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Meaningful Use: `Yes you can!`
Some 18 months ago, industry groups and providers far and wide were quick to point out the challenges they saw in the requirements to which they'd have to attest to earn the EHR “meaningful use” incentive funds provided in the HITECH section of ARRA, the American Recovery and Reinvestment Act.
More recently, however, a growing number of providers have become more optimistic, says Amy Machtay, a HIMSS certified professional in health information management, or CPHIMS. A consultant with Boughton and Orndorf Consultants (Orange Beach, Fla.), Machtay visits behavioral health organizations to conduct “readiness assessments” that get them started on the path toward meeting meaningful use requirements.
For providers who still utilize paper-based systems-still a sizable number-Machtay's engagement often starts with an earlier step-fact-finding that helps an organization to evaluate and select a certified EHR. For those who already have and use EHRs (typically these are “non certified” and therefore in need of upgrade or replacement), she says that the readiness assessment can begin immediately.
Oklahoma-based Grand Lakes is first CMHC to get EHR incentive funds
Grand Lake Mental Health, Inc. (Nowata, Okla.) serves behavioral health needs in seven counties of northeastern Oklahoma, with regional offices supported by an administrative center. About 10 years ago, Grand Lake adopted an electronic health records system, trained up its staff, and has made numerous expansions and changes along the way.
Because of that experience, Grand Lake's CIO, Steve LaFleur, felt optimistic about the organization's prospects for earning EHR “meaningful use” incentive funds as soon as he heard the details of Oklahoma's program last fall.
“We learned from a representative of the state that Oklahoma would be ready to begin the EHR incentive program and disburse funds in January 2011,” he recalls. In fact, Oklahoma has been a leader in implementing health information technology initiatives. It was one of the first states to win CMS approval for its state EHR incentives program and is the recipient of a $50 million grant to develop health information exchange (HIE) technology that could be shared with other states.
Once LaFleur reviewed the requirements for the Medicaid EHR incentive program, he knew Grand Lake could do it. Qualifying for the first year's incentive-which provides one-third of the total incentive offered-required Grand Lake to certify its “eligible providers” and “adopt, implement, or upgrade” to a certified EHR software package.
Because Grand Lake already used an EHR system, qualifying its eligible providers-two psychiatrists and a nurse practitioner-was straightforward. The state required that Grand Lake submit 90 days of records to demonstrate that a minimum of 30 percent of provider encounters were taking place with Medicaid patients.
With provider eligibility established, “all that was really needed [for first-year eligibility] was a promise that we would implement and begin using a certified record,” he says. After learning from The Echo Group that it expected to complete product certification in early 2011 for its product (Clinician's Desktop, version 8.13), he “communicated a number of times with the state to make sure that we were doing things right.”
“Once Echo got their software certified in February, we were ready to go,” says LaFleur, who sent in Grand Lake's application in on April 1. “Right now, we're on version 8.0 of Clinician's Desktop and we'll upgrade to version 8.13-the certified version-just as soon as we've tested all the pieces according to our local configuration. We're required to be using it by yearend,” he says, noting that they expect to be up and running this summer.
To qualify for second-year incentive funds totaling $8,500 per eligible provider, Grand Lake is now obligated to attest that, for any 90-day period of 2012, it meets 10 “core” and 5 “optional” meaningful use measures, as well as any quality improvement measures required by Medicaid or the state of Oklahoma program.
The prompt arrival of the first year's incentive payment the week of April 18 came as a pleasant surprise to LaFleur and the Grand Lake team. “Last week, our billing department saw that our doctors' deposits were much higher than usual. But when I saw the amounts, I told them, ‘I know what that is.’ The state funneled the EHR incentives into the flow of the other payments for our Medicaid services.”
In all, Grand Lake's three providers were paid incentives of $21,250 each, bringing their total first year EHR incentive to $63,750. By meeting meaningful use requirements for five more years, these eligible provider incentives will total the maximum of $63,750 each, or $191,250 in all. The incentives are initially paid to the providers, who then use an agreement to transfer the funds to the CMHC.
So, a natural question: What is Grand Lakes going to do with the money? LaFleur notes that a lot of the meaningful use requirements revolve around medical and physical health components. And, while he says that “we haven't yet chosen our core/optional measures, we're excited about bringing in the medical side to our facilities, so our clients can have both medical and behavioral health needs met.” He adds that Grand Lakes is looking at options to expand integration with federally qualified health centers, as well as facility redesigns that would add medical examination rooms.
“These funds will be used to make sure our infrastructure can handle the transition. We must adapt our health record to integrate with our treatment plans and ensure that initial client assessments cover both behavioral health and medical needs,” he says. The goal is for psychiatrists and primary care doctors to access and share the same record, inclusive of labs, test results, vital signs, weight, disease information, treatment planning, progress notes, and all the rest-without duplication and in real time.
LaFleur says that Grand Lake physicians and clinicians already are major users of telemedicine, through which they make 1,000 client visits per month. When it is necessary for therapists or case managers to provide in-home planning, therapy, or other services, he says that a “traveling” function in the EHR system enables them to complete concurrent documentation-including plan revisions, progress and treatment plan notes-with a “mini version” of the patient record, then “synch up” these additions with the full patient record immediately upon their return to the office.
Meaningful use measures “make sense”
“Every time I visit a provider, there are one or two individuals who've looked into the HITECH legislation who know something about it, as well as others who aren't at all familiar with the measures. But once we start walking through it, understanding the intent, the eligibility requirements, and the meaningful use measures, they begin to say, ‘hey, this makes sense’,” says Machtay. At a recent meeting, she says that a CMHC medical director spoke up and said, “Am I missing something? Aren't we already doing this for every patient? If we're not, then we should be.”
