How one orthopaedic practice earned $342,000 in Medicare incentive payments

Because the meaningful use program was defined with primary-care physicians in mind, participation by specialists has been challenging. But more than 9,000 orthopaedists have successfully attested and earned incentive payments. Using the right electronic health record (EHR) system and availing themselves of permissible exclusions for nonrelevant requirements, some orthopaedic practices have even done so without any negative impact on productivity.

One of those practices is St. Cloud Orthopedics in Sartell, Minn. This 19-physician group earned $342,000 in Medicare incentives last year, and their reporting period began a mere 2 weeks after they first implemented their EHR. To unearth the key to their success, Jackie Ryan, manager, AAOS practice management group, interviewed David L. Kaus, MD, and practice administrator Bill Worzala.

Ms. Ryan: How long have you been using an EHR?

Mr. Worzala: We successfully transitioned from paper charts to the SRS EHR in July 2012.

Ms. Ryan: Can you describe your EHR selection process and identify the factors that were most important in your decision?

Dr. Kaus: We were looking for an EHR with widespread success in large orthopaedic practices, one that would not require massive changes to our practice styles and would have no negative effect on physician productivity. We were well aware of the high cost of a failed EHR implementation and knew that an EHR designed for primary care would not work in our office. We had reviewed and refused point-and-click, templated EHR systems due to the productivity impact. The system we chose does not require physicians to keep clicking during patient encounters to create the documentation. It enables us to keep the focus on productivity while helping us attest to meaningful use. We obtained proposals from multiple EHR vendors and narrowed it down to two that we observed in site visits at practices like ours.

Ms. Ryan: How long was the implementation process, and what kind of support and training did you receive before going live?

Mr. Worzala: The implementation went faster than anticipated. On-site training and weekly calls prepared us to hit the ground running. It was a very smooth process, and, as promised, we never had to reduce our patient volume, even during implementation.

Ms. Ryan: Why was meaningful use important to you?

Dr. Kaus: Although the EHR incentives did ultimately offset the cost of our EHR purchase, we were more concerned about avoiding the penalties. We also wanted to be positioned for the future.

Ms. Ryan: Which meaningful use measures did you exclude and which menu measures did you choose to report?

Mr. Worzala: Our physicians claimed exclusions for the two public health menu measures—immunizations and syndromic surveillance—because neither is relevant to orthopaedics. We reported vital signs; we already documented height and weight, but we had to add blood pressure to satisfy meaningful use. This year, physicians can separately exclude blood pressure, but we have decided to continue reporting it.

For the remaining three menu measures, we selected drug formulary because our software automatically included this capability, patient education, which already was a standard part of our practice, and creating a patient list. This was a one-time task that was easy to do using the advanced reporting capabilities that are part of our EHR system.

Ms. Ryan: Did the physicians have to make any changes to their practice style or documentation methods to meet meaningful use? How did the requirements affect the surgeons?

Dr. Kaus: Our staff accepted most of the responsibility for meeting the measures; as surgeons, we spent minimal time on meaningful use documentation. We didn’t have to make any major changes in the way we document patient care—we continue to dictate our notes. Getting the patient’s current medications into the EHR initially required a significant increase in nursing intake time, but this has lessened substantially as new patients become follow-up patients. We did have to increase our use of ePrescribing, and that is now an integral part of our practice.

Ms. Ryan: How did you modify the staff’s workflow to efficiently achieve meaningful use?

Mr. Worzala: We allocated meaningful use responsibilities throughout the practice to handle them in the most cost-effective manner. Our nurses handle clinical tasks such as smoking status and vital signs, while our front desk staff records demographics when patients check in and distributes clinical summaries when they check out.

Ms. Ryan: Who helped you through the meaningful use process? Did you require the services of a consultant or your Regional Extension Center?

Dr. Kaus: The meaningful use training provided by our EHR vendor was abundant and thorough. Their dedicated Government Affairs department and implementation staff went above and beyond to help us understand the requirements, plan our workflows, and meet the thresholds. We attended Meaningful Use University at the User Summit (our vendor’s annual client meeting) and took full advantage of the educational webinars, videos, training documents, and attestation guide that were offered—all of which made meaningful use as painless as possible. We required no outside assistance.

Ms. Ryan: What steps did you take to ensure that you would be prepared to attest successfully?

Mr. Worzala: Our EHR provides a color-coded Automated Measure Calculation report that shows how each physician is performing at any point during the reporting period (Fig. 1). We ran these reports on a weekly—and when necessary, daily—basis, so that we were able to correct our workflows as soon as any shortfalls were detected. Consequently, there were no surprises when we were ready to attest.

Ms. Ryan: Were there any surprises in the attestation process?

Mr. Worzala: Attestation was easier than we had anticipated. The website from the Centers for
Medicare & Medicaid Services (https://ehrincentives.cms.gov/hitech/login.action) is easy to navigate and allows physicians to authorize an administrative staff member to attest on their behalf.

Ms. Ryan: What do you know now about meaningful use that you wish you knew beforehand?

Mr. Worzala: The weight of the meaningful use responsibilities should not fall on the physicians. We would not have been nearly as concerned about the impact on our physicians had we known how much could be met by clinical and administrative staff. Also, we had concerns about the clinical quality measures (CQMs) because most of the measures were not relevant to orthopaedics and we reported many zeros. We were relieved to learn that there were no thresholds for CQMs.

Ms. Ryan: What advice can you share with other orthopaedists considering meaningful use?

Dr. Kaus: Assign a staff member to manage meaningful use and be responsible for workflow distribution, training, and performance monitoring. This will free physicians to focus on seeing patients.

Ms. Ryan: Are you starting to prepare for meaningful use Stage 2?

Mr. Worzala: Right now we are focusing on maintaining the workflows we put in place last year for Stage 1 so that our physicians can earn their second incentives ($12,000 for a full year of meaningful use). Stage 2 doesn’t start until 2014 and only requires 90 days of reporting next year, so we plan to analyze the new requirements in depth later this year. We expect to receive the same support, training, and workflow advice from our EHR vendor that we had in Stage 1.

Ms. Ryan: What were your initial thoughts toward meaningful use? Have they changed since your success?

Dr. Kaus: Initially, the idea of adding primary-care functions to our established clinical workflows was an issue. We were also concerned about the extra work that meaningful use could impose on our physicians. Looking back, however, it was easier than we’d expected. With guidance from our vendor, we assigned meaningful use workflows to the appropriate staff members and excluded measures not relevant to our practice. It also helped that our EHR does not require overly burdensome data entry.

Ms. Ryan: What would you say to other orthopaedists who are concerned about implementing an EHR in their practice?

Dr. Kaus: The decision to adopt an EHR should not be driven by meaningful use, but rather by the benefits it can deliver to your physicians, your patients, and your practice. Perform your due diligence—talk to other orthopaedists to see how they’re using their EHR systems. Implement a system that is easily configured to the manner in which you practice, and avoid any system that diminishes your productivity, even in the short term.