NAM emphasizes the importance of interoperability during EHR selection

Electronic health records (EHRs) enable independent physicians to seamlessly and efficiently record visit notes, monitor their patients’ progress, and track outcomes for improved population health. EHR interoperability enables physicians, laboratories, and other healthcare providers to electronically communicate in real-time, reducing the potential for errors and increasing their ability to work together for positive patient outcomes.

A recently released National Academy of Medicine (NAM) special publication outlines the need for EHR interoperability between healthcare providers, stating that “several common causes of medical errors, including drug errors, diagnostic errors, and failure to prevent injury, can partially be addressed by better data exchange among patients, medical devices, EHRs, and other health technologies.”

While the majority of hospital and independent physicians’ practices do use EHRs, the lack of EHR interoperability between them means that “information from multiple sources, devices, and organizations across the care continuum are unable to flow at the right time, to the right party, and for the right patient,” according to the NAM report. The publication cites 2016 statistics which indicate that 96 percent of hospitals and 78 percent of physicians’ offices were using EHRs.

The key to EHR interoperability is in the selection of the EHR system itself for the independent physician’s practice. As the NAM publication indicates, “most health care providers spend time and money setting up each technology in a different way, instead of being able to rely on a consistent means of connectivity.”

Victor J. Dzau, NAM’s president says, “To ensure that health care dollars are spent in pursuit of health care delivery systems reaching desired levels of care quality, safety, and efficiency, interoperability must be a top priority.”

Solutions such as Elation Health’s Collaborative Health Record enable the independent physician to automatically share updates directly from their Clinical EHR. Other providers are immediately notified so they can take action based on the most up-to-date clinical information. Collaborating with other providers is done with the click of a button, so the independent physician always has the most current and accurate patient information.

Sam Peirce
November 5, 2018


Researchers recommend EHR certification for pediatric care

Just as women and men are different, physically, so are adults and children. Many researchers have found that those differences also require differences in the electronic health record (EHR) capabilities for each patient age group.

The 21st Century Cures Act for States includes a section for “Assisting doctors and hospitals in improving quality of care for patients.” In regard to EHRs and pediatric care, section 4001(b) specifically states that the Office of the National Coordinator for Health Information Technology (ONC) “must encourage, keep, or recognize the certification of health IT for use in medical specialties” and that Health and Human Services (HHS) “must adopt certification criteria to support health IT for pediatrics, and begin certification soon after.”

Pew researchers have urged the ONC to institute a voluntary certification program for EHRs related to pediatric care, stating that is a “a golden opportunity to make digital records more effective for the youngest and often most vulnerable patients.” Pew emphasizes the positive effects of using EHRs for patient care, but also cautions that mistakes are often made when caring for children.

One potentially devastating case occurred in 2013, when “a 16-year-old patient in California was inadvertently given 38 times the appropriate amount of an antibiotic; the physician didn’t realize that the EHR’s default setting multiplied the amount entered by the patient’s weight. As a result, the patient suffered a near-fatal grand mal seizure.”

Researchers at Pew emphasize that “ONC should focus on rules to better monitor and test EHRs—including safety evaluations of high-risk functions such as weight-based drug dosing in pediatric care—that go beyond current requirements for EHRs and focus on the issues that emerge in the care of children.”

While requirements are currently in place for certified EHR usage, including certification for electronic prescriptions, researchers are strongly recommending that EHRs also undergo a certification process specifically for use in pediatric care given the many physical differences between adult patients and children.

Sam Peirce
October 31, 2018


How lack of interoperability affects value-based care

Healthcare providers transitioning to value-based care face many challenges. The shift from the traditional fee-for-service emphasis on quantity of patient visits to the value-based reimbursement model requires extensive reporting and compliance with Centers for Medicare & Medicaid Services (CMS) regulations. Administrative burdens can hamper the delivery of value-based care for independent physicians. Another challenge is the practical application of electronic health record (EHR) interoperability for coordinated care.

The independent physician’s ability to collaborate with other healthcare providers, particularly to care for patients with chronic or complex conditions, is a critical factor in value-based care delivery. The challenges in EHR interoperability for coordinated care can impede the physician’s ability to share patient data and to electronically receive data from other physicians that could be crucial for the proper care of that patient.

Nishant Anand, MD, Chief Medical Officer for Population Health Services, Chief Transformation Officer for Adventist Health System and Chairman of the Adventist Health System ACO, recently provided written testimony at a House subcommittee hearing on Examining Barriers to Expanding Innovative, Value-Based Care in Medicare. In regard to interoperability, Dr. Anand stated that “As patients navigate throughout the continuum of care—through physician offices, hospitals, same-day surgery centers, or community clinics—their records should be easily transferrable between all organizations.

