1 BACKGROUND FOR RESOLUTION Electronic Health Record Survey Results Vanderburgh County Medical Society May In your opinion, has the use of Electronic Health Records impacted patient care? a. Yes: 95% b. No: 5% 2. If you responded yes to question 1, has patient care been impacted positively or negatively? a. Positively: 51.4% b. Negatively: 48.6% 3. Has there been a change in the amount of time that you spend on your patient s records? If so, has the change been a. Considerably more time spent?: 71.8% b. Considerably less time spent?: 7.7% c. About the same amount of time as before?: 20.5% 4. Do you think that you are exposed to greater liability due to omissions or acts of commission in your medical record documentation since using electronic medical records? a. Yes: 54.6% b. No: 43.6% 5. Are your patients more or less satisfied with your implementation of electronic health records? a. More satisfied: 25.6% b. Less satisfied: 23.1% c. No difference: 51.3% 6. Are you satisfied with the way that electronic medical records have been mandated by Medicare/Medicaid? a. Yes: 28.2% b. No: 71.8% 7. Have you had any difficulties with the implementation of electronic health records? a. Yes: 76.9% b. No: 23.1% 8. How do you rate the quality of information captured by electronic health records? a. The quality of information is better: 30% b. The quality of information is worse: 42.5% c. The quality of information is about the same: 27.5% 9. What role would you like to see the Medical Society play in assisting you with the implementation of electronic health records? a. Seminars for ways to be EMR efficient in the office b. Take an active role in eliminating the mandate for all physicians to utilize electronic records. Many of us kept quite good paper records. c. Direct user reviews of the Pro's and Cons of a particular system such as: cost and time spent, user friendliness etc. d. Help make care patient-centered rather than data-centered. e. None I am part of Deaconess and they have provided all the help needed. f. Working to make the EMRs in our region compatible with each other; anticipating a future time of one universal EMR. g. We already have it
2 h. Pushing for a financial incentive for the extra time and money spent i. Information to consuming public j. Collaborate with other Medical societies in Indiana, improving EMR to make it user friendly. More input from PRACTICING PHYSICIANS. The Non physician experts helping the physicians in developing the records rather than telling the physicians we made the mess and you deal with it. k. Free seminars l. Pay for it m. Aid in the exchange of information between systems. n. It's too late to make much of an impact. o. Not sure much assistance can be provided. I wish local hospitals would seek recommendations from providers prior to selecting a system. Two hospitals and two EHR formats which do not talk to each other does nothing to improve patient care or reduce the cost of health care. p. Help to ease burdensome regulations q. Honestly, I do not believe that you can do a lot. This is the mandate and now we must deal with it. I do appreciate that the VCMS has gone to the trouble of inquiring r. Less ridiculous regulations for proving "Meaningful use." It is not "meaningful! s. As a proponent of EMR/EHR adoption. I have been on my EMR for 3 years and will never go back to paper. t. Protection from the trial lawyers. The FBI can't keep records secure how do they expect a doctor s office to do so. There will be a tidal wave of lawsuits when PT.'s medical records show up on the internet. Some PTs are voicing concern about confidentiality. u. Having payers acknowledge extra time and investment into EMR. Now this cost is transferred to us. v. Coordination of records between health care systems 10. Do you have any additional comments or concerns not addressed in this brief survey? a. It probably does no good to comment at this late date, as there is a federal mandate in place. b. Emr was the final straw driving me out of private practice. I spent more time, was less productive and spent more time paying attention to a computer screen than my PTs. I think there were more lab and pharmacy errors as well and less pt satisfaction c. No d. I believe that an integrated EMR improves patient care and safety and is well worth the cost and inconvenience of implementation. e. First question should have been: Do you use electronic health recording. I would have said 'no' and bypass all the questions. I am retired. f. Question 3 doesn't allow for an answer of "a little more time" spent. I don't know enough to answer question 6 g. It is a very expensive project for the medical practices already overburdened with a multitude of regulations h. Something s got to give between the demand for quality of care vs economy of care vs liability. i. Need is for much better systems at this time they are mostly for data collection, not ease of use. Some advantages, lots of disadvantages at this time j. The Government rethink her role in medical field. There should not have been a mandate for something not tested yet. The government is playing with the lives of people without realizing the consequences of ill advised mandate. Delaying the mandate for some time till the EMR is really helpful. k. I've been retired too long to make any comments. l. My responses are for EHR used in the hospital setting. My responses may differ slightly for my office use of EHR. m. Information retrieval is easier but input is very time consuming. There is less time for direct patient care. The error rate is high due to inadequate training, lack of vigilance by users, facilities allowing users to input information that they do not understand or do not know how to record accurately, information systems that do not allow for accurate information input or do not readily accept it without multiple extra steps or developing work-arounds, and systems that accept
