Question

Understanding the Impact of Incentive Programs for Electronic Health Records

All System owns and operates a hospital and employs primary care physicians, general surgeons, and oncologists. The hospital purchased a surgical practice in 2012. Part of the purchase included the purchase of the electronic medical record system that was a certified EHR. In January 2014, the hospital transitioned the primary care physicians, surgeons, and the radiologist in the hospital to a new certified electronic health record, the implementation of which was completed 10 months later in October of 2014.

The EHR vendor is insisting that unless major upgrades are purchased, adopted, and fully implemented the health system could be faced with significant penalties particularly as it relates to the management of chronic disease populations, the prevention of readmissions, patient portals, and enhanced interoperability.

1. Under QPP, evaluate and determine which physician groups are qualified for which QPP plan (if any): (a) primary care practitioners, (b) emergency room physician, (c) surgeons, or (d) radiologists.

2. Describe the timeline of the program and its potential financial impact on the individual health care providers and its impact on the healthcare system?

3. Describe the process the physicians and health system must complete avoiding significant payment decreases by not complying with new MIPS and MACRA.

4. Discuss what the hospital must do to comply with the new QPP standards issued by CMS.

5. What role does interoperability have on the hospital system's ability to meet Readmission Reduction Program goals?

Answer 1

1. Primary care practitioners will be qualified for QPP because they are dealing with all kindof patients and EHR will be more lucrative for patients with chronic health problems which are dealt by them.

2. Financial impact:

• Have been developed from erroneous or incomplete design specifications;
• Be dependent on unreliable hardware or software platforms;
• Have programming errors or bugs;
• Work well in one context or organization, but be unsafe or fail in another; and
• Change how clinicians do their daily work, thus introducing new potential failure modes

impact on health care system:

o Providing accurate, up-to-date, and complete information about patients at the point of care

o Enabling quick access to patient records for more coordinated, efficient care

o Securely sharing electronic information with patients and other clinicians

o Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care

o Improving patient and provider interaction and communication, as well as health care convenience

o Enabling safer, more reliable prescribing

o Helping promote legible, complete documentation and accurate, streamlined coding and billing

o Enhancing privacy and security of patient data

o Helping providers improve productivity and work-life balance

o Enabling providers to improve efficiency and meet their business goals

o Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health

o Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity.

o Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.

o Improved efficiencies and lower health care costs by promoting preventative medicine and improved coordination of health care services, as well as by reducing waste and redundant tests.

Better clinical decision making by integrating patient information from multiple sources.

3.

New under MIPS, the three categories that require submission of data (Quality, Advancing Care Information and Clinical Practice Improvement Activities) can be submitted through a single vendor.

There will no longer be competing and confusing submission deadlines, overlapping vendors or duplication of rules.

Claims reporting for the Quality measures and attestation for Advancing Care Information is still an option. You will choose the reporting mechanism that works for you.

The Qualified Registry submission option has been the most reliable, flexible and cost-effective method for PQRS submission. The proposed changes to the rules promise to make the Qualified Registry method more attractive and effective by allowing the submission of CPIA and ACI as well as Quality.

The Group Practice Reporting Option (GPRO) that worked well for PQRS will also be available through MIPS. If you elect to report as a group in the Quality Performance Category, you will report as a group for the remaining categories

4.

1. Choose measures applicable to the practice.

2. Determine the eligible populations, per measure specifications, such as demographics and codes.

3. Verify reporting frequency, per measure specifications, and multiply it by the determined population (this is your eligible instances).

4. Divide your eligible instances by 60% to learn your minimum number of submissions to meet data completeness.

Quality Performance Category Reporting Requirements

To achieve the highest score in this category (60 points), clinicians will need to report on at least six quality measures, including at least one outcome measure or high-priority measure. Clinicians can choose from over 206 measures and must collect a full calendar year of data.