To provide true value-based care, physicians must be able to communicate with each other and with patients seamlessly and in real-time. Physicians who take advantage of EHR interoperability for coordinated care are able to receive and view test results, specialty physician visit notes, and other vital information related to the care of the patient electronically. Without interoperability, the patient must bring records to each physician visit or the primary care physician must request records from specialty providers. Either of those options could be time-consuming and result in lower quality care.

Dr. Anand adds that “One of the greatest challenges to achieve this level of interoperability is the lack of a single patient identifier that can move from system to system and ensure records can be passed between disparate entities without fail.” Without EHR interoperability, the patient and the independent physician face an “experience that is difficult and cumbersome, tests and treatments that are duplicated, and vital lifesaving information that is not always available.”

Sam Peirce
October 29, 2018


How adopting health data standards could enable interoperability

Electronic health record (EHR) interoperability is a key piece in the sharing of patient information between different EHR systems and healthcare providers, improving the ease with which doctors can provide care to their patients and patients can move in and out of different care facilities. However, there are a number of EHR interoperability challenges that must be overcome to allow for true coordination of patient care among multiple providers.

Adopting health data standards can be part of the solution to overcoming those EHR interoperability challenges. The Office of the National Coordinator (ONC) for Health Information Technology (Health IT) is “working to enable the health IT community to convene and rapidly prioritize health IT challenges and subsequently develop and harmonize standards, specifications and implementation guidance to solve those challenges.”

The ONC publishes the Interoperability Standards Advisory (ISA) as “a way of recognizing interoperability standards and implementation specifications for industry use to fulfill specific clinical health IT interoperability needs.” Included on the list of standards “to watch,” that could impact and help overcome EHR interoperability challenges, include:

  • Consolidated-Clinical Document Architecture (C-CDA) — C-CDA is a framework for creating clinical documents that contain both human-readable text and machine-readable XML. Targets include Health Information Exchanges that comply to the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009, the Final Rules for Stage 1 Meaningful Use, and the 45 CFR Part 170 – Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule, as well as EHR vendors.
  • Direct — is a standard for sending health information securely over the internet. The ability to send secure direct messages is critical for independent physicians to communicate with specialty providers and with patients.

ONC is responsible for “curating the set of standards and specifications that support interoperability and ensuring that they can be assembled into solutions for a variety of health information exchange scenarios.”

Sam Peirce
October 16, 2018


Eligible physicians have until October 15 to resolve MIPs scoring errors for 2017

Physicians participating in the Merit-based Incentive Payment System (MIPS) during the 2017 performance year have until October 15, 2018, to access and review their performance feedback. The Centers for Medicare & Medicaid Services (CMS) has extended the deadline for a targeted review to offer additional time given the complexities of the scoring system, the impact the score will have on 2019 MIPS payment adjustments, and the concerns received by CMS from physicians.

A targeted review provides the opportunity for clinicians, groups, or those participating in certain Alternative Payment Models (APMs) to request that CMS review their MIPS payment adjustment factor(s), if they believe there is an error with the 2019 MIPS payment adjustment calculation.

Concerns received by CMS included the application of the 2017 Advancing Care Information (ACI) and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity credit for successful participation in the Improvement Activities (IA) Burden Reduction Study, and the addition of the All-Cause Readmission (ACR) measure to the MIPS final score. After reviewing the concerns, CMS identified a few errors in the scoring logic and implemented solutions.

Eligible physicians should sign-in to the Quality Payment Program website now to review their performance feedback. If an error still exists with the 2019 MIPS payment adjustment calculation, the targeted review process is available until the deadline of October 15, 2018.

For those physicians who need additional assistance or answers to specific questions, the Quality Payment Program Service Center can be reached by phone at 1-866-288-8292, (TTY) 1-877-715- 6222, or by email at

2017 was the first performance year for the Quality Payment Program, which CMS refers to as the transition year. The 2017 MIPS final score will affect the associated 2019 MIPS payment adjustment. CMS encourages all eligible physicians to conduct their targeted review before the deadline of October 15, 2018 at 8:00pm (EDT).

Sam Peirce
October 10, 2018


Learning more about the Primary Care Medical Home Model (PCMH)

The Primary Care Medical Home, or Patient Centered Medical Home is a model for transforming the organization and delivery of primary care. The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not only as a place but as a model of the organization that delivers the core functions of primary health care.

