This post was authored by Thad Waites, MD, FACC, past chair of the Board of Governors.

The ACC is launching a vigorous digital transition. In fact, the world is launching this transition. The House of Medicine and the health system in general has been said to be late going digital. But now with the Centers for Medicare and Medicaid Services’ (CMS’) Meaningful Use criteria, the federal government's encouragement, and the broad global rollout of new clinical technologies, we can’t afford not to move forward. Unfortunately, even the computer world is learning how difficult it is for Medicine to go digital.

In the microcosm of my clinic in Hattiesburg, MS, we have transitioned to a new electronic medical record (EMR) system, and there are certainly some lessons learned. My clinic consists of 250 multispecialty doctors with satellite clinics and a close connection to a single hospital system. Before we transitioned, we already had a very acceptable web-based software program that was modular, served our needs fairly well, but was outpatient. We needed to evolve into a larger program and would that also could be seamless with the hospital's system.

The decision to buy a new EMR from one of the major software vendors was not an easy decision. The cost was high, and the work required to transition was immense, it pulled professionals away from their jobs in the clinic. At some point personnel and physicians from every area had to train at the software vendor's campus. Additional costs were also involved, not to mention it was difficult to convince 250 physicians that this was the right thing to do.

The project was painstakingly done. It took two years to fully transition and involved carefully established timelines. It was important to have a physician champion as the leader of the project and it also helped that this physician was on the clinic governance board.

The clinic transitioned on a single launch date. Expecting the unexpected certainly applied to the first several days after the launch. Our servers malfunctioned, users were being shut down throughout the day for several days, and doctors, who had already reduced their workload for the transition, were greatly affected. Needless to say, there was a great deal of consternation. Fortunately the problem proved to be software glitches and not hardware problems. Since we had major brand servers and one of the leading software vendors, it was a surprise that these glitches had not been encountered before in other launches. Once the initial problems worked out, it has been relatively smooth sailing ever since. However, since doctors were seeing fewer patients, the entire system experienced a decrease in the bottom line during that time.

There were several lessons to be learned in our launch. Transitioning from regular dictation to voice recognition dictation or template notes has been a vital but difficult part of the transition. In addition, going from check-off order sheets to a computerized physician order entry (CPOE) has been critical but difficult as having to find the right name for a procedure, the associated diagnoses, and even where to sign the order takes time. Whether it is better to launch in one fell swoop rather than unit by unit is definitely open to debate. It is important that all issues post launch are handled by a helpdesk that is specific to EMR issues and that has adequate personnel to handle the load. It has also been vitally important for the end users to help each other.

We are now approximately 9 months into the transition and from what I hear our production is within 5 percent of what it was prior to the launch. This may or may not be a permanent decrease in production, but based on conversation with other health systems, this may just be a permanent effect of “going digital.” As for the hospital, we are now gearing up for the transition to the same EMR software.

There is no doubt that if we could transport ourselves into the future, all of American medicine will be digital. This will be beneficial to patients, the system, and even the providers. It is the going over, however, that can be quite bumpy. I therefore will end with a quote from William Shakespeare: "I am in blood steeped in so far that should I go no more, returning were as tedious as the going o’er."

This post was authored by James Fasules, MD, FACC, Senior Vice President of Advocacy.

E-prescribing has been shown to improve safety and convenience for patients and clinicians, while also saving clinicians and pharmacists time and money. In an effort to encourage e-prescribing use, the Centers for Medicare and Medicaid Services in 2009 launched the E-Prescribing Incentive Program. As part of the program, providers that met the program criteria are able to earn an incentive payment on top of their Medicare Part B earnings.

Three years later, the program is still moving forward. Providers who e-prescribe 25 times between Jan. 1 and Dec. 31, 2012 will receive a one percent bonus – a definite incentive in this time of declining reimbursement. (Other restrictions apply and can be found here.) The newest addition, however, is that all eligible providers not participating in the program are subject to gradually increasing penalties. While it’s too late to avoid the 2012 penalty, there is still time to avoid the 1.5 percent penalty for 2013 … although the June 30 deadline is fast approaching.

According to CMS, individual eligible professionals and group practices can avoid the penalty by meeting the following six-month reporting requirements between now and the end of June:

• Individual eligible professionals: 10 e-prescribing events via claims
• Small e-prescribing group using the group practice reporting option (GPRO): 625 e-prescribing events via claims
• Large e-prescribing group using the GPRO: 2,500 e-prescribing events via claims

More information is also available here.

