Today the Bipartisan Policy Center’s Task Force on Delivery System Reform and Health Information Technology (IT) released an important report, Transforming Health Care: The Role of Health IT, which outlines recommendations for the most effective use of health IT to achieve the triple aim through new models of care delivery and payment reform. I am a member of the task force – we’ve been working on this plan for over a year.

Following the authorization of up to $30 billion to support health IT under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the report was created to identify real-world examples and best practices that facilitate coordinated, accountable and patient-centered care; and to make recommendations for ensuring that current health IT efforts support delivery system and payment models shown to improve quality and reduce costs in health care, in ways that best utilize scarce public and private resources.

I joined the Bipartisan Policy Center’s co-chairs, former Senators Tom Daschle (D-S.D.) and Bill Frist, MD (R-Tenn.), and former Governors Ted Strickland and John Engler, at a policy briefing featuring prominent leaders in the field to release the report and discuss how to make it happen.

The report identifies key gaps and barriers to achieving widespread adoption of health IT, including: misaligned incentives; a lack of health information exchange; limited level of consumer engagement using electronic tools; limited levels of Electronic Health Record (EHR) adoption; privacy and security concerns; and multiple federal priorities that all require focus and attention.

The task force also identified several goals and recommendations to overcome these barriers including: aligning incentives and payment with higher quality, more cost-effective health care, accelerating health information exchange efforts, accelerating and supporting engagement of consumers using electronic tools, expanding education and implementation assistance, addressing concerns about privacy and security, and further aligning federal health care and health IT programs. Incidentally, the task force has had a kind of brilliant idea on how to get beyond the unique patient identifier controversy – which is politically stalled. We suggest developing “patient tracking” systems to manage patients securely over the continuum.

After the press event was over I had lunch with Daschle, Frist, Strickland, and Engler to talk further about implementation ideas and how the ACC can help move this. The good news is most of the field of cardiology and the ACC with its quality tools and programs are already working to implement most of these recommendations, but as the health care landscape changes and the cost of health care increases, it is important now more than ever to adopt new models of care delivery.

For more information, visit www.CardioSource.org/HealthIT.

KevinMD had a great guest post recently by Mary Pat Whaley on the time associated with a patient visit. I think the title sums up the blog well: “Your 10-Minute Office Visit Needs 8 People and 45 Minutes of Work.”

As Whaley notes, even the shortest of office visits have a lot of work behind-the-scenes that needs to be done; seeing the patient is just a small part of the overall visit.  And, I would submit that far more than 8 people and much more than 45 minutes is required.   Health care is a regulation- and administration-heavy field, and this requires time to make sure the regulatory and administrative rules are followed. For example, HIPAA requires privacy forms to be filled out prior to the patient being seen. Verifying someone’s insurance information is time-intensive. Not to mention ensuring that we charge the patient the right co-pay based on their insurer and insurance plan. On top of that, pay-for-performance programs require time- and technology-intensive data collection during and after the visit. All of this, and more, makes up one “10-minute office visit.”

Whaley concludes: “The practice, the patients and the overseers of health care want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.”

I have to agree with her. The complexity of the American health care system is incredible. And, the layers of complexity account for much of the cost. Our system has been built by accretion.  We “reform” the system by adding on layers of regulation, of bureaucracy, of administration.  As you look behind the eight people figured in this visit, the cost if not the time includes coders, compliance workers, claims specialists, re-claim specialists, computer network and now electronic health record experts,  lawyers, front office personnel, and even standard maintenance personnel for the  building.

As the regulation and administrative burdens add on, the cost of practicing gets greater and it is harder to cover these expenses with income.  Add to that more and more cuts to cardiology, and it’s no wonder that a large number of private cardiology practices are integrating with hospitals. Last year, the ACC reported the results of a survey of ACC members that found nearly 40 percent of private group practices were currently integrating with hospitals or merging with other practices. An additional 13 percent of all cardiovascular practices were considering hospital integration or a merger in the next three years to help stem the financial burden.

These are uncertain times for cardiology and for the House of Medicine in general.  To be clear, the ACC supports the triple aim of better health, better health care, and at less cost. But to get there, we will have to deal with the repercussions of massive changes, and may I say probably the accretion of more layers, to our health care system. In my opinion, “dealing” with the repercussions will not be enough – we need to shape the discussions if we want to be pleased with the health care system structure of the future.  And, maybe we can even help peal away some of the layers.

Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule on e-Prescribing last week. The final rule establishes the requirements for successful reporting of the e-prescribing measure, while also finalizing additional hardship exemptions for avoiding the 2012 e-prescribing penalty that begins on Jan. 1, 2012.

The ACC, along with the AMA and others, have had significant concerns regarding the implementation of the 2012 penalty and have urged CMS to reconsider the details and timing and to thoroughly consider the effects of this position on specialists such as cardiologists. Although the final rule does not extend the reporting time, it makes it easier for physicians to be eligible for hardship exemptions and addresses many of the concerns the ACC raised.

Under the rule, final hardship exemption categories for eligible physicians are as follows:

• Practitioners who have registered to participate in the Medicare or Medicaid EHR Incentive Program and have adopted certified EHR technology.
• Practitioners who are unable to e-prescribe due to local, state or federal law or regulation. (This proposed exemption is designed to address practitioners who primarily prescribe controlled substances.)
• Practitioners who infrequently prescribe. (For 2012, this means a practitioner must not have had the opportunity to e-prescribe at least 10 times between January and the end of June 2011.)
• Practitioners who provide services that are not included in the e-prescribing measures (e.g. does not provide office visits).
• Practitioners with practices located in rural areas without high-speed Internet access.
• Practitioners with a practice located in an area without sufficient available pharmacies for e-prescribing. (This includes natural disaster-caused disruptions.)
  

