In the midst of unprecedented, troublesome financial news hammering our specialty this year, lies a small respite of relief: many neurologists have started to collect Medicare incentive dollars and are well underway to receive a total of $44,000 over the next five years for successfully meeting electronic health records (EHR) meaningful use standards.
According to the Centers for Medicare & Medicaid (CMS) report released earlier this year in September, of 74,035 providers paid to date, 2,231 were neurologists who received $39,152,237 in aggregate, averaging close to the maximum of $18,000 each for their first year of compliance. [A provider must accumulate at least $24,000 in Medicare charges to have earned the first year maximum incentive of $18,000; neurologists working in Health Professional Shortage Areas (HPSA) are eligible to earn a 10% bonus on top of their incentive payment.]
Last month, 1,026 of those neurologists who had met meaningful use requirements and successfully attested to CMS were sent a survey. The AAN received 77 responses reflecting a wide variety of experiences ranging from poor to excellent. The survey also found a broad range of involvement in the incentive program with some neurologists taking the reins for their practices and others delegating the project to their office managers and administrators.
Neurology Today spoke with several of the neurologists who contributed to the survey and asked them to share their tips for success as well their greatest challenges.
HELP WITH THE LEARNING CURVE
Edward M. Leaton, MD, a general neurologist from Midlothian, VA, was among those who had attested in 2011, reporting results for the final 90 days. He and his partner have been using eClinicalWorks as their EHR since December of 2010. After trying to meet the requirements on their own, and failing, they decided to incentivize their office manager with a bonus if the practice was successful.
Dr. Leaton attended the AAN practice webinars and also got help from his EHR vendor at a rate of $100 per hour, which was well worth it, he said, noting that they ultimately received $36,000 as their first payment from CMS. The office manager's role now includes making sure that patients receive their continuity of care documents (CCD), one of the requirements, and reviewing monthly reports to confirm that the doctors are in compliance with the requisites.
“The biggest challenge was learning how to enter everything as structured data, since our EHR would only recognize responses entered in a specific manner,” he said. “Because we don't use physician extenders, we have to serve as data entry clerks and enter everything,” he added. Dr. Leaton's practice is well under way to receive their second payment when they attest after participating for the entire year of 2012.
Another neurologist who successfully collected incentive revenues, including $54,000 for EHR compliance for his three-person neurology practice in Glens Falls, NY, is Vinodrai M. Parmar, MD. His practice has been using Medent, an EHR and practice management software solution, which also prompts users to meet meaningful use standards for each patient encounter. (The EHR displays a green dial for compliant notes and a yellow dial for those that fall short.) Dr. Parmar estimates that during the first three to four months after adoption, their productivity fell by 25 to 30 percent. However, this year, it has increased 15 percent as the program saves considerable time when they see follow-up patients.
“The first two to three months learning to use the EHR as well as the rules for meaningful use was difficult,” he admitted, but said that part of their EHR training package included meeting the requirements. “The trick to success is setting things up correctly from the beginning. Stick with it…you have to change with the times.”
WHAT LARGER PRACTICES DO
Larger practices tended to designate a champion of change who learned the meaningful use rules and taught it to others. Neil R. Holland, MD, who has been practicing in a group of eight in a West Long Branch, NJ, practice for the past 12 years, and took the lead with his group, said: “Although I collect some inane data that has no relevance to a neurology patient's care, overall, it has been worthwhile.” Dr. Holland, like others, found that some of the criteria, such as counseling about nutrition for an elevated body mass index, were simply not applicable to neurology, unless the patient was on valproate for migraine and struggling with weight gain, for example.
His group began using eClinicalWorks a little over a year ago and received a basic two-day training, which did not include instruction in meaningful use. Dr. Holland spent many weekends creating a “macros” program (letters or words that automatically expand into preset sentences) and templates (data fields that are automatically populated from information stored) for the EHR, and subsequently coached his partners, who after learning the program, shared their macros and templates as well. But even though they've found solutions that make them more efficient, feelings are overall mixed.
“Although I love the way it handles data, the notes are so horrible and telegraphic that even I have a difficult time remembering what it was I had wanted to say,” he said. One of the group's neurologists refused to participate in the program; as a result his notes are not integrated, a situation that despite his reservations, Dr. Holland now realizes was not in the best interest of the practice.