In addition, individual eligible professionals and group practices can also avoid the penalty by filing for a significant hardship exemption. Hardships exemptions are available to providers who are unable to electronically prescribe due to local, state, or federal law or regulation; have or will prescribe fewer than 100 prescriptions during a six-month reporting period (Jan. 1 – June 30); practice in a rural area without sufficient high-speed Internet access; or practice in an area without sufficient available pharmacies for e-prescribing. Hardship exemptions must be submitted through the Quality Reporting Communication Support Page no later than June 30. These requests are granted on a case-by-case basis and all decisions are final. Given the issues experienced last year by providers trying to request exemptions via the website, CMS has developed two documents outlining how to navigate the support page (Quality Reporting Communication Support Page User Guide and Tips for Using the Quality Reporting Communication Support Page). The College urges members not to wait until the deadline to file for an exemption!

For more information on health IT visit CardioSource.org/HealthIT.

That great, growling engine of change – technology – Alvin Toffler, Future Shock, 1970. (Harper, S&S)

The ACC this week submitted its comments to the Centers for Medicare and Medicaid Services (CMS) on its proposal for the second stage of the Electronic Health Record (EHR) Incentive Program. EHR adoption and meaningful use of these technologies is not an easy feat given the constant development of new technologies and the many challenges associated with true interoperability across different platforms. CMS and the Office of the National Coordinator (ONC) for Health IT have definitely undertaken a herculean task. The College’s comments outline the concerns with moving forward with Stage 2 without a careful analysis of Stage 1 – including the challenges associated with participation, as well as the positive results. To quote our comment letter: “We are concerned that the sum total of the requirements contained within this proposal seek to change behavior too rapidly without enough appreciation for the potential consequences.” We will be continuing to work closely with both CMS and ONC to refine requirements in a way that helps, rather than hinders, participation by cardiovascular specialists. (Read the ACC’s summary of Stage 2 requirements).

Meanwhile we are still in the first stage of the EHR Incentive Program, which is good news. However, this year marks the last year for physicians interested in participating to receive the maximum benefit of program participation. Physicians can earn up to $44,000 over five years if they meet the program requirements and begin participating in 2011 or 2012. First-year participants must only comply with the program’s requirements for 90 days, which means interested parties (not already participating) have until Oct. 1 to comply. (Check out this helpful guide from CMS).

We have also partnered with the Managed Care Advisory Group (MCAG) to help members receive incentive payments under program. MCAG uses a dashboard to track physician progress in meeting the Meaningful Use requirements and help identify problem areas. Once requirements are met, MCAG completes and sends the application for the incentive bonus to CMS. MCAG will be hosting a free webinar for ACC members from 1-2 p.m. on May 24, so stay tuned for more information on how to register. CMS also offers a number of resources, accessible via the College’s Health IT page, to help providers through the process themselves. The College is working with CMS to co-host a webinar later in June.

Last night the Million Hearts initiative hosted a fantastic reception in Washington, DC, that was sponsored by the ACC, along with the American Heart Association and the Association of Black Cardiologists. The event not only provided us with an opportunity to highlight our commitment to help prevent 1 million heart attacks and strokes over the next five years, but also network with other public and private stakeholders around this shared goal.

The Million Hearts initiative was launched in September to directly address heart disease and stroke – two of the leading causes of death in the U.S. – by bringing “together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country” (read a previous blog post about the initiative here). The program is jointly managed by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), with former ACC Senior Vice President for Science and Quality Janet Wright, MD, FACC, leading the charge.

During the reception, ACC CEO Jack Lewin, MD, committed the College to educating both consumers and the entire cardiac care team about the best, evidence-based strategies for reducing cardiovascular disease. In particular, we are excited about the opportunity to help monitor progress toward the goals of the campaign and provide important feedback to providers through the ACC’s PINNACLE Registry^TM.  On the consumer front, the ACC’s CardioSmart^TM National Care Initiative will play an important role in educating consumers about the “ABCS” (Aspirin for high-risk patients, Blood-pressure control, Cholesterol management, and Smoking cessation) and everyday strategies for healthy living.

These and other strategies are also highlighted in a recent letter to Health and Human Services Secretary Kathleen Sebelius. I personally am very excited about the opportunity to partner with Million Hearts on this important venture that takes an important step towards dethroning heart disease as America’s #1 killer.

