Optometrist Richard Driscoll, of Keller, Texas was a pro at EHR. After all, his Total Eye Care practice had gone paperless more than a decade earlier. But, just because his patient records popped up on computer screens instead of being neatly filed away in manila folders didn’t mean he had achieved the practitioner’s Holy Grail of the federal Health Information Technology for Economic and Clinical Health (HITECH) Act. That is, meaningful use. (See “ What is ‘Meaningful Use’?”.)

“We had EHR in place, but we weren’t using all of it (for meaningful use),” Dr. Driscoll says. For example, electronic medical prescribing was not being fully utilized. The patient portal was collecting dust and his staff didn’t routinely ask patients about their smoking habits, weight, race or ethnicity.

With the federal clock ticking for EHR compliance in order for O.D.s to avoid Medicare payment cuts and to reap the benefits of reimbursement, Dr. Driscoll and his staff got busy. He sought guidance from his certified EHR software vendor, and carefully went through the 15 meaningful use core measures and 10 menu set measures of meaningful use as dictated by the Centers for Medicare and Medicaid Services (CMS).

Based on the list of requirements, he checked off what meaningful use measures his practice was already doing on a daily basis, determined what measures didn’t pertain to eye care where he could qualify for an exclusion, and what benchmarks he still needed to fulfill in order to become a meaningful user. Dr. Driscoll also sought feedback from colleagues on standard of care and clinical reporting requirements, such as counseling patients on the adverse affects of smoking and being overweight.

Then he started practicing. For one month, he and his staff met regularly to work out the kinks as they test-drove their EHR system to be sure it was meeting the meaningful use standards before they started their 90-day reporting period.

After several staff meetings, weekly compliance reports and some fine tuning, Dr. Driscoll is on course to meet the 90 days of meaningful use reporting for 2011, and to qualify for maximum reimbursement from the government.

“It frankly wasn’t difficult to do,” Dr. Driscoll says. “We weren’t using everything in our EHR system before. If you already have a system in place, you are better off. I wouldn’t want to start EHR and meaningful use at the same time.”

Whether you’ve made significant meaningful use strides like Dr. Driscoll, have already received your first reimbursement check or are still mulling over when to launch an EHR system, fellow optometrists and experts offer some sage advice on how you can become a meaningful user.

Nuts and Bolts of Meaningful Use
In 2009, President Obama signed the HITECH Act to improve the nation’s health care system by urging meaningful use of EHR through financial incentives. The bottom line for O.D.s and other health care providers is that they can receive Medicare or Medicaid dollars (but not both) if they become meaningful users.

What is ‘Meaningful Use’?
“Meaningful use” simply means using certi fied EHR technology in significant ways that can be measured in quality and in quantity. Are you using EHR in a “meaningful manner,” such as for e-prescribing? Are you using it for electronic exchange of health information to improve quality of health care? Are you using it to submit clinical quality and other measures? These are forms of meaningful use.
The Medicare program offers up to $44,000 per provider, and the Medicaid program offers up to $64,000 per provider—however, 30% of your patients must be on Medicaid for you to qualify for the Medicaid program. Also, not all states have launched their Medicaid EHR program yet.

To receive maximum incentive payment for Medicare, doctors need to start participating by 2012. Medicare-eligible professionals who don’t become meaningful users by the end of 2015 will be penalized with a Medicare payment adjustment.

To receive reimbursement, you need to meet the 20 meaningful use objectives, which consist of 15 core objectives and five out of the 10 menu set measures.

“Some of the measures are fairly easy to implement and some will require a change in clinical procedures,” says Neil Gailmard, O.D., M.B.A., president and COO of Prima Eye Group, a management services alliance based in Atlanta. “The criteria will be rolled out in stages over the next four years.”

Additionally, you need to make sure you are using software that has received the stamp of approval from the Office of the National Coordinator for Health IT (ONC). “You must use the certified software to meet each of the meaningful use objectives as they are described,” says AOA Health and Information Technology Committee member Jay W. Henry, O.D., M.S. “To ensure you are doing it correctly, you must understand the requirements of your software, and you should run a report regularly to determine your compliance with each objective.”   

Tips from the Pros
Even an EHR expert like Dr. Henry still needed to make some changes at his Columbus, Ohio, private practice in order to achieve meaningful use.

“It is important for all doctors to understand that even if they have been using an EHR for many years (as I have), they will have to make changes to become a meaningful user,” Dr. Henry says.

He offers these helpful tips to get started:

  • Convert to the certified version of your current software (or purchase new certified software).  
  • Once the software is in place, read and comprehend the 25 Stage 1 meaningful use objectives and how they apply to your office. You should determine which five of the 10 menu set objectives you will attempt to accomplish.
  • Consider if you qualify for any exemptions, such as if you write fewer than 100 drug prescriptions in the reporting period. If so, you would be exempt from two objectives, generating and transmitting permissible prescriptions electronically (e-prescribing, or eRx) and using computerized provider order entry (CPOE) for medication orders.
  • Then, determine how your workflow must change in order to accomplish the objectives that are needed. “Things that might cause change would be making sure you capture all patient medications and drug allergies, or maybe figuring out how your office will achieve height, weight and blood pressure information,” Dr. Henry says. “Will you just ask the patients, or will you physically measure and weigh them?”

