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If you’re not storing your patient data in electronic health records, your reimbursements are going to be reduced in the coming era of “outcomes-based” health care . . . and it could even impact how you treat your patients.

We bank, shop and communicate online, but even though the U.S. government has spent billions encouraging the electronic storage and sharing of patient information, we’re still slow to adopt maintaining our health information online. That’s changing as health care evolves from fee-for-service to outcomes-based, and any eyecare professionals not “meaningfully using” electronic health records (EHRs) are sure to see their reimbursements reduced starting in 2015.

In the new emerging world of health care, as it converts from pay-for-performance to outcomes-based, optometrists, like all health care professionals, will be paid on the quality of their care, not on how many times they perform a particular service. Practitioners and the care their patients receive will be measured, and their reimbursements will be adjusted up or down accordingly, both by government programs as well as by managed vision care companies.

While financial incentives have been extremely effective in encouraging optometrists to use EHRs, it’s important that they know what the ultimate end game is and that EHRs are just the beginning.

EHRs are intended to be the foundation upon which the architecture of patient-centered and value-based health care delivery is being built. It is on this foundation that the changes coming in health care reimbursement will be constructed, and even though some plans are still being drawn and re-drawn, construction continues on the new health care model as changes in reimbursements influence the evolution of health care in general and eyecare specifically.

In addition to taking the first step of digitally storing patient data in EHRs, the conversion from fee-for-service to outcomes-based care will also require that all health care participants be capable of electronically exchanging information and using the information that has been exchanged. This is known as “interoperability.” Two ways to achieve interoperability are with Health Information Exchanges (HIEs) and Registries.

Brett M. Paepke, OD, of First View Eye Care Associates in Plattsburgh, N.Y., who has successfully implemented RevolutionEHR’s software, explained what optometrists need to know and why: “Data sharing, developing a better understanding of outcomes and, in turn, improving care is at the core of Meaningful Use, HIEs, and Registries. Since the dawn of Meaningful Use, many providers have bemoaned the perceived need to ‘jump through hoops’ to participate, but in many cases, providers haven’t been shown why they are required to document their care in certain ways. Data sharing is the ‘why.’ Meaningful Use ensures that the data will be in a standardized format that can be effectively and efficiently utilized by other providers.”

After health care providers have successfully implemented EHRs, the digital patient information they store can then be shared automatically and electronically through HIEs, which enable other authorized caregivers to access that information. Patient information from EHRs can also be automatically and electronically shared with Registries, where it will be aggregated with other similar patient information to determine best practices for particular conditions.

“Both HIEs and Registries are in existence now and serve different purposes,” explained Paepke. “HIEs serve the primary purpose of facilitating data exchange between providers. Registries can be thought of as ongoing studies of specific conditions or groups of conditions within a specialty. As an example, an HIE might allow eyecare providers to share medical record data to assist in the coordination of care of a glaucoma patient. On the other hand, a Registry might collect data on glaucoma management that allows providers to compare their data to benchmarks and assist in reporting data for pay-for-performance programs.”

Rewards and Penalties
Payers are using both the carrot and the stick to encourage practitioners to first adopt the use of EHRs and then eventually integrate with Registries and HIEs to facilitate greater coordination of care and improve the quality of patient outcomes. Among the carrots being used are payments from the Centers for Medicare and Medicaid Services (CMS) to providers who have attested to the Meaningful Use of EHRs. Eligible optometrists who have attested to Meaningful Use have received in aggregate over $260 million in incentives from CMS (see "Thousands of ODs Have Received Incentive Payments for Using EHRs").

Any practitioners who have not already begun the process of attesting to Meaningful Use are out of time to receive incentives. Now, penalties will begin to be implemented for those not using EHRs. Beginning in 2015, one of the sticks designed to discourage practitioners from continuing to practice without the use of EHRs will go into effect. Optometrists who have not attested to the Meaningful Use of EHRs by 2015, will be subject to penalties. Payment reductions begin in 2015 for providers who are eligible but choose not to participate.