While Machtay acknowledges that “there was early pushback about the [meaningful use] thresholds being high, the feedback I'm getting lately is that organizations find this very useful, very practical.” This, she says, is a product of the process used to develop them. “Dr. Blumenthal [the recently retired head of ONC] and his team get very high marks. The acceptance of Meaningful Use measures reflects the wide participation of physicians, the medical industry, and other professionals who were involved.”
“Many organizations say that once they go through the measures, and see their value, it's not about the incentives anymore. It becomes a valuable tool to improve quality. I hear that over and over again,” she says. Then, she recalls a recent HIMSS meeting, when a CIO said, “The money is not the driver here. I didn't have kids just to get the tax deduction.”
Assessments create a starting point
For any provider organization, the road to meaningful use begins with a benchmarking exercise that compares its current processes and outputs to those required for meaningful use attestation. The assessment process that she employs typically starts with a one-day meeting that reviews the purpose and intent of ARRA's HITECH provisions, the nature and qualification requirements for incentives, and the elements of Stage 1 meaningful use. This is the meeting “where the lights come on,” as providers “recognize the practical value of the MU measures and see the alignment with their organization's care and quality objectives,” she explains, noting that most elect to go forward with the next step-the readiness assessment.
Meaningful Use Core Measures: To meet Stage 1 Meaningful Use criteria, all providers must attest to (or meet exclusion criteria for) 15 “core” measures. According to readiness assessments provided by Boughtin and Orndoff Consulting, behavioral health providers who already use EHR systems in their organizations meet about 45 percent of the 15 core measure requirements, on average. Scoring ranges from zero (no familiarity with the requirement) to seven (meet the requirement or meet exclusion criteria).
Meaningful Use Menu-Set Measures: Stage 1 also requires that providers select, then attest to meaningfully using, five out of ten “Menu Set” measures, including one “public-health” related measure. According to readiness assessments provided by Boughtin and Orndorf, behavioral health providers who already use EHR systems in their organizations meet about 55 percent of the ten Stage 1 menu set measures, on average. Scoring ranges from zero (no familiarity with the requirement) to seven (meet the requirement or meet exclusion criteria).
The Boughton and Orndorf assessment begins with a simple question: Does the organization currently use any form of electronic records system? Machtay notes that “providers whose processes are more paper-based often ask for help in assessing EHR vendors. They know that they're not capturing data, and therefore wouldn't have meaningful benchmark assessment scores.”
With providers like these, Machtay takes a different approach. “I help them to align the accomplishment of meaningful use requirements with the implementation process for the EHR software that they select.” The resulting process then feels a lot more like a typical EHR implementation, even as it blends process-conversion and system implementation steps vital to delivery of a working EHR system with process and system training steps that incorporate Meaningful Use requirements.
“In some ways, it may be easier for those organizations with paper-based systems to ‘learn from scratch’ how to implement an EHR and achieve Meaningful Use than for those who have to modify or upgrade existing, but non-certified EHRs, along with internal processes, to meet MU requirements,” she says.
Providers with EHRs are already “halfway home”
For providers who already have an EHR, an assessment may offer very good news. Machtay says that Boughton and Orndorf assessments begin with a two-day visit, during which the consultant examines provider policies, work processes, system capabilities, and outputs with the help of knowledgeable staff. This examination becomes the basis for a detailed assessment report that is delivered several weeks later. Typically, an assessment includes a range of departments and staff functions:
C-level management
Medical (MD and Nurse Practitioners)
Clinical staff (Psychologists, Therapists)
IT
Compliance
Operations
Finance
Administrative
Intake/Front Desk
Human Resources
Medical Records
Of course, each assessment covers all of the 15 “core” set and 10 “menu” set measures, as well as selected clinical quality measures included with the requirements for meaningful use. Machtay says that Boughtin and Orndorf assessment results show that behavioral health providers who already use an EHR system typically meet 45 percent of Core Measures (see figure 1) and 55 percent of MU Menu measures (see figure 2).
Machtay says that presentation of assessment findings, generally done in a one-day meeting with the provider, identifies MU measures where the organization needs work. Common weak spots involve:
Electronic exchange of data, especially with regard to meeting security and privacy protections.
Understanding and implementing Clinical Decision Support, a concept that currently is more widely understood and embraced in medicine than in behavioral health.
Development and delivery of patient health records (PHRs) through web-based “portals,” another comparatively new concept.
Development of “patient clinical summaries”-brief printed reports made available to the patient following an appointment that summarize current findings.
Another, nearly universal weak spot involves the use of Computerized Physician Order Entry, a practice that Machtay believes to be the most challenging of the entire meaningful use process-not just for behavioral health, but for all of medicine. “That,” she says, “is the one that most organizations save for last.”
Gap analysis drives two-year MU plan
After presenting the assessment findings, the meeting continues with a “gap analysis” discussion. Machtay says this discussion “identifies the practical elements needed to support a meaningful use effort.” The analysis uncovers needs including elements of computer hardware or software, missing operational processes or procedures, and needed changes in organizational workflows.
The final step in the readiness assessment involves development of a Meaningful Use action plan. According to Machtay, this management-level plan:
Establishes leadership for the effort.
Appoints a “subject matter expert” responsible for following MU developments, resolving questions, getting needed clarifications from CMS, etc.
Enumerates and formalizes procedures, policies, phases, and projects essential for:
meeting the adopt-implement or upgrade (AIU) requirements in year one of the Medicaid EHR incentive program
meeting attestation requirements for meaningful use for a 90-day period in year two.
Develops a format for tracking and monitoring progress in meeting the organization's MU requirements over a two-year period and includes methods for identifying and resolving implementation challenges.
Behavioral Healthcare 2011 May-June;31(4):64-69
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