For more information on the Million Hearts initiative, including partner commitments, visit the Million Hearts website. Be on the lookout for an article about Million Hearts in the Nov./Dec. issue of Cardiology Magazine. For additional CardioSmart patient fact sheets or to view the fact sheets in Spanish, visit CardioSmart.org.

The Department of Health and Human Services (HHS) yesterday launched the exciting new Million Hearts initiative aimed at preventing 1 million heart attacks and strokes over the next five years.

The public/private program, which will build on work already underway as a result of the Affordable Care Act, is focused on empowering Americans to make healthy choices such as preventing tobacco use and reducing sodium and trans fat consumption, as well as improving care for people who do need treatment by encouraging a targeted focus on aspirin, blood pressure control, cholesterol management and smoking cessation. It will be led by Thomas Frieden, MD, director of the Centers for Disease Control and Prevention, and Donald Berwick, MD, administrator for the Centers for Medicare and Medicaid Services, along with ACC’s Janet Wright, MD, FACC, who is leaving her post as ACC's SVP for Science and Quality to serve as director of the program.

“Heart disease causes one of every three American deaths and constitutes 17 percent of overall national health spending,” said HHS Secretary Kathleen Sebelius. “By enlisting partners from across the health sector, Million Hearts will create a national focus on combating heart disease.”

I, along with President-Elect William Zoghbi, MD, FACC, Vice President John Gordon Harold, MD, MACC, and Board of Trustees member William Oetgen, MD, FACC, attended the announcement to underscore our long-time commitment to the very issues being addressed by this program. The College is excited about the opportunity to support this effort through our CardioSmart national care initiative, as well as through our continued efforts to encourage the adoption and use of point-of-care tools and data registries. These tools and resources will be critical to helping providers not only provide the most appropriate care, but track patient outcomes.

ACC’s pediatric and congenital heart disease cardiologists and nurses have long been lobbying for universal screening for congenital heart disease, including the very inexpensive ‘pulse oximetry’ test for newborns. This approach to early detection of more subtle forms of congenital heart disease can prevent related serious complications and promote early diagnosis and treatment. The ACC has endorsed the recommendations of an HHS working group on pulse oximetry screening for all newborns -- something we helped become a priority for them. In September, an HHS advisory committee finally recommended that pulse ox be added to the list of screenings for 30 core conditions that HHS recommends for all newborns, but requested a special working group look into how it might be implemented. The working group’s recommendations are published in Pediatrics. Former chair of ACC’s Adult Congenital and Pediatric Cardiology (ACPC) Council Gerard Martin, MD, FACC, is one of the authors of the recommendations. Geoffrey Rosenthal, MD, FACC, also deserves special recognition in these efforts. 

Implementation of pulse ox screening helps detect the most common congenital heart defects by measuring blood oxygen levels. The recommendations state that if pulse ox detects low oxygen levels in a newborn, he or she will receive further evaluation, including first being evaluated for other conditions that might cause low oxygen levels (like infection) and would receive an ECG. A pediatric cardiologist would then interpret the ECG. The recommendations note that the biggest concern is the threat of false positives, which would expose the newborn to unnecessary testing, and perhaps unnecessary hospital transfer. As such, the recommendations include strategies to reduce false positives, such as waiting 24 hours after birth to screen and making sure the baby is alert rather than asleep when the test is administered. Following the release of the recommendations, HHS said that a “plan of action” is expected very soon. The recommendations are available online. The ACC is working with Mended Little Hearts on a CardioSource forum to discuss challenges with pulse oximetry screening – check it out here.

By David May, MD, PhD, FACC, senior physician and founder of Cardiovascular Specialists, PA, in Coppell, Texas, president of the Texas Chapter of the ACC and a member of the Board of Governors’ Steering Committee.

*****

Like a Sergio Leone western, e-prescribing (e-Rx) has been viewed by many as a dark and foreboding landscape in which physicians must have a broad, sweeping view of the electronic health care vista alternating with intimate, close-up reflections on each patient encounter. In reality, e-Rx accomplishes neither of these things perfectly. It is, however, here to stay.

The concept of e-Rx is quite simple.  The ability to submit an accurate, understandable, legible prescription without typographical mistakes from the point of care to the pharmacy is a vitally important part of any safe health care system.  Because of how important it is, the development and facilitation of the e-Rx process is one of the key elements in the overall plan for the further advancement of the electronic health infrastructure for the U.S.