3 information then hide it from retrieval by anyone other than the person who input the information and this does not just apply to protected psychiatric records. n. The implementation of EHR is a long way from fulfilling expectations of quality and safety improvement. o. Future doctors will have much less trouble adapting to the EMR. However, I fear that instead of the EMR being used in some way to educate and improve competencies, it will be used to follow patients with collection of non-medical demographics (akin to spying) and make payment for services possibly based on a sliding scale or grade dependent on if the patient meets or follows certain defined healthcare parameters, or on what medical decisions are made, money spent, amount of hospitalizations, or other factors in the care of patients. p. Well, so you asked... I work in the operating room at several locations in our community and I take care of a large variety of patients including critically ill people. At the conclusion of their surgeries when the patients are emerging from anesthesia in the OR I frequently observe that the surgery nurse is preoccupied with the computer sorting out the electronic medical records. The anesthesiologist is left alone to fend for the patient. Sometimes I see the surgery orderly pitching in to help, but the RN is where? Yep, on the computer. This is a step in the wrong direction; one of these days I'll have to make a tsimmes out of it. So what can the VCMS say about this? Not so much, I guess. But pay attention: if the patient's care is being jeopardized where you work because of the EMR then you better address it and now! q. Your survey is a bit negative and non specific. For question 8. "garbage in and garbage out". Doctors who were doing a poor job of patient care/documentation were isolated from scrutinywe can all see the issues now. The implementation of an EMR will not fix process issues it will amplify process issues. Once we as physicians get beyond the "it is not my job" mentality the sooner we can work on improving the system for our patients and ultimately for ourselves. r. see above s. I think hospital EMR has increased access to old records, but I'm concerned about the "homogenization" of patient records due to use of boilerplate text which is intentionally vague and non-specific. While reviewing the EMR-listed goals of a hospitalized psychiatric patient last week, I pointed out that there wasn't a single statement that didn't apply to every member of the treatment team in the room.
4 RESOLUTION PATIENT CENTERED MEDICAL HOME 8/14/12 Dear reference committee, I summited the resolution on PCMH in order to increase visibility and dialogue related to Indiana based primary care initiatives. The resolution is based on a strong references and vetting process lead by the AMA, AAFP, and AAP in Across the US, there are many regions that are creating and supporting NCQA level 3 medical homes to improve care and in response to accountable care. In Bloomington, the large practices and the health care system (representing 200 physicians) have explored feasibility NCQA certified medical home and growth to medical neighborhoods where primary care, specialists, and other players are better aligned on care coordination which reduces preventable emergency care and hospital admissions. Despite the merit of PCMH, there continues to be lack of differential payment to primary care physicians to create the staffing, process, and technology investments necessary. It appears Indiana is behind neighboring states like Michigan and Ohio who both have a much higher percentage of NCQA certified practices given the payer and employer financial support. Most recently, the CMS Center for Innovation awarded 7 regions major funding to deploy a Comprehensive Primary Care Initiative 0TUhttp://www.innovations.cms.gov/initiatives/Comprehensive-Primary-Care- Initiative/index.htmlU0T. I believe that ISMA has the potential to engage on this topic in collaboration with IAFP and the Indiana Chapter of Pediatrics with Indiana Medicaid and other significant payers in our state. Thanks Todd Rowland MD U0T
5 UBACKGROUND FOR RESOLUTION Compiled by ISMA Staff American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA) Joint Principles of the Patient-Centered Medical Home March 2007 Introduction The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient s family. The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians, have developed the following joint principles to describe the characteristics of the PC-MH. Principles Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. Physician directed medical practice the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Whole person orientation the personal physician is responsible for providing for all the patient s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. Quality and safety are hallmarks of the medical home: Practices advocate for their patients to support the attainment of optimal, patientcentered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient s family. Evidence-based medicine and clinical decision-support tools guide decision making
6 Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. Patients actively participate in decision-makinug Uand feedback is sought to ensure patients expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model. Patients and families participate in quality improvement activities at the practice level. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff. Payment appropriately recognizes the added value provided to patients who have a patientcentered medical home. The payment structure should be based on the following framework: It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit. It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources. It should support adoption and use of health information technology for quality improvement; It should support provision of enhanced communication access such as secure e- mail and telephone consultation; It should recognize the value of physician work associated with remote monitoring of clinical data using technology. It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-toface visits). It should recognize case mix differences in the patient population being treated within the practice. It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting. It should allow for additional payments for achieving measurable and continuous quality improvements. Background of the Medical Home Concept The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving a child s medical record. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.