Once you have a good idea of what information you’ll need to collect and how you will collect the data, it’s time to determine and understand how your software tracks each of the meaningful use objectives. For each objective, the software will determine if the objective applies to a specific patient encounter (denominator), and then it will determine if you have met the objective (numerator), Dr. Henry explains. “If you do not understand how your software tracks each objective, you may think you are doing it properly, but still you would not receive credit,” he says. One example of this is if you record the smoking status of patients ages 13 and older in the history, but your software only tracks it when it is recorded in a specific field elsewhere in the encounter called “smoking status.”

Optometrist Ryan Wineinger, of Shawnee, Kansas, was one of the first O.D.s to start meaningful use reporting. “Get in and understand the details of meaningful use before trying to do it. Understand what a meaningful user is,” he says. “I learned a lot on the CMS website. Meaningful use should become a reading requirement before you get started. You don’t know what questions to ask unless you know what you are trying to get to.”

Benefits of Meaningful Use
Besides a nice reimbursement check, O.D.s who have gone through the process are also realizing some benefits from meaningful use to their practice and to the profession.

When you take a look at each meaningful use objective, you see that many of them actually have been created to help improve and enhance patient care, Dr. Henry says. For example, implementing drug-drug, drug-allergy and drug formulary checks could potentially save a patient’s life if you catch a drug interaction or drug allergy before actually prescribing the medication.

“How about the importance of automated clinical decision support rules? These can help you make sure that you are meeting the standard of care for a certain condition or disease,” Dr. Henry says. “Providing patients with proper education as well as providing them with a clinical summary can certainly help improve patient care and patient understanding of their conditions.”

Dr. Wineinger believes meaningful use may actually help propel optometrists further into the mainstream medical arena. “Some patients see their optometrist more than their primary care physician,” he says. “If we are recording their vital signs, meaningful use may improve patient care, in a roundabout way, because those patients are touching base with us more frequently than their primary care physician, which allows us more education with the patient to improve their overall health.”

And for Dr. Driscoll, who plans to go “live” with meaningful use this month, the process is getting easier. “I’ve had EHR since summer 2000, and now I’m finally going to be reimbursed for it, or at least partially,” he says. “I think meaningful use has made our practice better. One of the key provisions of meaningful use that enhances our patient care, for instance, is that we can set up a rule that if a patient’s [intraocular] pressure is greater than 20, a window pops us asking if I want to order any glaucoma testing. Overall, meaningful use has improved the quality of care.

Pitfalls to Avoid

Attaining meaningful use can pose challenges. Doctors who have gone through it recommend avoiding the following pitfalls:
  1. Don’t ignore your staff: “I think the biggest pitfall to avoid is to make sure you involve your staff in your goals and ideas of moving to an EHR,” Dr. Henry says. “Get their input because it will affect everything they do as well as what you do each day. Just be sure not to drop a bombshell on them by announcing without their knowledge that you will be starting an EHR next week!”  
  2. Insufficient hardware. You need a powerful dedicated server, large network capacity, additional workstations, high-speed scanners and a fast internet connection, Dr. Gailmard says.
         Dr. Henry also suggests optometrists should use the exact hardware their software vendor recommends, be sure it is networking properly and hire IT help when needed so you don’t have problems with the software that really stem from hardware problems.   
  3. Not allowing time to practice and train. Allow enough time to set up the software before going live, and be sure you allow for adequate or proper training prior to doing so, Dr. Henry says.
         Adds Dr. Driscoll: Make sure you practice and get the kinks out before you start your 90-day reporting period. Once the patient is gone, you can’t ask about their smoking history.
  4. Spending more time with the computer than with the patient.  Consider incorporating scribes in the exam room to take over the data entry, Dr. Gailmard suggests.
  5. Not updating information on the national providers database. Be sure all the doctors in your practice have up-to-date information about where they practice in the national providers database. “My associate’s information wasn’t current, and she was registered at a former practice where she had previously worked,” Dr. Driscoll says. “If we hadn’t updated the information, her former practice would have received credit for meaningful use instead of us.”
  6. Being afraid of exclusions. “With meaningful use, an exclusion isn’t a bad thing,” says Dr. Wineinger. If you understand which meaningful use objectives don’t pertain to you, you don’t have to spend a lot of time figuring out how to set them up in your software. “One example of an exclusion for optometrists is immunizations. I can’t imagine a lot of optometrists in America do immunizations, but there is a meaningful use measure for recording that,” he says. “You can exclude yourself from that objective and then you don’t have to worry about that in your software.”
  7. Rushing to be sure you meet deadlines. It’s important to understand and expect to run behind schedule at first, expect technical difficulties, expect something won’t work exactly as planned and understand there will be tension and anxiety, Dr. Henry says.  “But also realize that patients will be extremely impressed and very understanding as you move forward with new technology.”
  8. Launching EHR and meaningful use simultaneously. Don’t try to do too much at once. “Coming from the viewpoint of a doctor who has used EHR for the past six or seven years, I would work on installing and getting the EHR going first and get used to the system. Then educate yourself on meaningful use,” Dr. Wineinger says. “Don’t get lost in meaningful use if you are a new user.”