The medical home incorporates five functions and attributes:

Comprehensive Care

  • Meeting most of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
  • The team of care providers may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.
  • Many smaller practices build virtual teams connecting themselves and their patients to providers and services in their communities.


  • Provides health care that is relationship-based and actively supports patients in learning to manage and organize their own care at the level the patient is comfortable with.
  • Patients and their families are also members of the care team and therefore are informed partners in creating care plans.

Coordinated Care

  • The PCMH coordinates care across all aspects of the health care system, including specialty care, hospitals, home health care, community services and supports.
  • Creating clear and open communication among patients and families, the medical home, and members of the larger care team.

Accessible Services

  • Responsive to patients’ preferences regarding access.
  • Gives available services with shorter waiting times for urgent needs, improved in-person hours, 24/7 telephone or electronic availability to a member of the care team, and alternative methods of communication like email and telephone care.

Quality and Safety

  • Public sharing of quality and safety data and improvement activities is an important indicator of a complete commitment to quality.
  • Dedicated to quality improvement by engaging in activities like using evidence-based medicine and clinical decision-support tools to advise decisions with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management.

Tools and resources to help implement PCMH

The Primary Care Practice Facilitation (PCPF) Curriculum: supports the development of the workforce that is prepared to help transform primary care by supporting a widespread adoption of the new models of care delivery and the use of continuous quality improvement. It is used to train both new and experienced practice facilitators in the knowledge and skills needed to support meaningful improvement in primary care practices.

Foundational Supports for the PCMH Model:

The Agency for Healthcare Research and Quality (AHRQ) also recognizes the central role of health IT in being able to successfully implement the medical home.

Health IT

  • Can support the PCMH model by collecting, storing, and managing personal health information, and aggregate data that can be used to improve processes and outcomes. It can also support communication, clinical decision making, and patient self-management.


  • A primary care workforce including physicians, physician assistants, nurses, medical assistants, nutritionists, social workers, and care managers all trained in providing care based on the elements of the PCMH, is an important factor in the model.


  • Current fee for service payment policies are incapable of fully achieving the PCMH goals.
  • Payment reform is needed to achieve the potential of primary care and the medical home.

Sam Peirce
October 1, 2018


The history of value-based care

The Centers for Medicare & Medicaid Services (CMS) defines value-based care as those programs that “reward health care providers with incentive payments for the quality of care they give to people with Medicare.” CMS began emphasizing value-based, quality healthcare over the quantity of provider visits in 2008. Since then, additional programs have been put into place that direct the reporting requirements and the payment levels based on certain circumstances.

In 2008, CMS initiated the Medicare Improvements for Patients and Providers Act (MIPPA) which, in part, rewarded eligible healthcare providers for electronic prescriptions. The next year, the Health Information Technology for Economic and Clinical Health Act (HITECH) was included in the American Recovery and Reinvestment Act of 2009 (ARRA). HITECH established programs under Medicare and Medicaid to provide incentive payments to eligible healthcare providers for the “meaningful use” of certified electronic health record (EHR) technology.

The Affordable Care Act (ACA) was implemented in 2010. ACA placed more emphasis on quality care and authorized a number of value-based programs that rewarded healthcare providers based on that quality rather than on quantity. Just a few years later, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law as a bipartisan legislation on April 16, 2015.

CMS states that “MACRA created the Quality Payment Program that:

  1. Repeals the Sustainable Growth Rate formula
  2. Changes the way that Medicare rewards clinicians for value over volume
  3. Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
  4. Gives bonus payments for participation in eligible alternative payment models (APMs)”

In recent years, healthcare provider feedback regarding the reporting burdens and complications placed upon them by value-based reimbursement program requirements has caused CMS to re-evaluate some of their initiatives. CMS has launched an Innovation Center supporting “the development and testing of innovative health care payment and service delivery models.” The Innovation Center seeks further input from physicians and other healthcare providers as they test “various payment and service delivery models that aim to achieve better care for patients, smarter spending and healthier communities.”

Sam Peirce
September 25, 2018


Tips for avoiding a payment penalty in 2018 for MIPS

Minimum reporting requirements for the Merit-based Incentive Payment System (MIPS) track of Medicare’s Quality Payment Program (QPP) have been raised somewhat for 2018. Previously, independent physicians had only to report on one measure to meet the qualifications. For 2018, however, physicians must earn a minimum of 15 points to avoid a payment penalty.

The American Medical Association (AMA) has published a list of tips for independent physicians so they can earn incentives and avoid the payment penalty. The AMA tip sheet points out that the general formula for determining an independent physician’s score within a performance category is: “Points earned by physician / total possible points within the performance category x performance category weight = Earned points.” It adds that “A physician’s four performance category scores (as well as any bonus points) will then be added to determine a physician’s final score.”