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 provides the guidelines for the incentive program we now define as the e-Prescribing Incentive Program. It was implemented in 2009 as a stand-alone program in addition to the Physician Quality Reporting System (PQRS). Providers who wished to participate in the e-Rx program could but did not have to participate in the PQRS incentive program.

Two years post-implementation, where does the program stand? Let’s review the good, the bad and the ugly.

The Good
The electronic submission of a prescription from the point of care to the pharmacy reduces errors by providing accurate, dose-correct prescriptions without illegible handwriting in a timely fashion. It benefits providers and pharmacies by allowing 24-hour submission and its asynchronous communication eliminates the “phone tag” delay associated with telephone submission and the twisted, often illegible faxed-in prescription. For patients, medicines are available in a timely and expeditious fashion with accurate tracking available. In my private practice, we’ve seen fewer mistakes in prescriptions, faster turnaround time in the pharmacy, and incentive payments in 2009 and 2010 of 2% of our Medicare Part B professional reimbursement through the e-Prescribing Program.

The Bad
The implementation of e-Rx submission requires providers to alter their normal work flow and develop additional skills. In addition, the enhancing and maintaining staff training is mandatory. For example, in my practice, the nurses are responsible for making sure the prescriptions make it to the right pharmacy for the patient. We had to devote a lot of resources to training to make sure this happens for every prescription. With a little creativity though, we were able to make this a more enjoyable experience by implementing the training as a game.

In addition, e-Rx requires great attention to detail, in that if your Internet access is not reliable, electronic submission can be problematic. Due diligence is necessary to be certain that submission has “gone through” successfully, and this is a departure from handing a patient a prescription and being done with it.

The Ugly
Like the PQRS incentive program, e-Rx incentive “carrot” is rapidly changing to an incentive “stick.” The 2012 payment adjustment reporting period is Jan. 1 to June 30, 2011. Practices that have not submitted 10 e-Rx submissions per provider by June 30, 2011, will be penalized 1% of their Medicare professional fee reimbursement for 2012. In addition, registry submission of the e-Rx information is not allowed for this time frame. The e-Rx information must be submitted by claim with the appropriate G code and evaluation and management code.

The E-Prescribing Program may not be perfect, but unlike a Sergio Leone western, it’s a reality. In order to avoid a one percent (1%) decrease in the covered professional Medicare reimbursement for 2012, you must be e-prescribing before June 30 of this year. See www.cardiosource.org/HealthIT for more resources to get started.

Did you know experts estimate that there are at least 1.5 million adverse drug events per year in the U.S.? Or that at least one-quarter of medication errors are believed to be preventable? Or that on average, hospital patients are subject to at least one medication error per day? Or that, at their most conservative estimates, experts projected 530,000 preventable adverse drug events among outpatient Medicare patients alone in 2003, excluding direct patient contact? These statistics from the 2006 Institute of Medicine (IOM) report, entitled, Preventing Medication Errors: Quality Chasm Series, highlight the grave need to reduce preventable medication errors and adverse drug events.

We’ve known medication errors to be a problem since at least the publication of the IOM report five years ago. In fact, some of the data cited in the IOM report are from studies published as early as 1995. So why are we still struggling to adopt proven methods of reducing these preventable harms?

One of these proven methods that reduces medication errors is e-prescribing. Congress has attempted to incentivize practitioners to adopt e-prescribing as part of the Medicare Improvements for Patients and Providers Act of 2008. For those who used e-prescribing systems to generate and transmit electronic prescriptions in 2009 and 2010, there was a 2 percent bonus for Medicare providers. Not a lot of money to be sure, but enough to more than justify the expense of an e-prescribing system. The bonus begins to phase out in 2011, so those who e-prescribe in 2011 will receive a 1 percent incentive payment. Less money than before, but still more than enough to cover the cost of an e-prescribing system.

So if 1 and 2 percent bonus payments aren’t enough to incentivize clinicians, what will be? How about an upcoming 1 percent Medicare penalty in 2012 for those who do not e-prescribe. Yes, if you are not e-prescribing in 2012, your Medicare payments for an entire year will be docked 1 percent. It’s fairly simple to qualify: clinicians must generate and transmit at least 10 e-prescriptions at the time of an office visit. However, the kicker is you must do this before June 30, 2011. June 30th is very, very soon, so it’s important you get started right away if you don’t want to be subject to the Medicare penalty.

