PURPOSE OF MEETING

The primary objectives of the 14th Web conference of the Electronic Health Records Workgroup (EHR WG), chaired by Dr. Jon Perlin and Ms. Lillee Gelinas, were to hear presentations on the financial/business case domain and to discuss recommendations to make to the Community.

INTRODUCTORY REMARKS

Dr. Perlin and Ms. Gelinas began the meeting at 1 p.m. The February 22, 2007, EHR WG meeting minutes were approved. Dr. Perlin announced that this meeting would include two presentations: a VistA Office EHR (VOE) update from Dennis Stricker, a Doctor’s Office Quality Information Technology (DOQ-IT)/Office Systems Survey overview from Jim Sorace and Sue Fleck, and a demonstration of DOQ-IT U from Chuck Parker. These presentations would provide a springboard for discussion of structural and process measures for advancing the adoption and implementation of electronic health records (EHRs). In the latter half of the meeting, Betty Ranslow also provided the group with testimony on the National Governors Association (NGA) meeting and the Internal Revenue Service (IRS)/Stark exceptions.

KEY TOPICS

1. Presentations

Cultural/ Organizational: DOQ-U Demonstration. Chuck Parker and Sue Ordway, Masspro, provided a demonstration of how to use the DOQ-IT University tool, which is funded by CMS. They highlighted the systems different modules, or learning sessions, that contain lessons, learning goals, quizzes, and surveys in an easy-to-follow format. With a focus on care management, these modules provide physicians with the tools necessary to assess their readiness for an EHR or develop a project charter for a health information technology (HIT) adoption project. DOQ-U is in general release now, and Masspro has received positive feedback about the effectiveness of the tools.

2. EHR WG’S AHIC Recommendation Planning Session

In the second half of the meeting, EHR WG members focused primarily on the financial/business case domain, identifying financial levers that could be proposed to AHIC for expediting adoption of EHRs.

A. Financial/Business Case Domain

The EHR WG discussed whether the best strategy in terms of financial incentives would be a “big bang” approach that attempts a widespread adoption over a short period or a much less aggressive, gradualist approach that makes incremental increases in adoption over a longer period. In addition to this discussion, a number of possible recommendations were suggested:

• Include contractual language in health plan contracts that is geared towards generating initial capital for physicians as they adopt and use EHRs. A section of the executive order encourages and facilitates the provision and receipt of high quality and efficient health care, and such approaches may include pay for performance models of reimbursement consistent with current law.

• Create multiple incentives, both up front and long term. Possible incentives included:

  • Grant programs or tax credits to reduce the cost of acquisition and implementation

  • Reimbursement reform that would recognize and reward the use of EHRs submitted to the payer

  • Subsidized government loans to small physician practices that are based on forgiveness or interest forgiveness over time in order to prevent physicians from having to seek out loans from banking institutions

  • Physicians’ purchasing cooperatives

  • Open-source, low-cost EHR products and platforms.

• Frame a principle around payer collaboration in the development of incentives, particularly pay-for-performance incentives, which would support HIT adoption.

• Encourage insurance company incentives (Massachusetts Blue Cross Blue Shield was held up as an example of a company helping providers acquire and use EHR/HIT). It was noted that insurance companies have a vested interest in improving health care performance as a way to reduce outlays on claims.
• Clarify whether issues of interoperability should be solved first or in tandem with the rollout of a robust EHR system.
• Include pay-for-improvement programs in health contracts. The programs would include structural measures (1/3), process measures (1/3), and outcome measures (1/3). The program would aim to avoid penalizing early adopters by emphasizing outcome in physicians’ offices that already have functional EHR systems and structural payments for those that are just implementing HIT.

Staff Action Item #1: Formulate possible financial recommendation focusing on pay for improvement using structure, process and outcome measures.

• Dr. Perlin noted that a presentation on insurance company incentives from a representative of the insurance companies in Massachusetts, particularly the Boston Blue’s approach may be helpful.

B. Legal/Regulatory Domain

The EHR WG discussed two previous recommendations from the February minutes: one recommendation for CMS to help in clarifying what is and is not allowed in terms of safe harbor relative to the Stark regulations, and one recommendation to encourage broader use of malpractice premium credits to encourage adoption. Although the group did not finalize either recommendation, the following conclusions were reached:

• Do not submit a recommendation to AHIC regarding Stark regulations. Instead, direct any questions and requests for clarity regarding Stark and anti-kickback to ONC.

Staff Action Item #2: WG members should forward questions and requests for clarity regarding Stark and anti-kickback to ONC.

• Two possible competing recommendations were put forward in regards to malpractice premium credits:

• A recommendation to encourage malpractice insurers’ broader use of malpractice premium credits to encourage physicians to adopt and use EHRs

• A dual-pronged recommendation that (1) requests additional research on ways to refine the estimates of risk reduction and increase using HIT and (2) analyzes what can be done now, given that there are some carriers who are offering malpractice premium cuts for using EHR.

No consensus was reached on the recommendation.

Staff Action Item #3: Work on a background resolution concerning encouraging malpractice insurance companies to issue premium credits to physicians as a way to encourage adoption of EHR.

C. Cultural/Organizational Domain

• Ensure that there is appropriate support for DOQ-U as the system moves forward.

D. State-of-the-technology Domain

• The EHR WG did not put forth potential recommendations in this critical component.

E. Privacy and Security Domain

• The EHR WG did not put forth potential recommendations in this critical component.

• The EHR WG asked Ms. Ranslow and ONC to keep them up to date on issues dealing with privacy and security.

3. Public Comment

Angela Johnson, the American Osteopathic Association, noted that most physicians are in smaller practices. As a result, she appreciated the EHR WG’s focus and recognition of issues surrounding smaller practices.

SUMMARY OF ACTION ITEMS

Staff Action Item #1: Formulate possible financial recommendation focusing on pay for improvement using structure, process and outcome measures.

Status Action Item #1: Currently a draft recommendation.

Staff Action Item #2: WG members should forward questions and requests for clarity regarding Stark and anti-kickback to ONC.

Status Action Item #2: Resolved.

Staff Action Item #3: Work on a background resolution concerning encouraging malpractice insurance companies to issue premium credits to physicians as a way to encourage adoption of EHR.

Status Action Item #3: Currently a draft recommendation.

MEETING MATERIALS

Agenda

Medpac Report to the Congress: Medicare Payment Policy, March 2005, Chapter 4: "Strategies to improve care: Pay for performance and information technology" (Look at structural measures pgs 191, 196-199)

Executive Order: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs

Executive Order: Four Cornerstones of Health Care Transparency