Experts urge for improvements in quality measures for primary care physicians

Because family physicians routinely see complex patients of varied backgrounds and medical needs, it’s time to create a better way to measure quality outcomes in primary care.

That’s the opinion of the National Quality Forum’s Measure Applications Partnership (MAP), which announced findings of a report aimed at identifying performance metrics the Department of Health and Human Services could potentially eliminate.

MAP is made up of some 150 healthcare leaders from 90 public and private organizations. It make recommendations several times a year for improving quality metrics. However, it does not consider the steps HHS and CMS would be required to take to make the changes.

While MAP typically recommends new measures or changes to those already in place, last month’s report suggested removing 51 of 240 measures that are included in seven federal programs and used to determine payments to physicians. The report also recommended finding ways to improve performance measures in nine other federal programs.

A report last fall by Johns Hopkins’ Armstrong Institute for Patient Safety and Quality mirrored MAP’s recommendations. That report identified specific steps policymakers should take, including:

  • Have one body that sets healthcare standards, similar to an organization like the Financial Accounting Standards Board, which sets standards for public companies. The body should be independent and work to determine who quality data is gathered.
  • Understand the science behind performance measures and encourage collaboration between government agencies that work in this field. That would decrease the $15.4 billion spent annual measuring and reporting quality metrics.
  • Disseminate data efficiently. With adequate funding, policymakers can determine how to communicate the correlation between quality and cost differences to patients.

Both reports said improving the way primary care physicians measure and report quality outcomes is vital to the longevity of independent practices. For many doctors, too much of a focus on these areas leads to burnout and a feeling of disconnect between clinician and patient.

At Elation, we strive to help independent physicians build relationships and focus on providing the highest quality care for patients. A well-designed EHR for primary care provider is vital to physicians’ ability to capture accurate quality data while treating patients.

We also know the move to CPC+ model will deliver incentives to physicians who meet quality metrics. To do so, solo practitioners will need help from a trusted partner like Elation.

Let us show you how we can help. Contact Elation today for a demonstration.

Tyler Comstock
May 22, 2018


CMS changes to marketplace plans may affect primary care

Healthcare costs are rising but wages are not. On the Affordable Care Act (ACA) marketplace, cost-sharing reduction payments are being eliminated. The Centers for Medicare & Medicaid Services (CMS) has announced changes in marketplace plans that affect the way patients choose to access their healthcare services. All of these add up to choices for patients that may impact their ability or desire to visit their primary care physician.

Financial considerations are significant in the choice of plans under the ACA for many patients. Low-income patients, in particular, must balance the monthly cost of their healthcare plan with their expected expenditures for preventive and catastrophic care. All patients must choose between the bronze, silver, and gold plans on the marketplace.

Although the bronze option is less expensive on a monthly basis, it does typically carry the highest deductible for the year. In fact, as explained in an article published by the Robert Wood Johnson Foundation (RWJF), “Marketplace plans as a rule have high deductibles; the medians for bronze, silver, and gold plans in 2018 are $6,400, $3,800, and $1,250, respectively.”

The RWJF article points out, though, that “Due to the quirks introduced by the elimination of cost-sharing reduction payments (CSRs), subsidy-eligible customers often found they could get better deals by choosing bronze or gold. The share of marketplace enrollees in bronze plans, in particular, increased from 23 percent to 29 percent. Among those new to the marketplace, the trend toward bronze was even greater—34 percent of new enrollees on chose bronze plans.”

So while patients may choose the bronze option because it costs less each month to keep their healthcare coverage, they may be hesitant to visit their primary care physician because the visit itself will be costly for them as the plan does not offer primary care coverage. The RWJF article explains that, “62 percent of bronze plans require that the deductible be met before any cost-sharing for primary care, while this is the case for less than 25 percent of silver and about 18 percent of gold plans.” As patients look for ways to save on their healthcare expenses, these financial barriers may keep them from being able to access primary care services.


Tyler Comstock
May 14, 2018


Study shows the impact of EHRs on the primary care providers’ patient encounter

A recent study published in Family Medicine was conducted in an attempt to update and more clearly detail the amount of time primary care physicians spend with patients when using electronic health records (EHRs). As the researchers indicated in their report, “Although several studies of the impact of EHRs on physician work report an effect on time as a percentage of their work day, almost no previous studies measured the actual time spent.”