“It’s coming, and it’s coming fast,” said Steve Baker, president of technology provider, Eyefinity, referring to payment reductions coming as a result of not implementing the Meaningful Use of EHRs. “Those who waited until 2015 to begin attesting to Meaningful Use no longer have access to the incentives that were made available to those who attested to Meaningful Use starting in 2011.”

Optometrists who have not successfully demonstrated Meaningful Use of certified EHR technology will be subject to payment adjustments of their Medicare reimbursement, starting with a 1 percent reduction in 2015, two percent in 2016, and 3 percent in 2017 and each subsequent year, unless it is determined that for 2018 and subsequent years that less than 75 percent of eligible providers are meaningful users, in which case the payment adjustment will change by one percentage point each year until the payment adjustment reaches 95 percent.

The Stages of Meaningful Use
Meaningful Use is being rolled out in stages, with Stage 1 requiring that providers store and share patient data, Stage 2 working toward advancing clinical processes, with the ultimate goal of improved patient outcomes expected to be achieved in Stage 3 (see graphic, below). Stages 1 and 2 have already been defined (see “Comparing and Understanding the Stages of Meaningful Use”), while the requirements of Stage 3 have yet to be released.

To meet these requirements, HIEs were created to facilitate the exchange of patient data among caregivers, and Registries can be instrumental in advancing clinical processes to help practitioners’ quality reporting requirements while working toward the ultimate goal of improved patient outcomes

Meaningful Use of electronic health records begins with Stage 1, in which patient data must be stored and shared electronically, and continues through Stage 2’s advanced clinical processes to reach improved patient outcomes in Stage 3.
This is not to say that Meaningful Use, like health care reform itself, has not been without controversy. Some providers see using EHRs as coming between the doctor and the patient by requiring that the caregiver spend more time entering data instead of communicating with the patient. There is also the concern of data breaches. Just last month, over 30 medical societies, led by the American Medical Association, sent a letter urging federal regulators to make major changes to the EHR Meaningful Use program.

This was followed by CMS indicating a potential willingness to make it easier to adhere to Meaningful Use by shortening of 2015 reporting requirements in a proposed new rule expected by spring 2015.

In a Jan. 29, 2015, blog post, Patrick Conway, MD, chief medical officer at CMS, said “Since the first year of the EHR Incentive Programs in 2011, the United States has seen unprecedented growth in the adoption and Meaningful Use of EHRs. To date, more than 400,000 eligible providers have joined the ranks of hospitals and professionals that have adopted or are meaningfully using EHRs. This means that millions of patients across the nation are benefiting from the potential of better coordinated care among professionals, more accurate prescribing, and improved communication. The new rule, expected this spring, would be intended to be responsive to provider concerns about software implementation, information exchange readiness, and other related concerns in 2015.”

Still, while at times delayed and subject to controversy, the EHR Meaningful Use program continues, as health care moves closer and closer toward the universal electronic storage and sharing of patient data.

“After going from paper to electronic, the big change now is going from electronic to standardized,” said Eduardo Martinez, development manager of software provider, MyVision Express, referring to the next step in the transition in which data will be exchanged using a standardized language that enables disparate EHRs to communicate.

Quality Counts
Other carrots being used to encourage the Meaningful Use of EHRs include increased payments for those practitioners who can show that they are improving the quality of patient care by coordinating with other caregivers. For example, the Physician Quality Reporting System (PQRS) provides an incentive payment to practices that satisfactorily report data on quality measures.

PQRS also includes a stick to discourage bad quality care. Beginning in 2015, the program applies a negative payment adjustment to eligible providers who do not satisfactorily report data on quality measures for covered professional services. In some cases, reporting the necessary PQRS data can be achieved by participating in Registries that aggregate thousands or millions of pieces of patient data to determine which diagnostic devices and treatment procedures achieve the best results.

While it will take time to build a fully interoperable infrastructure of coordinated care and communication across health care providers, patients, and public health entities that improves health care quality, lowers health care costs, and improves population health, the impact has begun with millions of incentive dollars already paid to practitioners and reimbursement penalties on the horizon.