Left to our own devices, far fewer doctors would have taken on the Herculean task of converting from paper to electronic records so quickly and abruptly. Such is the power of a federal mandate. As with any change that’s forced rather than voluntary, mistakes and frustrations are inevitable. But to thrive in a busier and more competitive future, we need to embrace new ideas that might set us up to be better, more productive clinicians. Electronic health records (EHRs) are at the foundation of this transformation. 

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The primary goals of EHR im-plementation include improving practice efficiency through paperless workflow, enhancing access to patient data to support clinical decision making and increasing patient compliance through education. You gain an organized office with accurate data at each workstation and support the practice’s financial health by reducing Rx remakes and transcription errors. 

Many eye care providers have already implemented or are looking to integrate EHRs into their practices. But both new EHR converts and prospective ones must be educated about common concerns when merging their software into their daily work life. From esoteric rules governing meaningful use (MU) milestones to everyday snafus, we will outline these issues and offer the most effective solutions.

Meaningful Use
The term meaningful use generates a wide array of emotions––resentment, frustration, perhaps worries about government oversight and hopefully also a bit of positive anticipation for a better future—but, in reality, MU just requires minor modifications to the way we already do things. For example, a few core requirements in Stage 1 ask providers to document things like problem lists, patient demographics, active medications and medication allergies. We all have done this from day one of our training, but the move to an EHR requires providers to become familiar with how each piece of data is added to the patient’s record. 

Stage 1 MU challenges providers because of its inability to let us see how changes we make today translates to improved patient care. It can help to think of the MU program as a “crawl-walk-run” scenario. 

Stage 1 represents the crawling phase, where data gets captured and recorded properly. If certain parts of a patient record are not documented in a specific way, it can compromise the ability to electronically exchange that data with others so it can be incorporated into the recipient’s system. 

Thus, jumping right into the exciting parts, where data gets shared among providers, would be running before you can crawl.

With that in mind, here are some of the Stage 1 objectives that tend to present bigger challenges to providers moving from paper records:

1. Clinical Summaries

The goal: More than 50% of encounters should end with the patient receiving an official doc-ument summarizing data from the visit within three days. 

The challenge: Potential change to checkout procedures required to provide patients with the summary.

T hings like active medications, medication allergies, diagnoses and associated care plans allow patients and their families to better understand the visit, as well as provide them with a document they can take to other health care providers. 

Today’s Meaningful Users know this as a document they traditionally printed out for patients, but the advent of personal health records (PHRs) and portals allow for electronic delivery by pulling the relevant data directly from the patient’s encounter in the EHR. For example, a patient can log into their PHR and generate a clinical summary of their previous visits whenever they desire. Additionally, secure messaging systems allow providers to exchange the electronic form of these documents with each other and drop medication lists, medication allergies and diagnoses right into the patient’s record in their EHR.

2. Patient Electronic Access

The goal: More than 50% of unique patients need to have online access to their health information within four days of their visit. 

The challenges: Patient acceptance; workflow modification required to assign and dispense online access credentials.

W hile assigning usernames and passwords to patients seems easy, doing so takes a good deal of effort. A patient who sees no value in electronic access will simply refuse or discard their credentials. While this won’t count against the provider for Stage 1, it makes the patient an impossible target for increased expectations in Stage 2. 

Functionality can vary between EHR vendors, but connecting the practice to personal health records allows patient access to the information in their medical record. This promotes patients’ involvement in their own care and supplies other doctors with valuable clinical information. For example, if a patient tells her primary care physician that her eye doctor is treating her for a condition, but isn’t sure of the medication name or diagnosis, the patient can access her PHR and provide the latest clinical summary to her PCP.

Office meetings should be held to determine the optimal point of the encounter for delivery of credentials as well as the proper approach to promotion. 

It can help to think of PHR promotion in the same regard as dispensary sales. There are practices that excel at anti-reflective lens dispensing; if their techniques are explored, they undoubtedly promote and recommend the technology at multiple points in the encounter. 

For example, everyone in the practice who wears glasses likely has anti-reflective lenses, the doctor prescribes them from the exam room, the opticians follow through with their own recommendations, there might be in-office promotional materials, and so on. The net effect is that the value of AR-coated lenses increases through each stage of the visit. What would happen to sales if the office simply handed the patient a brochure? Quite often, the latter approach is taken with PHR promotion. The low levels of patient use that result will ultimately come back to haunt the provider in Stage 2.

