How EHR capabilities will affect Medicare quality pay

A recent change in the rules governing physicians’ use of electronic health records (EHRs) spares doctors from having to upgrade their systems by the end of this year. 

Even with this rule change, however, physicians still face great uncertainty with regard to their EHRs and how they must report quality data to the Centers for Medicare & Medicaid Services (CMS).

Under the Merit-based Incentive Payment System (MIPS), Medicare’s new pay-for-performance program, doctors could lose money unless they score higher than average in MIPS’s three performance categories: quality, practice improvement and the use of EHRs-the category known as Advancing Care Information. 

Until recently, they also had to upgrade their EHRs to the latest government-certified versions to meet all MIPS requirements in 2018. Participants in qualified Alternative Payment Models-the other track in CMS’s program-also had to get upgrades.

But in late June, CMS proposed that physicians be allowed to use either their current “2014 edition” certified EHRs or the new “2015 edition” certified products in 2018. Although the final rule won’t be issued until fall, observers expect this feature to be included in it.

While this move by CMS gives physicians some breathing space, it also raises a number of questions. For starters, when will practices have access to the new EHRs? Should physicians accept a 2015 edition upgrade when their vendor makes it available? 

How will the Medicare payment program’s proposed rule affect Advancing Care Information requirements, depending on whether a practice has a 2014 edition or a 2015 edition product? Will the upgraded versions give them what they need to report quality data directly to CMS?

Quality reporting

Physicians will not need 2015 edition EHRs to do quality reporting or to report their practice improvement activities under MIPS next year. But they will have to report on quality measures for a full calendar year, which means they need to gear up their reporting strategy before January 1, 2018. 

Shari Erickson, MPH, vice president of governmental affairs and medical practice for the American College of Physicians (ACP), says she hopes that the 2015 edition EHRs will make quality reporting easier. 

Naomi Levinthal, MS,  a practice manager for the Advisory Board Company, a Washington, D.C., consulting firm, believes most major vendors will include in their new versions the ability to pull and report quality data to CMS electronically. 

Currently, some practices pay their vendors extra to perform these functions, experts say. David J. Zetter, CHBC, a practice management consultant in Mechanicsburg, Pennsylvania, doesn’t trust EHR vendors to do this job right. Several of his clients that use EHRs-some from major vendors-received letters from CMS saying their quality reporting had failed in the Physicians Quality Reporting System (PQRS), the predecessor to the quality portion of MIPS, he says.  

“If you’re going to fail with PQRS, you’re going to fail with MIPS as well,” Zetter says.

Terry Hashey, DO, a primary care physician in Jacksonville, Florida, says his practice saw a 20% accuracy rate on a colonoscopy report it ran on its EHR. On average, he says, the quality data he extracted from that EHR was only 60% accurate. Not surprisingly, he  switched recently to a new EHR that he believes has a more reliable quality reporting system.

Reporting alternatives

What are the alternatives if practices don’t want to report quality data directly from their EHRs? 

Zetter suggests they use “qualified registries,” which are run by private firms. These CMS-approved registries cost as little as $300 per provider per year, he notes. “They have one responsibility: find the data [in your EHR] and report it to CMS,” he says. The companies also provide reports to physicians on their data, which most EHR vendors don’t do, he says.

Hashey says his former software vendor wanted to charge him $5,000 plus an annual subscription fee to give him a registry-based “dashboard” that would enable him to  compare his performance to that of other doctors.

The cloud-based company that he recently moved to supplies that benchmarking data, derived from the information it has on all of its clients, he says, and reports his data to CMS. It doesn’t charge him a fee for that, but it takes a percentage of his gross revenues for providing, hosting and supporting his EHR and doing his billing.

Erickson suggests that practices consider reporting quality data through a CMS-approved qualified clinical data registry (QCDR). Usually run by a specialty society or a quality collaborative, a QCDR typically costs a few hundred dollars per provider per year (although some are free) and gives “meaningful feedback to practices in a real-time way,” she says, by extracting EHR data.

The ACP itself operates a QCDR, she adds. One of the few multispecialty registries, it includes all of the MIPS measures and then some, she says. It’s appropriate for internists, internal medical subspecialists and family physicians.

Levinthal agrees that QCDRs are a good alternative. She points physicians to the CMS website, which lists these organizations, along with specialties and costs. 

Delay in availability

Partly because CMS didn’t release its 2015 edition specifications until last year, many EHR developers have not had time to get their new products certified. 

Rick Reeves, chairman of the certification workgroup of the HIMSS EHR Association and director of government relations for EHR maker Evident, is confident that the products of the EHR Association’s members will all be certified by January 1, 2018. Only 78 EHRs have been certified to date, including those from Allscripts, Cerner, Epic, Greenway, and NextGen, Levinthal says.

A number of major vendors are missing from that list, she notes. Moreover, most of the certified products are not yet available to customers. 

Edward Gold, MD, an internist and leader of a 96-provider group in Emerson, New Jersey, says that his practice’s EHR vendor is still beta testing its new 2015-certified version, but he expects his group to have it by the end of the summer. 

Smaller practices are the ones that face the real challenge, he says, because many of them use lesser-known EHRs that may not get certified for the 2015 edition. Levinthal agrees this would be a challenge for small practices, especially if it forces them to switch to new EHRs.

Levinthal and Gold concur that letting practices use either the 2014 or 2015 edition EHRs in MIPS next year will provide much-needed flexibility to physicians. 

One advantage of giving vendors more time to reprogram their EHRs, Zetter says, is allowing them to fix the bugs in their software rather than having practices discover the bugs and try to deal with them. There are also other kinks that take practices time to work out before an implementation can be considered successful, he observes.

Just before the Medicare payment reform proposed rule was released, the Office of the National Coordinator for Health IT (ONC) told Medical Economics that physicians should not worry about the 2015 edition requirement because the reporting period for Advancing Care Information would be only 90 days long in 2018. As a result, ONC said, practices could meet those requirements later in the year, after implementing their upgraded EHRs.

Levinthal is skeptical about that argument. She says that it usually takes between 12 and 18 months for the typical practice to implement and fully adopt these functions on which they will be evaluated.

She thinks it likely that many practices will not get their EHR upgrades until the middle of 2018. If that is the case, she says, it’s unrealistic to expect most physicians to use those EHRs for the Advancing Care Information criteria even in 2018. 

The ACP’s Erickson says the college  is pleased that the proposal allows physicians to phase in their MIPS participation gradually. “That will give EHR users time to become effective and efficient under the current MIPS landscape,” she says.

Practical advice

If practices have to switch to a new EHR because their current vendor doesn’t get certified, it could take quite a while to implement the new system fully, Levinthal notes. 

So she advises practices to contact their vendors now and find out when their EHRs will be 2015 edition-certified and what parts of it will be certified, as some portions of a system’s capabilities could be certified and others could not be. It’s critical that practices match up the certified functions they need for the MIPS measures they plan to report, Levinthal notes.

“You don’t want to find yourself in a situation where there are any gaps,” she says.

In addition, practices should get a firm date for an EHR upgrade and map out which new functions they’d like their users to learn first, she says. These should include the core requirements of Advancing Care Information, she stresses. 

With his new EHR, Hashey will have access to a registry of all his patients and not just those on which he’s reporting to CMS. He says he wants to use the data to improve the quality of his care. “[The new EHR company] promises to help me manage my entire population, instead of just a sampling of 30 Medicare patients,” he says.

This is the right attitude for physicians to take, Zetter says. “If you’re going to stay in business and you have a decent amount of Medicare revenue, you’re going to need this data,” he says.