Observers participating in the study shadowed primary care physicians, including “attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas.” They recorded time spent with patients as well as EHR screen time, using personal watches or cell phones.

Elation Health recognizes the challenges faced by many primary care physicians who desire patients’ medical records that can be easily accessed and that are always current and accurate. We also recognize that primary care physicians need more face time with patients and less screen time. The results of the study actually indicate that the physicians and residents that were observed spent a mean time of:

  • 35.8 minutes per visit
  • 2.9 minutes working in the EHR prior to entering the exam room
  • 16.5 minutes of face-to-face time
  • 2.0 minutes working the EHR in the room (73.4% of the visits)
  • 7.5 minutes of non-face time (mostly working in the EHR)
  • 6.9 minutes of EHR work outside of normal clinic operational hours (64.6% of the visits)

Elation’s Clinical First EHR solution helps physicians reduce their screen time, enabling them to spend more time engaging with patients. Most EHRs rely on a linear workflow which forces back-and-forth screen toggling and extra clicks. Elation’s Cockpit View surfaces everything primary care physicians need in a unique three-pane console, providing more flexibility.

With Elation’s EHR, primary care physicians can order and reorganize windows based on the specific practice workflow — helping physicians surface the information they need quicker and more efficiently. Physicians can document visit notes, order lab tests, e-prescribe, and write referrals in any order.

Clinical First is a commitment to building a provider-centric Clinical EHR that exists at the nexus of the clinical workflow, supports the physician-patient relationship, and drives outstanding patient outcomes.

Greg Miller
May 8, 2018


Solutions to value-based care obstacles

For independent physicians, following the changing regulations for reporting value-based care can be a significant challenge. The Centers for Medicare & Medicaid Services (CMS) has shifted its focus between programs and, in fact, is seriously considering scrapping the Merit Based Incentive Payment System (MIPS) that has been at the center of its value-based trend.

Providing value-based care continues to be, in its essence, an important part of a primary care physician’s daily practice. Quality of care is more critical to the patient than quantity of visits. However, there are many obstacles to providing and reporting that value-based care, beyond the CMS uncertainties.

Some of those value-based care obstacles – and their solutions – include:

Patient engagement. The ability to engage patients in their own healthcare is critical to the quality level of their care. Communication with patients on their follow-up plan, clarifying instructions and answering post-visit questions, can increase that engagement. Additionally, arranging “regular discussions with a care manager who really ‘knows’ their conditions and concerns helps to establish trust and engagement that will deliver ongoing benefits in terms of both patient satisfaction and physician insights.”

Effective care management for “super utilizers.” Independent primary care physicians are often faced with the challenge of patients who need to be seen multiple times for complex conditions. Some research points to extraordinary usage figures: “80 percent of healthcare costs are driven by 20 percent of patients and … 50 percent of costs are incurred by just 5 percent of patients, aka Super-Utilizers. Among Medicare fee-for-service (FFS) beneficiaries, people with multiple chronic conditions account for 93 percent of Medicare spending.” Behavioral Health Integration Services (BHI), and Chronic Care Management (CCM), both CMS programs, offer mechanisms for the primary care physician to more effectively manage the care of patients with chronic conditions.

Access to sufficient comprehensive information. Coordinating care with specialty providers and having easy access to information from laboratories and healthcare facilities is a necessity for quality value-based care. An integrated, coordinated electronic health record (EHR) system offers independent physicians the ability to do just that. Specifically, interoperable EHRs allow the electronic 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.

Roy Steiner
April 23, 2018


Why is Elation the best EHR for primary care physicians?

The electronic health record (EHR) provides primary care physicians with immediate access to patients’ medical data, before, during, and after the patient visit. Electronic records eliminate the need for paperwork, including searching through a paper file and waiting for additional records to be included in that file. The physician is prepared for each patient with a thorough understanding of that patient’s history and medical profile.

With the move toward value-based care in the medical field, EHRs become even more important for the primary care physician. The Office of the National Coordinator for Health Information Technology (ONC) states that the value-based care concept means that “doctors and other clinicians can focus on coordinating care to ensure their patients, especially those with chronic conditions, get the right care at the right time — while avoiding medical errors and duplication.”

The use of EHRs can be a significant factor in the primary care physician’s ability to provide and report on that critical value-based care. Why use Elation EHR technology as a primary care physician? Elation’s Clinical First EHR is a commitment to building a provider-centric Clinical EHR that exists at the nexus of the clinical workflow, supports the physician-patient relationship, and drives outstanding patient outcomes.

