Home Forums Discussions Meaningful Use EHR Purgatory-Help

I am a Physiatrist practicing in SoCal and am trying to navigate the development of an EHR strategy using AC. Our challenge:
62% of my CMS patients are seen in Acute Rehab-Facility code 21. Not enough to secure CMS EHR exemption (90% code 21 or 23). The balance 37% of my CMS patient volume is seen in a Hospital based SNF and 1 external SNF-facility code 31. with less than 1% seen in office-facility code 11. All my clinical data (dictations, progress notes, labs etc...) are created outside my office and are faxed to help create my patient charts. Sooooooo....I dont qualify for EHR exmeption, possibly do qualify for EHR incentive (CMS wizard says maybe...but cannot get CMS to confirm) and am trying to determine:
1. Based on above should I deploy EHR plan?
2. if so how can all external clinical data from external sources sent in pdf form be used to populate MU fields in AC to have a chance at MU incentive?
3. Will MU be based on total CMS patient volumes or only 37% SNF or better yet 1% office?

I am certain CMS will imposs penalties when the time comes.....but as noted above can't determine what to target.
if we move ahead our achitecture looks to be:
Medisoft---X Link---AC---Updocs.

If anyone out there has similar issue..or can offer guidance or even clarification insight..I am keen to understand what approach may make best sense?
I would like to try and deploy and at least try and achieve MU this year to secure monies....
Sorry for length of post.
Up late on the left coast....

B/R

Roxanne Hon, M.D.

Roxanne,
Some of these answers are best obtained through CMS and of course some are a matter of opinion.
For example, regarding #3, it looks like the answer is to use the 37%:
"CMS specified in the final rule that the statutory definition of "hospital" used in the EHR Incentive Program does not apply to hospitals and hospital units excluded from IPPS, such as rehabilitation or psychiatric units (75 FR 44448). Therefore, patients treated in these units should not be included in the denominators of measures." reference here
On the other hand, what is the breakdown of that 37%? (What is the POS code for the "Hospital based SNF")?

Maybe others here have a different idea, but I would think that using AC (or any other EMR) will not be worth the trouble, unless you have some staff with a lot of free time. You could use a PDF management program to cut and paste those notes into the appropriate fields of AC. That in itself would be laborious, but then you would have to go back and enter the appropriate MU fields for each encounter (VS, smoking history, etc); not to get into all of the CQM's.

While I cant speak to the MU reimbusement, youmay find that going with AC makes it easier to keep up with pts in multiple venues. For a couple thousand (assuming 1 provider) this would be a low cost solution. This is especially relavent if you dont get MU money. While there are "free" alternatives, they are not as elegent, sell data, and have ads.

The government is flaky. If you cannot get a straight answer, assume NO

Roxanne,

One of the first practices that we brought up on our hosted platform was a Physiatrist; her need was to see patients in different venues, centralize all of the correspondence concerning her patients,and simplify the technology of her practice.

As Wendell observes, it doesn't have to be an expensive endeavor, and the goal should be to help you practice.

Our Physiatrist attested after being on the platform for 90 days, and is now focused on how to use Updox to her advantage.

In thinking about your situation, I see the solution differently, and so reach a different conclusion than Jon. I would not try to figure out how to get notes from everywhere to go into Amazing Charts; instead, I would remotely enter all those notes into AC in the first place, and reproduce them for the local facility to put into THEIR charts however they wish. This is one place the cloud based AC plan might be hugely helpful. Leaving aside the CMS requirements, a laptop with WIFI connectivity would fix everything: send note to a central repository from anywhere, print copies locally. Pending that, having a central computer at work and using a laptop with LogMeIn and UpDox to deal with faxes would fix the document technical problem for those things that do need to be imported. And, even if you didn't qualify for MU money, your records will be better and care will improve.

