (or shouldn’t) implement an EMR. I think many of them will, but they’ll do it for the inherent benefits of EMR software and not for the EMR stimulus money.

I’m still really disturbed by the fact that we have so few practical meaningful use details. Sure, we have a lot of guidelines and a lot of prognosticators guessing at what they mean and how they’ll be measured. We even have a certifying body trying to guess what the EHR certification will be. Sadly, they’re all still guesses.

Let’s just take a simple example for a second and see some of the complexities.

Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

This certainly seems pretty straight forward. Probably about as straightforward as it comes as far as objectives. Basically, 75% of the prescriptions have to be ePrescribed using a certified EHR technology to meet the meaningful use guidelines.

Of course, the real question’s going to be around the word “permissible.” What’s considered a permissible prescription? I imagine this was added because currently you aren’t allowed to ePrescribe controlled substances. If I remember right, controlled substances make up about 15-20 percent of prescriptions. Certainly it wouldn’t be fair to include something that you’re not legally allowed to prescribe electronically in the requirements. Are there other exceptions under the “permissible” rule?

What’s going to happen once ePrescribing of controlled substances is allowed? Will doctors then be required to flip a switch and start sending controlled substance prescriptions electronically as well? Once they’re allowed, they’ll be considered permissible, no?

Let’s also not be surprised if the technology is built to do eprescribing in 2 systems (controlled vs not controlled). Of course, this adds a bit more complexity to measuring the 75% of prescriptions done electronically.

Also, does it give anyone else a bit of angst that the EHR software is basically going to spit out a report saying, “Yes, I ePrescribed 75% of my prescriptions.” I’m not sure how you scale a more sophisticated solution, but just taking some report from an EHR seems plenty gameable to me.

Will ONC be going around and doing some audits of the submissions to ensure that the data was actually good and not messed with? Can you imagine the challenge of having to audit some 300+ EMR vendors. Good luck with that.

I also love how the ePrescribing has to be done with a certified EHR system. A part of me really feels for those specialists that only write a few prescriptions a week. They get to learn the fun thing we call ePrescribing and they forget what they learned by the next time they have to ePrescribe.

UPDATE: Thanks to Russ in the comments, he pointed out the issue of calculating a percentage when your EMR won’t know if you just handed them a paper prescription instead of ePrescribing. I guess the criteria assumes they’re going to order the script and then print it out instead of sending it electronically? So, maybe the criteria should say 75% of scripts ordered in the EMR sent electronically. Just makes me laugh to think about it.

Lest ye think paper scripts don’t happen with an EMR, we can at least argue for them happening during EMR downtime (or printer or workstation or internet or…downtime). Although, they happen other times as well. How will an EMR calculate that percentage of prescriptions? Are they going to translate the freetext note that was entered into the EMR about the paper script that was given? Ideally the doctors will just enter in the script after the fact, but that’s not always the case.

I’m sure I’m missing other intricacies. My point is that there’s still a lot of unanswered questions around meaningful use. It would be nice to get some answers. It would be nice if ONC had a way to get and provide practical answers. You’d think they’d want that type of interaction as well.

I’ve been wanting to write about ePrescribing controlled substances since 9/13/09. In fact, I even did write post about the FDA approving a pilot to do electronic prescribing of controlled substances which I posted on that day. Turns out, it was a press release that was sent to me prematurely, so I hid it from view.

Well, a couple weeks ago, the Drug Enforcement Administration (DEA) released it’s interim final rule on ePrescribing of controlled substances (PDF). John Halamka described some of the most important details of this rule on his blog:

(a) To sign a controlled substance prescription, the electronic prescription application must require the practitioner to authenticate to the application using an authentication protocol that uses two of the following three factors:
(1) Something only the practitioner knows, such as a password or response to a challenge question.
(2) Something the practitioner is, biometric data such as a fingerprint or iris scan.
(3) Something the practitioner has, a device (hard token) separate from the computer to which the practitioner is gaining access.
(b) If one factor is a hard token, it must be separate from the computer to which it is gaining access and must meet at least the criteria of FIPS 140-2 Security Level 1, as incorporated by reference in § 1311.08, for cryptographic modules or one-time-password devices.
(c) If one factor is a biometric, the biometric subsystem must comply with the requirements of § 1311.116.