With Elation’s EHR solution, the primary care physician can work concurrently, not consecutively. The Cockpit View surfaces everything the physician needs in a unique three-pane console, giving complete flexibility in how care is delivered. The primary care physician can document visit notes, order lab tests, e-prescribe, and write referrals in any order, all from the same screen.

Monitoring a patient’s health on an ongoing basis is critical to identifying areas that need further diagnosis and treatment. Elation’s EHR enables primary care physicians to holistically evaluate their patient population with a longitudinal record that trends vitals and lab values over time. The physician can quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.

Elation is focused on helping the primary care physician deliver quality, value-based care in an effective and effective manner. Our EHR solution plays a significant role in that mission.

Greg Miller
April 17, 2018


Study shows effects of primary care on health utilization

A recent research study, published in a National Bureau of Economic Research (NBER) paper, examined the medical visit patterns of low-income patients. In particular, the researchers sought to determine whether cash incentives would encourage those patients to visit a primary care physician and whether that visit would subsequently result in lower healthcare costs and decreased emergency room (ER) visits for the target group.

In a follow-up to the original study regarding cash incentives and utilization, the team sought to “examine how the incentives affected health care utilization beyond the initial PCP visit.” In addition, the researchers set out to “assess whether an initial PCP visit changes utilization and spending, using the random assignment from the experiment to provide exogenous variation in PCP visit.”

As a result of both studies, the researchers are able to “provide new evidence on whether a low-cost investment in incentives can encourage desired health care utilization, and on whether primary care alters utilization patterns and reduces high-cost care in a low-income safety net population.”

They found that incentives did encourage the patients to visit their primary care physicians, both for an initial visit and for follow-up visits. They also found that the ER visits were modestly reduced for these patients, although outpatient visits actually increased within the first six months after the primary care visit.

Incentives were most effective in encouraging less-healthy patients to visit a primary care physician. The researchers found that their “results were not driven by relatively healthy subjects who could more easily avoid the ED than those who were in poor health.”

Surprisingly, healthcare spending increased slightly for the incentivized patients over the short term. It is expected, however, that decreased spending may occur over a longer period of time, as patients are better able to manage their chronic or complex conditions through continued and consistent visits to a primary care physician.

Nick Dealtry
April 11, 2018


Patient Longitudinal Records (PLR) v. Comprehensive Health Records (CHR)

For the primary care independent physician, a patient’s electronic health record (EHR) offers a single, convenient location to review that patient’s medical history and input visit notes. In essence, the EHR is a patient’s longitudinal record (PLR), “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.” The information can include “patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.”

The PLR enables the primary care physician to gather the patient’s full medical history. Typically, when reviewing a paper chart, the physician may only input the information necessary for a specific visit rather than spending time flipping through handwritten notes from previous visits for the full profile. The EHR offers the physician a complete longitudinal record at the touch of a button, so the primary care physician can trend labs and vitals over multiple encounters for a more holistic and longitudinal overview of the patient’s health.

When that medical data is shared between the primary care physician and a specialty physician, lab, or healthcare facility, it is shared as a collaborative health record (CHR). An independent physician taking advantage of CHR technology can compare data with colleagues with the click of a button. A CHR is always tailored to the patient and the physician’s specific clinical needs around that patient.

Patients with chronic or complex conditions, in particular, rarely see only one physician. They may require diagnoses and treatment from specialty physicians, tests and x-rays from a laboratory, and even a stay in a healthcare facility. With a CHR, the primary care physician can access that patient’s information from any provider in the network without waiting on faxes, requesting records, or chasing down results.

Likewise, when taking advantage of the collaborative EHR, other physicians treating that patient will get immediately notified so they can take action based on the most up-to-date clinical information. The patient receives accurate, timely treatment based on current data. CHRs can help reduce wasted time and potential errors by enabling all appropriate physicians complete visibility into the patient’s health.

Greg Miller
April 10, 2018


2018 MACRA updates for primary care physicians

The trend toward value-based payments began with the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that was signed into law in April 2015. Since then, there have been updates and additional programs included in MACRA, such as the Quality Payment Program (QPP). MACRA created a new framework for independent physicians who will be rewarded financially for providing high-quality care, through two tracks for payment: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs).