Hi Jon,

My thanks for your response: The 37% breakes down pretty simply: 65% Hospital Transitional Care Unit-Facility code 31 as CMS views this unit as a SNF. The balnce is to the external SNF same facility code. I learned as with eRx I was in the penalty based on denominator codes of same type for both TCU and external SNF...and no way to control Rx based on facility control. Ultimatly I have usurped the eRx TCU and SNF process at time of discharge by handling the discharge scripts through my office with a copy to the facilities for their records......then sending the sript electroncialy. This amorphous process will allow me to meet ERx demands moving forward....
I have considered looking for a pdf program, but figured if I was to go that route I might as well spend time relocating that data to an EHR system.
I had hopes that between my PM (Medisoft) and with UpDox I could develop workflow to move data to the needed fields with limited replication...and believed that if I only had to focus on the 37% group I might have a fighting chance.

Roxanne

Hi Wendell

I do beleive we need to evlove and move to at the least and EMR standard.......annually I see approx: 300-400 new patients. My typical chart is very small as repeat customers on average have a very low retunr rate...maybe every 5-10 years:)
The cost of my chart is: $2.56 for materials (folder/paper, toner contribution etc...) and approx $1.12 of labor placing the landed chart cost around $3.68 or rouhgly $1200 annually as an operating cost.
This cost while not totally offeset could better be applied to technology that moves me forward. I like what i have seen from AC based on what this fact:
I want to block and tackle rather than run a West Coast offense.....AC seems to fit this and will allow me to keep my Medisoft PM.

B/R

Roxanne

Hi David,

The challenge I face is EHR and document control in the facilities I visit. Both the Hospital and SNF require the dictation, progress notes etc....to be done in their system. I considered what you have offered in comment but found the following:

1. I am required to utilize the facility system so as the ensure their EHR systems capture data.
2. Based on this I would be doing double entry if I went to a tablet based solution that sent to my EHR.

On average the office receives approx 700 pages of clinical data (dictations, notes, labls etc....) monhtly.....all faxed from facilities or pulled from their systems by my office.

B/R

Roxanne

Hi Indy

At present here is breakdown of the achitecture my office has mapped as possible solution:

Medisoft v17 Advanced (will have to be upgraded to Pro: $2600-$3000 Inital cost)

X-Link approx $1000 plus upgrades at time of Medisoft or AC new version.

AC approx $2k ($1k therafter)great value I believe

UpDox annual of approx $500 based on service and page volume estimates.

I do have some hardware upgrades that look to be pegged at $1500k one time (Workstation replacement and migration to Windows 7. A few other periferals etc...

In total proejcted project inital cost of about $7k and $1k-$1500 in IT support costs.
Annual of about $1800 assuming Medisoft and AC upgrades every 2-3 years or so.

For a solo practice in California with avg CPT reimbursement per encounter of approx $80, Managed care out the wazoooo and MediCal payments the lowest in the lower 48 any solution that allows me to maintain 25% overhead is welcomed. The one glitch being my need to stay with Medisoft and 700 pages of faxed docs monthly.


B/R

Roxanne

Jon,

I read the 75 FR 4448 standard and wanted to express my thanks to you for the link......this does help me focus on what appears to be the facility code 31 group....

Ironically with eRX the very volume of my POS 21 group was included and considered as part of the CMS eRx formula:

CMS included my POS 21 allowed/paid when considering the 10% rule of demoninator reimbursement. Rather all POS were used for top level calculation once it was determined I saw more than 100 patients per year and the allowed/paid of my POS 31 denominator codes was greater than 10% of my allowed/paid.

Cheers from the left coast and thank again.

Roxanne

I personally never paid for Xlink - Medisoft Advanced 17 recent update - cost was $1,100 and when installed did not work. After many e mails with sales they finally said that it appears that no one gets the upgrade to work without paying $400.00 for the 'supoort' to install - BTW after a week or two more they finally checked it and Medicare still has not fixed on their end so no pay since 12/23/11.