Taking the First Few Steps Without a Giant Leap
Even the staunchest supporters of EHR concede that temporary scheduling modifications need to be considered prior to the “go live” date. This will allow the entire office staff some extra time per patient during the first few days or weeks to get acclimated to differences in documentation and workflow. Without this adjustment, the potential for falling behind and getting frustrated increases significantly. There is just no escaping the fact that changing the way a provider has documented care for their entire career represents a big challenge.

Many providers note initial decreases in workflow efficiency when manually entering their findings into a computer, and difficulty maintaining a sense of engagement with the patient while doing so. Perhaps this represents an opportunity, though, to take advantage of efficiency boosters such as scribes and/or equipment integrations. For sure, the transfer of data at the push of a button allows greater accuracy and an even better patient experience than transcribing findings onto paper. 

To prepare users for the transition, EHR vendors may offer a demo or “sandbox” environment where new customers can practice and learn how to customize their production environment with their preferences. This can be a perfect time to give staff and family members their long overdue eye exams while they serve as demo patients. With proper preparation, practice and planning, any initial slowdown can be short-lived.

3. Medication Reconciliation

The goal: More than 50% of patients transitioned/referred into the provider’s care need to have medication reconciliation performed.

The challenge: Obtaining an official, accurate list of a patient’s medications.

G one are the days of a patient handing over a Post-It note with a few medications scribbled on it. Meaningful Use steps up the expectations on providers to maintain accurate and up-to-date lists of their patients’ medications. Why? Accuracy of the med list is not only important to the care of the patient in the practice, but also for the clinical documents that get shared between providers in MU. 

As a Menu objective, medication reconciliation involves the use of an official medication list to populate or update the list in the EHR. To ensure success, notify all front office staff who answer telephones of this need when scheduling an inbound referral. Often, that call will originate from the referring provider’s office that can provide the list or Summary of Care document immediately. This avoids tracking down a medication list at the time of the encounter. 

4. Transition of Care Summary

The goal: More than 50% of patients transitioned/referred out of the provider’s care need to have a Summary of Care document sent to the receiving provider.

The challenge: Workflow modification during the referral process.

T his objective is complementary to medication reconciliation, as the Summary of Care document contains the active medication list needed for review and a summary of previous procedures, medication allergies, diagnoses and other pertinent information useful to the patient’s care.

To meet this Menu objective, providers need to generate a Summary of Care document in the EHR and include it with any other materials that they typically provide during a referral. Certified EHRs make this process straightforward as the document is critical to data sharing. However, the challenge is making this additional step in the referral process routine.

Auto-Coding Doesn't Mean Correct Coding
EHRs allow you to automatically code an encounter. While this is a nice feature, be aware that auto-coding engines simply tally the number of elements addressed in the EHR during the encounter. Auto-coding features have no way to consider the actual medical necessity of those elements as they relate to the Reason for Visit. As a result, auto-coding features alone don’t guarantee the codes generated are appropriate or will pass an audit.

As an example, imagine a patient presenting for emergency care whom the optometrist saw one week earlier for a comprehensive encounter. Does the Reason for Visit at the second encounter require a comprehensive review of systems or an update to past, family and social history? The temptation is to pull that data forward from the previous visit so all the fields in the EHR are completed. However, the medical record needs to reflect what was actually performed during the course of the encounter. If a review of systems isn’t pertinent to the Reason for Visit, it shouldn’t be performed or populated in that encounter. An encounter with more fields populated than necessary to address the Reason for Visit will reflect an artificially high CPT code for the visit when auto-coded.

So while auto-coding has its place, it shouldn’t be relied upon to replace a provider’s coding knowledge. In instances where the EHR precisely reflects what the provider deemed necessary for the care of the patient based on that day’s Reason for Visit, however, auto-coding will produce the proper code.

5. Record Vital Signs

The goal: More than 50% of unique patients of any age need to have their height and weight documented, and 50% of patients older than three must have their blood pressures documented.

The challenge: Deciding how to report on objective; modification to exam testing protocol.