Smaller practices of 15 or fewer clinicians can meet the performance threshold and avoid a payment penalty by:

  • Reporting one high-weighted Improvement Activity
  • Reporting one medium-weighted Improvement Activity and 1 Quality measure
  • Reporting six Quality Measures
  • Reporting Advancing Care Information base score and one Quality measure

Tips for larger practices of 16 or more clinicians to meet the performance threshold and avoid a payment penalty for 2018 include:

  • Reporting two high-weighted or four medium-weighted Improvement Activities
  • Report two medium-weighted Improvement Activities and four Quality measures
  • Report Advancing Care Information base score and two Quality measures

The AMA points out that, in developing these tips, it assumes “the quality measures reported meet the data completeness requirement (60% of all eligible patients and report each measure for a minimum of 20 patients) and that the practice is scored on the all-cause hospital readmission measure.”

2018 reporting impacts the independent physician’s 2020 MIPS payment. Following these tips now can help the healthcare provider qualify for incentive payments and avoid a penalty.

Sam Peirce
September 18, 2018


How CMS is trying to tackle interoperability

In a continuing effort to promote interoperability between electronic health record (EHR) systems, the Centers for Medicare & Medicaid Services (CMS) has issued, as part of their recently published proposed changes, a renaming of the Merit-Based Incentive Payment System (MIPS) Advancing Care Information performance category to Promoting Interoperability (PI). Interoperability is, quite simply, a sharing of information between EHR systems, to enable seamless collaboration among healthcare providers.

CMS states that the renamed Promoting Interoperability category:

  • Emphasizes patient engagement and the electronic exchange of health information using Certified Electronic Health Record Technology (CEHRT).
  • Is worth 25% of the MIPS Final Score in 2018.
  • Is comprised of a Base, Performance, and Bonus score. All added together to give a clinician or group a Promoting Interoperability performance category score. Must fulfill the Base score to earn a Promoting Interoperability performance category score.
  • Includes a minimum performance period of 90 days.
  • Requires the use of CEHRT to capture data and fulfill the performance category

To aid in the transition, CMS has established two Promoting Interoperability measure sets that are available for clinicians in 2018:

  • Promoting Interoperability Objectives and Measures
  • Promoting Interoperability Transition Objectives and Measures

CMS explains that the “measure set a clinician or group selects will depend on the CEHRT edition. Clinicians and groups who exclusively report the Promoting Interoperability Measures using 2015 Edition CEHRT will earn a 10% bonus.” Providers can report the Promoting Interoperability Objectives and Measures if they have 2015 Edition CEHRT or a combination of 2014 and 2015 Editions of CEHRT. Providers who have 2015 Edition CEHRT, 2014 Edition CEHRT, or a combination of 2014 and 2015 Editions of CEHRT, can report the Promoting Interoperability Transition Objectives and Measures.

The interoperability score is based on factors such as patient access to records, providing patients a summary of care, secure messaging capabilities, clinical information reconciliation, and reporting certain improvement activities using CEHRT.

Sam Peirce
September 4, 2018


2017 MIPS performance results so far

The Quality Payment Program (QPP) is an incentive program for healthcare providers implemented by the Centers for Medicare & Medicaid Services (CMS). The QPP rewards value and outcomes, in a move toward value-based care, through two separate programs: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). The healthcare provider’s performance is measured in terms of Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost.

To be eligible for the MIPS program, the healthcare provider must meet the low volume threshold set by CMS, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. The initial goal for CMS was to have 90% of healthcare professionals eligible for MIPS submit their data in 2017.

The preliminary results show that CMS has met their goal, plus a little more. The numbers show that 91% of those healthcare providers eligible for MIPS submitted their data successfully in 2017. Accountable Care Organizations (ACOs) showed even more impressive numbers with 98% submitting data in 2017. Additionally, 94% of small and rural healthcare practices submitted MIPS data successfully in 2017.

Most independent physicians probably did not see significant incentive payments, however. The MIPS structure is such that incentives are paid out from the penalties collected. In 2017, healthcare providers who submitted any data were able to avoid the penalties, to encourage participation.

Of those who submitted their data successfully in 2017, many providers will see neutral or minimally positive payment adjustments. The exception will be for those healthcare providers who achieved exceptional performance based on the scoring metrics. Those payments are made from an existing $500 million incentive pool.

The official CMS report on final MIPS scores was scheduled to be published in the summer of 2018.

Sam Peirce
August 29, 2018