Specialty Set Measures

While providers aren’t restricted to measures listed in the specialty sets that apply to them, they may find these sets helpful when selecting measures. Ultimately, though, providers should choose measures based on how their performance compares with corresponding benchmarks. They must, though, have a 20-case minimum to submit.

Always refer to measure specifications to verify applicable measures—even for those measures within the provider’s specialty set, as not all will be applicable. If the specialty set includes less than six applicable measures, report only the applicable measures. For the selected measures, if a provider or group sees less than 20 eligible patients, only the minimum score can be earned. Also, when outcome measures don’t apply to a practice, chose another high-priority measure.

All-Cause Hospital Readmission

Practices with 16 or more providers and at least 200 eligible cases are included in the additional measure for All-Cause Hospital Readmissions. CMS will calculate this measure from claims data and will score in the same way as the other Quality measures (that have benchmarks), from 3 to 10 points.

5.

Step 1: Call the patient within two days of discharge.

The care manager calls the patient within two days of discharge and conducts a post-discharge assessment, which covers critical aspects of the patient’s discharge plan:

· Does the patient understand the condition that led to hospital admission?

· Does the patient understand newly prescribed medications—what they are for and how to take them?

· What are the dates and times of follow-up appointments—with both the primary care provider (PCP) and any new specialists?

· What are the patient’s options for transportation to and from the appointment?

· For what signs and symptoms should the patient call the PCP or 24-hour nurse line?

· If the patient is a Medicare beneficiary, has one of their healthcare professionals followed CMS face-to-face visit requirements for transitional care management billing?

Step 2: Assess the patient’s self-care capacity.

Even though visiting nurses may intermittently come to the patient’s home, the care manager must ask several questions to determine the patient’s capacity for self-care on a 24-hour basis:

· Can the patient understand and carry out the recommended treatment plan?

· Does the patient have someone to call if they need help (other than in an emergency)?

· Does the care manager have permission to speak with the patient’s caregiver? If the patient has a spouse or significant other (caregiver), ensure that this person understands the care plan, the medications, and has the capacity to care for the patient.

· Is the patient at risk for depression? If the patient is at risk for depression, ask the PCP for the most appropriate next step, be it a referral, a medication or counseling.

· Can the patient or caregiver plan meals and shop for groceries?

· Can the patient perform activities of daily living, such as showering, toileting, and transferring from a bed to a chair and a chair to a bed?

If the patient can’t care for himself or herself, and doesn’t have a caregiver at home, the care manager will suggest a home health aide (HHA) or a personal care attendant (PCA), if the patient qualifies. Each state may have different requirements.

Step 3: Frontload homecare and ensure patient ‘touches’, if appropriate.

If a patient doesn’t have a family caregiver available, lives alone, has cognitive deficits, is below functional baseline, or has been diagnosed with a new condition, maximizing patient touches during the first two weeks after admission is important. According to the Briggs study, patient touches include telephone calls from a care manager or non-clinical support staff, and initial visits from a physical therapist, occupational therapist, speech therapist, HHA, or social worker/behavioral health specialist.

The Briggs study indicates that more frequent patient touches result in improved outcomes (lower readmission rates) and improved patient self-care confidence. Ideally, the care manager performs the assessment visit (patient touch) within one day after discharge.

Frontloading is defined as four or more patient touches by a nurse, care manager, social worker, or therapist. Fewer than three visits during the first two weeks raises risk for readmission, per the Briggs findings, and a higher frequency of visits and intensity of care align with improved outcomes.

Step 4: Conduct a home safety evaluation.

The care manager requests a home safety evaluation as soon as possible. Ideally, in cases that discharge directly home rather than to a rehab facility (e.g., some total joint replacements), a home safety evaluation happens prior to discharge. In some cases, a home health agency (e.g., Visiting Nurse Association) will work with the patient, family, discharge planner, and care manager to see the home before, or on the same day as, discharge to identify fall risks (e.g., loose area rugs, clutter in common areas, and lack of shower grab bars).