7 The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed their own models for improving patient care called the medical home (AAFP, 2004) or advanced medical home (ACP, 2006). 1Thttp://www.aap.org/en-us/professional-resources/practice-support/qualityimprovement/Documents/Joint-Principles-Patient-Centered-Medical-Home.pdf 1T
9 Comprehensive Primary Care Initiative Center for Medicare & Medicaid Innovation Page 1 of 3 8/21/2012 Comprehensive Primary Care Initiative Recent Updates: 07/26 - Updated to reflect that the practice application period has ended. 06/25 - Webinar video for primary care practitioners held 6/19 posted. 06/21 - Slides from "Primary Care Practitioners" webinar held 6/19 posted. Overview The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients. The Selected Markets From a pool of applicants, there are 7 selected CPC initiative markets. Hide These markets are multi-payer and may include private health plans, state Medicaid agencies, and employers. The participating payers in each market have entered into Memorandums of Understanding with CMS. Arkansas: Statewide (4 Payers) Read More Colorado: Statewide (9 Payers) Read More New Jersey: Statewide (5 Payers) Read More New York: Capital District-Hudson Valley Region (6 Payers) Read More Ohio and Kentucky: Cincinnati-Dayton Region (10 Payers) Read More Oklahoma: Greater Tulsa Region (3 Payers) Read More Oregon: Statewide (6 Payers) Read More
10 Comprehensive Primary Care Initiative Center for Medicare & Medicaid Innovation Page 2 of 3 8/21/2012 Primary Care Practices: Eligibility and How to Apply The application period for primary care practices was from June 15 - July 20th. During this period, primary care practice sites located in CPC selected markets were eligible to apply for the initiative. Information about practice eligibility, selection, terms and conditions for participation can be found in the primary care practice solicitation (PDF). Approximately 75 primary care practices in each designated market will be selected to participate in the CPC initiative. Background Primary care is critical to promoting health, improving care, and reducing overall system costs, but it has been historically under-funded and under-valued in the United States. Without a significant enough investment across multiple payers, independent health plans-- covering only their own members and offering support only for their segment of the total practice population-- cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices. A primary care practice is a key point of contact for patients health care needs. In recent years, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and helping clinicians spend more time with their patients. All around the country, health care providers and health plans have taken the lead in investing in primary care. Employers across the country have found that with health coverage policies that emphasize primary care, coordinated care, and other strategies that keep their employees healthy, they not only support a healthier workforce, they create a healthier bottom line. The Comprehensive Primary Care Initiative will build on these and other efforts. Initiative Details The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country. The resources will help doctors work with patients to ensure they: Manage Care for Patients with High Health Care Needs: Patient with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Participating primary care practices will deliver intensive care management for these patients with high needs. By engaging patients, primary care providers can create a plan of care that uniquely fits each patient s individual circumstances and values. Ensure Access to Care: Because health care needs and emergencies are not restricted to office operating hours, primary care practices must be accessible to patients 24/7 and be able to utilize patient data tools to give realtime, personal health care information to patients in need. Deliver Preventive Care: Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care. Engage Patients and Caregivers: Primary care practices will have the ability to engage patients and their families in active participation in their care.