The measurement and documentation of vital signs (e.g., blood pressure, height/weight) represents one of the biggest potential changes for eye care providers. Philosophically, optometrists need to decide if and how vital signs pertain to the care they provide. Logistically, how, when and where these vital signs are documented during an encounter must be considered. 

Opinions abound regarding ODs and the vital signs objective, but make no mistake: all eligible professionals are held to the same objectives in MU and there are no specialty-specific exclusions. The only exclusions available are for eligible professionals who believe that the documentation of blood pressure, height/weight or both are not relevant to their scope of practice.

6. Protect Electronic Health Information

The goal: Perform a security risk analysis addressing how the practice protects electronic health information. 

The challenge: Investment of resources (e.g., time and money).

A s a key component of both a solid HIPAA security policy and Meaningful Use attestation, the security risk analysis forces the provider to look for potential weaknesses in how their practice safeguards electronic protected health information (ePHI). Not only does the EHR system need to be considered, so too must any ePHI that might reside elsewhere in the practice (such as diagnostic equipment databases). When risks and deficiencies are identified, a risk mitigation plan must be designed, implemented and monitored with appropriate documentation.

A common example that turns up through the course of a security risk analysis is the presence of unsecured hard drives connected to diagnostic equipment like perimeters, cameras and OCTs. Even if a workstation is password protected, a drive can be stolen and easily hooked up to another computer, allowing ePHI to be accessed. Risk mitigation for this scenario might involve plans to employ full disk encryption for all data; documentation would be maintained to show how and when this was acomplished. 

While there is no requirement that a practice outsource this undertaking, the scope of the security risk analysis can be daunting. Thus, providers may wish to enlist an experienced third party to offer guidance and assistance with the process.

A Crash Course on Meaningful Use
To encourage EHR adoption and ease the financial burden on practices, CMS currently provides incentive payments to doctors who “meaningfully” use certified electronic health record technol-ogy (CEHRT). The payment program is winding down, however; 2014 is the last year a practice can start Meaningful Use (MU) and become eligible for incentive payments.1 

  2011 2012 2013 2014 2015 2016 2017 2018
2011 first year of MU Stage 1 Stage 1 Stage 1 Stage 2 Stage 2 Stage 2 Stage 3 Stage 3
2012 first year of MU   Stage 1 Stage 1 Stage 2 Stage 2 Stage 2 Stage 3  Stage 3
2013 first year of MU     Stage 1 Stage 1 Stage 2 Stage 2 Stage 3 Stage 3
2014 first year of MU
    Stage 1 Stage 1 Stage 2 Stage 2 Stage 3

Eligible professionals must demonstrate MU yearly and meet a number of goals and objectives in three stages, each with increasing requirements, to receive incentive payments and, soon, to avoid penalties. Providers who have not participated and attested to MU by October 1, 2014 will be subjected to a 1% reduction in Medicare reimbursements in 2015, with an additional 1% taken away for each subsequent year they do not demonstrate meaningful use (the penalty eventually maxes out at 3% to 5%).1

To meet the MU requirements in the first year, you must comply with goals and objectives for 90 consecutive days to garner incentive payments. Every year after that, you must complete the required objectives for the full year. Note that 2014 represented a small change to this as CMS allowed all providers to report over a 90-day period, again in an effort to allow EHR vendors to get 2014 certified products into the hands of their users. 

Examples of Stage 1 and 2 core and menu objectives for EPs are outlined in the table below. A full list of objectives can be found on the CMS website. Stage 3 will not begin until 2017 at the earliest and the final rules are not yet available.2

New Rules for Deadlines
Originally, the deadline for beginning stage 2 or 3 was after meeting the objectives of stage 1 or 2 for two years. However, modifications to this timeline ended up in Stage 2 starting in 2014 for EPs that had successfully attested to Stage 1 in 2012 or earlier, and Stage 3 getting delayed until 2017. The net effect is that providers who began the MU program in 2011 followed Stage 1 criteria for three years and will likely do the same for Stage 2.