Step 5: Order and install durable medical equipment prior to discharge.

The case manager from the discharging facility often arranges durable medical equipment (DME), such as a hospital bed, oxygen, CPAP machine, or nutritional supplements. The care manager then reviews the facility case manager’s orders, and collaborates with therapy and the home health agency to see what is still needed.

The care manager will communicate with the home health agency about unmet needs—raised toilet seats, commodes, walkers, etc.—prior to discharge. The home health agency can arrange select DME, such as stair lifts and specialized wheel chairs or walkers, after the initial visit. When there’s a gap between when the DME is ordered and when it is delivered, some communities have wheel chair loaner programs, and medical supply companies may be able to deliver equipment on a rental basis.

Step 6: Order an emergency alert/medication reminder system and preprogram important phone numbers on patient’s phone (e.g., PCP, family member, pharmacy, etc.).

The care manager orders an emergency alert system immediately if the patient has a history of falls, is elderly or in a weakened state, or lives alone and has a high-risk diagnosis. The most critical part of this system, however, is educating the patient on its use, and emphasizing that the device must be worn at all times, especially in the shower or bathroom. There are also medication reminder systems available for patients with memory deficits.

All patients must have important contact numbers on speed dial in their phones. Some phone systems, available through community agencies, display of photo of the contact when the patient hits the contact’s number. Ensure the patient knows how to use the speed dial function. If the patient does not have a cell phone, they can use a simple home phone with preprogrammed numbers.

Step 7: Implement fall prevention program, intervention, and education.

Although fall prevention may be included in the home safety evaluation, it warrants a separate category: falls are the primary cause of accidental deaths for people 65 and older, according to the Briggs study. Eighty-six percent of all hip fractures occur in patients 65 and older, and the National Institutes of Health (NIH) reports that an average of 21 percent of these patients die within one year of hip fracture. Findings also show that patients are five to eight times more likely to die within three months after a fracture.

Step 8: Provide in-home education on new diagnoses or unmanaged chronic conditions.

In cases of newly diagnosed or unmanaged diabetes, the care manager arranges in-home education with a certified diabetes educator (if one is available through the home health agency). For new cardiac, COPD, or cancer diagnoses, the care manager makes sure both the home health agency and the care manager review these cases. If the patient requires dietary changes, and the patient and primary care provider are agreeable, arrange a nutrition consult.

The care manager has the patient teach back the in-home care plan to ensure they understand the condition, self-care, and signs and symptoms of worsening condition, as well as when to call the PCP or 24-hour nurse line, if available. If there is a language or cognitive barrier, the teach-back method ensures the patients understand the care plan more effectively than a nod or simple verbal confirmation (e.g., “Yes, I understand.”)

Step 9: Connect the patient with community resources.

Community resources exist to help with many patient needs. A robust care management program will list community agencies that address patients’ social, religious, and cultural needs:

· Transportation programs.

· Senior center activities.

· Meals on Wheels.

· Cultural and religious centers.

· Food pantries.

· Volunteer opportunities.

· Condition-specific organizations, such as the Alzheimer’s Association and the American Cancer Society, and the Association for the Blind.

· Additional resources, if needed, such as housing, legal, and immigration services.

The care manager can collaborate with a social worker or the agency itself to arrange community resources for the patient. Some programs designate a non-clinical staff member or a community health worker to maintain a resource library. Some community resources have a representative who can visit the patient at home—an important service, as visits to high-risk patients offer more support and increase confidence in self-care and providing care for both the patient and the caregiver.

Step 10: Establish a best practice for follow-up phone calls after discharge.

There are many variations in follow-up phone calls for the first 30 days. As with patient touches, which contribute to better outcomes, follow-up phone calls are a critical part of the care plan. Many care management programs require calling patients at two, seven, fourteen, and thirty days. There are specific questions for each patient call.