11 Comprehensive Primary Care Initiative Center for Medicare & Medicaid Innovation Page 3 of 3 8/21/2012 Coordinate Care Across the Medical Neighborhood: Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients experiences with medical care. Under this initiative, primary care doctors and nurses will work together and with a patient s other health care providers and the patient to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts. The CPC initiative will test two models simultaneously: a service delivery model and a payment model: Service Delivery Model The service delivery model will test comprehensive primary care, which is characterized as having the following five functions: Risk-stratified Care Management; Access and Continuity; Planned Care for Chronic Conditions and Preventative Care; Patient and Caregiver Engagement; Coordination of Care Across the Medical Neighborhood. Payment Model The payment model includes a monthly care management fee paid to the selected primary care practices on behalf of their fee-for-service Medicare beneficiaries and, in years 2-4 of the initiative, the potential to share in any savings to the Medicare program. Practices will also receive compensation from other payers participating in the initiative, including private insurance companies and other health plans, which will allow them to integrate multi-payer funding streams to strengthen their capacity to implement practice-wide quality improvement.
12 BACKGROUND FOR RESOLUTION Health Care Delivery by Physician Assistants UIndiana Physician Assistant Committee Recommendations State comparison data: th Indiana ranked 47P P in PAs per capita Indiana has 1.2 PAs per 10,000 compared to the national average of 2.7 per 10,000 Indiana is 1 of only 9 states that require chart review within 7 days or less Indiana is only 1 of 14 states that prohibit Schedule II prescriptions Indiana is 1 of only 18 states with a ratio of 2 to 1 or less Recommendations: Clarify and potentially relax chart review provisions Permit more discretion between the physician and PA regarding the supervision and scope of practice requirements Increase number of PAs a physician may supervise **Recommend that ISMA work with PAs to put forth mutually beneficial language that will increase access to healthcare, not restrict practice. From the AMA The role of the physician assistant(s) in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the physician assistant based on the physician s delegatory style.
13 UBACKGROUND FOR RESOLUTION Compiled by ISMA Staff UCurrent ISMA Policy on Covenants Not to CompeteU: (READOPTED 09-58, HOD; RESOLUTION 99-33) RESOLVED, that the ISMA continue to endorse the AMA s policy on restrictive covenants. The AMA CEJA policy (E-9.02) states: Covenants not to compete restrict competition, disrupt continuity of care, and potentially deprive the public of medical services. The Council on Ethical and Judicial Affairs discourages any agreement which restricts the right of a physician to practice medicine for a specified period of time or in a specified area upon termination of an employment, partnership or corporate agreement. Restrictive covenants are unethical if they are excessive in geographic scope or duration in the circumstances presented, or if they fail to make reasonable accommodation of patients' choice of physician. (Issued prior to April 1977; Updated June 1998).
14 BACKGROUND FOR RESOLUTION Constraining Automatic Retroactive Medicaid Billing Physicians that have elected to not accept any new Medicaid patients, especially given the low reimbursement of Medicaid for physician services making financial operation of a clinic untenable, find their self-pay patients suddenly converting to Medicaid. The physician is obligated by the IHCP manual below to refund all moneys collected for the past 3-6 months and re-file the claims under Medicaid, resulting in significant financial loss to the physician. This is patently unfair to the physician that has rendered care to the patient at an agreed-on rate, then due to circumstances out of their control may incur financial penalties because of patient enrollment into Medicaid. IHCP Manual CHAPTER 12 Retroactive Member Eligibility Eligibility for Traditional Medicaid, Care Select, and Hoosier Healthwise Packages A and B can be established retroactively up to three months prior to the member s date of application. In instances involving an appeal, eligibility can be more than three months retroactive. When notified of member eligibility, the provider must refund to the member any payments made by the member for covered services (other than IHCP Package C copayments) rendered on or after the eligibility effective date. Example: An IHCP provider renders an IHCP covered service on August 1, 2010, to a patient on a private-pay basis. On October 1, 2010, the patient is enrolled in the IHCP retroactively to May 1, The patient informs the provider and furnishes a member identification card. When the member informs the provider of the retroactive eligibility, the provider needs to verify program eligibility using one of the Eligibility Verification System (EVS) options. After member eligibility is verified, the provider must adhere to the refund policy and refund the full amount paid by the member for the services rendered on August 1, The provider must bill the IHCP within one year of the date the member was retroactively enrolled (October 1, 2010). Providers must return money paid by the IHCP member as soon as possible