For 2018, the American Academy of Family Physicians (AAFP) lists a number of expected updates:

Small Practice and Complex Patient Bonuses: Independent physicians with smaller practices will receive a 5-point bonus on their Merit-based Incentive Payment System (MIPS) score. Eligible clinicians will also earn a bonus of up to 5 points for providing care to patients with complex conditions.

Increased Low-Volume Threshold: Eligible clinicians will be excluded from MIPS if they provided care to 200 or fewer Medicare Part B beneficiaries or if they received $90,000 or less in Medicare Part B payments.

Longer Performance Period: Independent physicians should be aware that the performance period in 2018 is a full calendar year (January 1 – December 31) for the quality and cost categories and is “any consecutive 90 days” for the advancing care information and improvement activities categories.

Data Completeness: Eligible clinicians participating in the quality category must report on at least 60% of their patients that are eligible for the measure, regardless of their payer.

Cost Will Be Scored: For the 2018 performance period, the weight of the cost category has increased to 10% and the weight of the quality category has decreased to 50%.

Virtual Groups Available: For those smaller independent physician practices, including solo practitioners and practices of 10 or fewer clinicians, the opportunity is available to join together as a virtual group in order to participate in MIPS.

Greg Miller
March 27, 2018


Getting serious about HIPAA

Patient-physician communication used to be simple. The patient came into the office to speak with the doctor or the physician telephoned and spoke directly with the patient. In today’s world of electronic communications, however, the potential has increased significantly for communicating private, confidential information in an unsecured manner.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was implemented as a way to make patient information safer. The act “required the Secretary of the U.S. Department of Health and Human Services (HHS) to develop regulations protecting the privacy and security of certain health information.” At the time, electronic communication was not as pervasive in the medical community as it is today.

Electronic protected health information (e-phi), such as that found in a patient’s electronic health record (EHR) is now covered under the Security Rule that was published as a Final Rule in 2003. EHR systems provide a secure way to communicate to the patient and to other providers involved in that patient’s care. The challenge comes when physicians and patients are attempting to communicate via other electronic channels.

Many patients are reaching out to their physicians via email or even social media direct messaging tools. Independent physicians must be careful when replying to these messages so they do not convey any information that is considered protected. Email systems outside of those used within EHRs, social media, texting, and other forms of unsecured communications may be easy to use but they also open up huge potential for HIPAA violations.

Online reviews may also tempt the independent physician with patient-specific information that is a violation of the privacy and security laws of the HIPAA act. For example, if a patient references the time she came to see the doctor for a knee pain, the independent physician can neither acknowledge the fact that she is a patient nor that she was seen for knee pain.

HIPAA is a serious matter. Protecting the patient’s information must be of paramount priority for the independent physician.

Tyler Comstock
March 22, 2018


Primary care physicians and hospitalists on care quality

When a primary care physician’s patient is admitted to the hospital, that patient’s care is quite often provided by hospital staff, including a hospitalist. As the term implies, a hospitalist is an internal medicine physician who practices in a hospital setting only. The hospitalist specialty is relatively new, having been initiated just over a decade ago.

A hospitalist has several differences over the primary care physician when caring for a patient who has been admitted to the hospital. The hospitalist has established hours to care for patients in the hospital and does not have to be called in from an independent practice when a patient needs care. The hospitalist is trained in hospital procedures and serves as the point of contact between nurses and other hospital staff and the patients’ primary care physician.

However, a recent study published in JAMA Internal Medicine found that the primary care physician’s familiarity with the patient’s medical history and prior established relationship with that patient may have a more significant impact on the level of care quality provided to the patient in the hospital.

The study, which involved over 560,000 Medicare patients, found that “patients cared for during a hospitalization by their own primary care physicians had slightly longer lengths of stay, were more likely to be discharged to home, and were less likely to die within 30 days compared with those cared for by hospitalists.” In addition, patients cared for by their primary care physicians while in the hospital had a slightly lower readmission rate than those who were cared for by a hospitalist.

The primary care physician may have an advantage in providing higher quality care, given the prior relationship and knowledge of the patient’s medical history. The hospitalist has some advantages in regard to being more familiar with hospital operations and being able to communicate more effectively with hospital staff. Hospitalists, in the study, tended to discharge patients earlier and to another healthcare facility, whereas the patient’s primary care physician was more likely to discharge patients to their own home.

Greg Miller
March 20, 2018