To add slightly more confusion to the timelines, CMS decided to allow the option to providers scheduled for Stage 2 in 2014 to attest to Stage 1 objectives again if they were unable to “fully implement” 2014 CEHRT due to delays in availability.5

           Meaningful Use Stage 1 and 2 Objectives    
        Stage 1       Stage 2
Completion of: 
  • 13 required core objectives
  • 5 menu objectives
  • Total of 18 objectives
  • 17 core objectives
  • 3 menu objectives from a total list of 6
  • A total of 20 objectives
Core Objectives
  • Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.
  • Implement drug-drug and drug-allergy interaction checks.
  • Maintain an up-to-date problem list of current and active diagnoses.
  •  Use secure electronic messaging to communicate with patients on relevant health information.
  • Perform medication reconciliation for transitions of care in which the patient is transitioned into the care of the EP.
  • Provide summary of health care record for each transition of care or referral.
Menu Objectives
  • Implement drug formulary checks.
  • Incorporate clinical lab-test results into EHR as structured data.
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach.
  • Record electronic notes in patient records
  • Imaging results accessible through CEHRT.
  • Record patient family health history.

1. Medicare and Medicaid EHR Incentive Program Basics. Available at: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.htm
2. Meaningful Use Work Group. Draft Recommendations Meaningful Use Stage 3. Available at: www.healthit.gov/facas/sites/faca/files/muwg_stage3_draft_rec_07_aug_13_.v3.pdf.
3. Centers for Medicare and Medicaid Services. Core and Menu Set Objectives Stage 1 (2014 Definition). Available at: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MU_TableOfContents.pdf.
4. Centers for Medicare and Medicaid Services. Stage 2 Overview Tip Sheet. Available at: www.cms.gov/regulations-and%2520guidance/legislation/ehrincentiveprograms/downloads/stage2overview_tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf.
5. Stage 2 Final Rule. Available at: www.gpo.gov/fdsys/pkg/FR-2014-09-04/pdf/2014-21021.pdf.

With ICD-10 around the corner and the Centers for Medicare & Medicaid Services (CMS) performing regular audits, it is important to continually improve record keeping. Specifically, we will discuss the “copy/paste” feature of many EHR systems.

Remember, there is a time and place for a copy or paste. Copying and pasting has been termed “auto-populating” or “cloning.” The 1997 Documentation Guidelines permit use of data gathered at an earlier visit as long as the information is germane to the visit and it’s clear the physician actually looked at the data that was forwarded from the previous record. 

Review information from earlier visits. You can demonstrate this with an audit log in the EHR, a check box or signature that the information was reviewed—for example, if you go back and review information from an earlier visit and even bring some of it forward with a note that states: “no changes from previous exam dated ___________,” with the doctor’s initials. 

Record what you actually do. “Information germane to the visit” means that data cannot be brought forward for the sole purpose of improving the level of coding.

Achieving Meaningful Use Through Team Meetings
While the provider is considered the Meaningful User, full staff participation is required for success. 

MU-related meetings should begin in advance of the planned start date of the reporting period and should involve a discussion of each objective, how it will be accomplished in the office and who is responsible. Have a discussion of “why” each objective is significant to the care of the patient to foster staff understanding. Many practices find weekly meetings leading up to the start of the reporting period offer the greatest benefit. 

Soliciting input from the entire team can be extremely beneficial. For example, during the discussion of assigning PHR access to a patient, the decision needs to be made about the best point of delivery and discussion of these credentials. While the provider might feel compelled to make that call, the front office staff likely knows better.

Appointing an “MU Lead” can also be helpful. This would ideally be a self-motivated staff member with an interest in leading the practice’s MU educational efforts. They would be responsible for keeping abreast of any changes or challenges that arise and coordinating efforts to overcome them. 

Once the MU reporting period has started, a review of the MU “scorecard” (part of all CEHRT) can be incorporated into meetings to serve as a barometer of progress. This allows success to be praised and particular areas of weakness to be identified and remedied. Without initial frequent review of statistical performance, fixing problem areas can be difficult.

Anticipate and Overcome
No transition from paper to digital records will be entirely free of setbacks. But with preparation and staff participation, you’ll be able to anticipate the stumbling blocks and move past them more smoothly. 

Dr. Paepke practices at FirstView Eye Care Associates in Plattsburgh, New York. Dr. Miller is a partner at EyeCare Professionals of Powell, Ohio, and serves as an adjunct faculty member for the Ohio State University College of Optometry.