Halamka also suggests they’ll consider 3 approaches to support strong authentication:
*Fingerprints (Bio-Key software?)
*Hard Tokens (such as those provided by RSA)
*Cell Phones (As Gemalto talked about in this video)

I also recently heard someone tell me that the banking has a 6 percent failure rate for matching people. It’s hard for me to believe that it’s high and that the banking industry is willing to deal with that type of failure rate. Of course, that’s not good enough for controlled substances. So, they’re going to have to find some way to lower the patient matching failure rate. Although, I wonder what the failure rate is with the current model. Seems like electronic prescribing shouldn’t make it any worse than it currently is.

Many people are sitting their on the proverbial fence waiting to see what’s going to happen with the HITECH act and meaningful use before they actually go and implement an EMR. Now, I’m not going to let those people off the hook from evaluating and selecting an EMR. That should be done anyway. However, lately I’ve been thinking that many of these clinics shouldn’t be waiting to implement technology in their offices. Sure, EMR is a game changer and a major change for any office and has tremendous upside (regardless of stimulus money). However, for those of you in the wait for HITECH act money camp, there are still a number of IT projects that you can implement today that will benefit you once you actually implement an EMR. Here’s just a few of them:

Fax Server – This is a HUGE game changer for those that have an EMR. The medical world still revolves around the fax machine and will for a long time to come. Implementing a fax server in your office is a great first step to prepare your office for an EMR. Plus, it can save a lot of paper. For example, you can just delete all those “spam” faxes that you get. Fax servers are great and by having it installed and your users trained on how to use it so that when you implement your EMR you can just directly upload your faxes into your EMR without ever printing out the fax.

IM (Instant Messaging) – I’m amazed at how useful our clinic has found IM to be in our office. It’s a great way for the nurses to communicate with the clinicians, the clinical people with the front desk and the nurses with each other. You do have to manage when to IM versus a phone call versus an email (or secure EMR message once you have an EMR), but there’s sometimes that an IM is a perfect way to communicate in a clinic.

Shared Drives – Setting up a shared drive for your office is simple to do and can save a lot of time. I’m surprised how many offices don’t use this. It’s not the best thing for patient data, but there are hundreds of other office uses for a shared drive to prove beneficial. Ideally this would be setup on active directory, but even if you just manually map a shared drive it can work well in a clinic.

IT Infrastructure – Good IT companies will come and do an analysis of your current IT setup for free. They’ll also give you an idea of what things you could do now that will prepare you for your EMR implementation. Plus, even if you don’t do some of the things until you get closer to implementing an EMR, it’s good to know the weaknesses in your IT infrastructure early so that you can make that part of your plans.

Those are just a few examples. I’m sure some will also mention ePrescribing on this list. I’m not totally sold on that idea, but would love to hear people who disagree. What other technologies can clinics implement now regardless of their EMR purchase?

ePrescribing seems like the in vogue thing to do these days. It’s part of the proposed meaningful use matrix and so no doubt we’re going to hear a lot more about it (and we should). However, ePrescribing isn’t without its challenges. A little while ago I put the question to you my readers about the challenges associated with ePrescribing. The following are a couple of the responses that I received from people about their experience with ePrescribing.

Doctor’s advocate that I am, I’ll start off with a doctor’s experience…
E-Rx has been one of the best additions to our EHR. We have reduced paper use significantly, and rarely have problems with transmission. The problems mainly relate to the extra work of entering which pharmacy the patient ants to use.

Overall, e-rx has been a very positive experience – saving time, paper and money. Our e-rx with Dr. First integrates fully into the EHR making the documentation seamless.

From someone who use to work for an ePrescribing company…
(1) There was a saying “Free is not cheap enough” i.e. even if you give away the service, many, if not most doctors are not interested in it, because of the time and effort to implement e-prescribing (HW, networks, training etc). The MIPPA incentives definitely helped, but many doctors still felt that they were insubstantial compared to the cost (mostly their time) that they would have to invest in this.

I agree with you that e-prescribing is an area where there is almost universal agreement that this is a service that is much better than the traditional paper and pen method. All the doctors I have spoken to agree on this. Over time, it will become more and more popular, especially as EHRs penetrate the market. The last data I saw from SureScripts indicated that over 100,000 providers were now eprescribing, which is significantly higher than even just last year.

From the owner of an EMR company talking about integration with an ePrescribing solution and challenges associated with it…
One of the links I found on the AMA web site (several months ago) referred me to iScribe. This site is sponsored by Caremark. It has, in my opinion, a relatively simple to use interface.

Any practice can use the service and there is no need to even interface to existing EMR or practice management systems.

Some interesting information for those looking at ePrescribing. I’d love to hear more experiences in the comments.