For those of you who do not yet have an e-prescribing system in your office, I encourage you to visit www.cardiosource.org/healthit for recommendations on what to look for in an e-prescribing system and other resources available to ACC members. For those of you who do have an e-prescribing system in your office but are unfamiliar with the Medicare E-Prescribing Incentive Program, you will also find resources on www.cardiosource.org/healthit. Also, I encourage you to check back here on the ACC in Touch blog for the next 5 weeks to hear more about e-prescribing from the perspectives of our colleagues practicing in a variety of settings.

The ACC wants to hear from you about e-prescribing! Are you participating in the program? If so, what do you think of it?

I was excited to be asked to attend to an invitation-only CMS meeting on Thursday of 25 leaders and CEOs of a few health constituencies with federal officials to discuss the potential of using registries and clinical data to improve care and lower costs (at long last). The gathering was co-chaired by CMS Administrator Don Berwick and Harvard Business School economist and health policy strategist Michael Porter. Berwick asked me to make some opening statements, and I presented the ACC experience and vision for NCDR, PINNACLE, and registries in general. What an opportunity! The few people invited were those he felt had influenced him along the way on the importance of using registries to achieve the triple aim (improving health care, improving health, lowering costs). It was a very good conversation.

Michael Porter discussed his research on registries in other parts of the world, and what they are accomplishing when done right. He noted that wherever he looks, that registries -- even voluntary ones -- improve outcomes, and this leads to improved clinical care models and lower costs. His data from Sweden is compelling. Interesting that this week’s JAMA highlights Sweden’s registry-produced data demonstrating the clear association between adoption of evidence-based guidelines and improved survival for ST-elevation myocardial infarction. We need more research of this kind here.  The guidelines are valuable -- along with clinical judgment.

Berwick may have been steering this conversation toward opening the doors to more federal support for registries and clinical data. The Office of the National Coordinator for Health IT is definitely on board, too. Farzad Mostashari (its head) is a big supporter of ACC and STS as well.

So what was the bottom line here?  Progress was made; but believe me there’s more convincing to do. More federal officials and agencies apparently see the value and necessity here of getting clinical data, adherence to guidelines (or routine comments as to why not), and routine feedback on performance to doctors and hospitals. The final agreement was to have follow-up calls, and to explore how to fund some diffusion of registries through the CMMI (CMS Innovation Center) and AHRQ.

We at ACC and STS need to assure that the follow through on our part will occur. We've been lobbying for registry awareness for far too long. 

The Centers for Medicare & Medicaid Services (CMS) last week issued a report that highlights significant trends in the growth of two “pay-for-reporting" programs: the ePrescribing Incentive Program and Physician Quality Reporting System (PQRS...formerly known as the Physician Quality Reporting Initiative or PQRI). According to the report, 2009 Physician Quality Reporting System and ePrescribing Experience Report, 119,804 physicians/eligible professionals in 12,647 practices received incentive payments under PQRS totaling more than $234 million—well above the $36 million paid in 2007, the first year of the program. Under the ePrescribing Program, CMS paid $148 million to 48,354 physicians/eligible professionals in 2009. Results show that participation in PQRS has grown at about 50 percent every year, on average, since the program began.

On average, 2009 bonus payments for satisfactory reporters in PQRS were $1,956 per eligible professional, but $18,525 per practice that participated. Eligible professionals received even more from the ePrescribing Program in 2009: the average bonus payment was just over $3,000 per eligible professional and $14,501 per practice.

The report also shows health care professionals report complying more often with evidence-based care practices. Based on reported data on the 55 measures that have been a part of the PQRI/PQRS program since it began in 2007, providers have improved the frequency for which they deliver recommended care by about 3.1 percent on average. Similarly, of the 99 measures that were part of the System in 2008 and 2009, performance improved at about 10.6 percent on average. In some cases, gains have been even more dramatic. More about the report is available on the CMS website.

The incentives are still trivially small to really move the system. At least our PINNACLE Registry users got fully reimbursed with no hassles through the PQRS program. For 2009, 172 providers from 14 practices used the PINNACLE Registry to report --100% successfully--with an average payment of $8,352 per provider. But the CMS incentives need to be made much more significant if we want these programs to work and to significantly improve quality systematically.