HELP FOR ACADEMICS
Academic neurologists like Kathleen M. Shannon, MD, a movement disorder specialist at Rush University Medical Center, have also attested to meaningful use, although as salaried physicians they have typically not collected the financial incentives themselves. Dr. Shannon started using Epic EHR along with her colleagues at Rush about a year and a half ago after mandatory training. Her hours were reduced to half time for two weeks and three quarters time for a subsequent two weeks after the EHR “went live.”
Dr. Shannon initially relied on a flipchart, which designated those portions of the EHR that needed to be completed, but now finds the process automatic. “A lot of doctors are angry in general about being required to use EHRs,” Dr. Shannon observed. But she has found distinct advantages such as the ability to pull up patient records from home, the ease in viewing all the medications that Rush patients take, the instantaneous creation of letters, and the time-saving functionality of “smart phrases” or macros that expand a few letters into entire sentences.
Dr. Shannon also has taken the time to create patient visit templates that have made her more efficient. “I have no work after clinic anymore!” she said. Despite her general enthusiasm, she wishes her software was more flexible, explaining that requests for modifications are poorly received.
DOLLARS FOR SOLO PRACTITIONERS
On the other end of the spectrum, quite a number of solo practitioners have collected meaningful use dollars. When Roxane S. Bremen, DO, set up her solo practice in Kansas City, MO, two years ago, after being employed in another practice for 15 years, she realized that paper charts would require a lot of space. So she signed up with Athenahealth for their integrated practice management and EHR solutions. The program prompts her to meet meaningful use as she is going along, and to make corrections, if necessary.
“There is no reason anyone should be unable to meet the requirements,” she advised, adding, “Don't be afraid, just embrace it.” Although it was stressful when she first started, and reduced her productivity somewhat, Dr. Bremen found it actually very simple to use because she has good typing skills.
Indeed, one of the biggest barriers to EHR use is not the technology itself, but rather the user's ability to type. Thomas A. Phipps, MD, one of a five-member general neurology practice with offices in Tualatin and Oregon City, OR, using the Centricity electronic medical record, said: “I type like I have mittens on and that's been my biggest personal challenge.” The practice spent about a year getting their software ready for meaningful use.
“Like most things with EHRs, it's the upfront investment, setting up the processes that make a difference,” Dr. Phipps advised. “Like painting, it takes more time to set up so that it's part of the workflow than to actually do it.” Fortunately, his practice has been able to save considerably on employee costs including filers and transcriptionists and offset some of their IT costs with the $74,000 in payment from CMS in 2011. They also anticipate receiving $92,000 for 2012 since they added another neurologist this year.
The ability to defray a portion of overhead costs with a share of the $40 million dollars of incentive money delivered to neurologists thus far may provide a significant short-term reprieve for those who have already seen the dissolution of consultation codes and are about to experience the financial strain from the decimation of electrodiagnostic codes. [See cover story, “Death by a Thousand Cuts: Medicare Slashes Neurology Code Reimbursements — Neurology Takes a Hit.”] Yet the process, for some, seems tainted by an undercurrent of pessimism regarding changes in the current practice of medicine.
“Once you get over your hurt feelings, try to make the best of it,” Dr. Holland said. “Think of it as a game, or it can become a soul-destroying process.”
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today and chair of the AAN Practice Management and Technology Subcommittee.
AAN RESOURCES FOR MEANINGFUL USE
* AAN's Medicare EHR Incentive Program Webpage: www.aan.com/go/practice/pay/ehr
* AAN Programming: 2013 Practice Management Webinar Series & 2012 Practice Management Webinar Recordings: www.aan.com/go/practice/coding/conferences
* 2013 Annual Meeting: HIT Colloquium: The Good, the Bad, and the Ugly (Free); Course: Making Sure Your Electronic Health Record System is a Success: www.aan.com/go/am13/events
* Neurology Today archive on electronic medical records: http://bit.ly/XibwIz
WHICH EHRs ARE NEUROLOGISTS USING?
This spring, the Centers for Medicare & Medicaid Services (CMS) released the products used by neurologists who earned the Meaningful Use incentive through November 2011. Here are the top eight (in order of most used):
* Epic Systems Corporation
* eClinicalWorks LLC
* GE Healthcare
* Greenway Medical Technologies, Inc.
* athenahealth, Inc
* Cerner Corporation
* e-MDs, Inc.
For more EHR vendor information, visit AmericanEHR Partners: www.americanehr.com.