I think it is smarter just to double enter in Medisoft and AC as that makes you double check the numbers for billing anyway and sometimes the person making appt. and entering chart is not a biller and screws it up. Takes a minute or two one time to enter in Medisoft and then it is in there.

Your CQM, etc will only count if you enter a CPT in AC, otherwise the only charts counted might be race, ethnicity, language which anyone can enter when they enter pt. Otherwise the only patients in numbers will be ones you enter a chart note in.

In a time crunch atm, but here are a few quick tidbits.

JBS addressed in an Updox thread how he uses a fax machine for inbound faxes that makes them digital, then they are auto-uploaded to Updox [cost for line and fax machine, but no per-page cost] For high volumes of inbound, the math makes good sense.

The Physiatrist on our hosted platform does significant dictation as well, and has a session open on the server at the location, and often is copy/pasting so that the generated dictation gets done once and goes into both systems as appropriate.

The Medisoft install can run on the same server, as well as Updox, so all of your practice data is accessible in one location.

Integration would also be a solution [in theory], but the tools are now available so that you no longer have to be dependent on the Hospital/Facility to do integration, you can do well without trying to get their cooperation.

Hi Steven,

Thanks for the post......something that might be of interest....I learned some time back that X link will not interface with Advanced...only Pro that allows for the middleware to work...maybe more urban legend that anything but was advised advance and pro (virtually the same less seats) could interface using X link but lots of Medisoft small practices who steered clear of unaffordable medisoft clinical were looking at more practicle solutions like AC....and since most solo/small groups docs use advance vs pro, if you cant sell the EHR at least get the upgrade:o and a few grand....not sure if this is true but seems to hold water to me.

We have considered the interface to reduce duplicate work based on staffing ratio of 1.27. Also since we streamlined our internal billing process we took on two other physicians to bill for: I do this to not as a profit center but as a way to create non-fee for service revenue, increase utilization of our fixed costs and help those we bill for reduce their billing expense.

FYI.....Our v17 upgrade was also a disaster using Mckesson tech support.......if you are still having issues consider using Accudata Services out of Florida. We have used them for years for medisoft training...they have a technical/trainng SWAT team in-house that eveloved out of v17 upgrade issues......they fixed our install, data transfer etc...in 1-2 days time.

B/R

Roxanne

I got mine to work with $400 upgrade (paid by McKesson as I am persistent) - spoke with the company who did it and they are in my State - for about 1,000 per year will provide ongoing support and switch me to new clearing house (Availity) instead of one through McKesson... still use Medisoft but change clearinghouse. I already pay 100-150 per month for RelayHealth and that will go away - Availity is free.

I may eventually switch to AC PM once it is perfected as I really hate medisoft and the ability for anyone to look up amount due, etc would be great.

just a thought re your estimate of maintaining a paper chart - you might be underestimating the costs of maintaining a paper chart.

in primary care, the chart is touched often. The associated labor costs, material costs and direct and indirect storage costs make a compelling argument in favor of AC as an EMR (AC annual fees, IT maintenance fees and hardware costs) even if there were no threat of future penalties or short term bonuses from insurers.

It may make sense to replace your paper charts with AC .. even if AC served only as a repository of imported items -

direct costs, indirect costs, landed cost; Not often is there a thread where people speak a lingo that I fully grok.

Hi Gino,

You are correct.....however as a largely facility based specialist the chart once created is not often used or added to based on the primary fact I do not see the same patient often or repeatedly. I do agree that the TCoO (Total Cost of Ownership related to both hard and soft costs) for the medical chart of say a PCP would be on order of magnitude 10x times the cost over the life span of the chart.
The real important part of the chart/labor cost offset for me actually to realocate those costs to something like EHR that will allow us to evolve towards better patient care. I am not looking to eliminate the cost bt redirect to something that has greater value and if possible a measurable ROI.

B/R

Roxanne