The ESC Congress for the first time is having two sessions dedicated to clinical registries in order to highlight the growing number of innovative registries, the data they collect and the conclusions that can be drawn from this data. The sessions focus on “Risk and Treatment Reality” and “Interventions and Devices” and showcase registries from France, Italy and more.

The prominent treatment of the registry data trials at ESC Congress 2011 is a testament to their growing importance. Registry research is unique because it uses real-world data. The patients included in the registry are not chosen because they have limited comorbidities or fit a certain profile, like in clinical trials, but are included simply because they are a patient at a participating hospital. What this means is that we can see what the effects of certain treatments are on patients who may never qualify for a clinical trial. The results are a better understanding of adverse outcomes and better treatment protocols. The ACC frequently requests for FDA to require new drug and device manufacturers to conduct post-market approval studies through registries to ensure that the new drug/device doesn’t have any adverse events not caught in the clinical trials.

Of course, that’s not to say that registries aren’t without limitations. Currently, it’s challenging to connect care between the outpatient and inpatient settings because the U.S. will not implement a unique patient identifier system that could connect a patient’s progress in the hospital to the ambulatory setting and, in some cases, back to the hospital. We’ll need to find a way to work around this. With the growing emphasis on reducing readmissions, hospitals will need to have a better understanding of why and which types of patients are most frequently readmitted. Registries should be able to help fill this gap.

ACC’s registries suite, NCDR (National Cardiovascular Data Registry), has experienced a landmark year in terms of the science researchers have produced. The following studies have been some of the most interesting:

1. Non–Evidence-Based ICD Implantations in the United States (JAMA, 305;1). Researchers found that ICD implantations were not in accordance with practice guidelines in 20+% of patients, most commonly because of newly diagnosed heart failure or an MI within 40 days.
   
   
2. Patterns and Intensity of Medical Therapy in Patients Undergoing PCI (JAMA, 305;18). The authors conclude that optimal medical therapy is underutilized in patients with stable CAD.
   
   
3. Association of Door-In to Door-Out Time with Reperfusion Delays and Outcomes Among Patients for Primary PCI (JAMA, 305;24). Study showing improvement is needed in the treatment of heart attack patients who require transfer to another hospital for primary PCI).
   
   
4. Appropriateness of Percutaneous Coronary Intervention (JAMA, 306;1): This study concluded that although the majority of patients are appropriately selected for PCI procedures, there are opportunities for improvement, especially in the non-emergency setting.
   
   
5. Hospital Variability in the Rate of Finding Obstructive Coronary Artery Disease at Elective, Diagnostic Coronary Angiography (JACC, 58;8). Former ACC Prez Pam Douglas, MACC, et al., find that hospitals vary greatly when it comes to the rate at which obstructive CAD is found in patients without known heart disease undergoing elective diagnostic coronary angiography or catheterization.

These are just five of the hundreds of studies using NCDR data that have been published over the registries’ 14-year history. We may not always like what the studies find, but it’s the measurement that pushes cardiology as a profession to move forward and to find ways to more consistently implement best practices and guidelines. By measuring patient care in an appropriate and actionable way, registries bring to light the invaluable improvements being made by physicians and care teams.

I commend ESC for bringing registry data to the forefront of their meeting. I think we’ll see more and more about registry data in the future, as it addresses some of the gaps left by clinical trial data.

This post is written by Denise Milestone, RN, of Parkview Health in Fort Wayne, Ind.

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In the last two years that e-prescribing has been used in my health system, Parkview Health in Fort Wayne, Ind., we’ve seen some major benefits, as well as overcome some challenges. The implementation process at Parkview was fairly straightforward. We started with a small group of physicians and nurses who were required to e-prescribe, and then we slowly added more practitioners to this group. We put out statistics on who was e-prescribing and how much and shared that with staff, so that physicians and nurses could see how they were doing compared to their peers. This did a lot to encourage adoption. Our staff seemed to pick it up most easily if they were younger and more computer savvy, but it was pretty simple for everyone to adopt. I would say it took about a month or two for everyone to get the hang of it.

I see the top three benefits of e-prescribing at Parkview as the following:

#3: E-prescribing cuts down on Parkview’s faxes and phone calls, both for the original prescription and for e-refills. We save on a lot of paper.

#2: Younger patients love it. It’s very convenient for them and they like not having to keep track of the prescription paper. But, it does seem like older patients miss having paper prescriptions and aren’t as comfortable with the idea of e-prescribing. We really have to educate not only the physicians and Parkview staff, but also the patients on the benefits of e-prescribing.

#1: Patient safety has improved. Not only is legibility addressed, but pharmacies are able to see in the system what drugs a patient is being prescribed and can make sure there aren’t any adverse events.

This is not to say e-prescribing is without challenges. In particular, we’ve had trouble adjusting prescriptions that start at one dose (like prescribing a patient a 20mg tablet twice/day) but then after a set period of time increase (like to a 40mg tablet once/day). Previously we have noted this clearly in the prescription area. Now, we have to add a comment in the notes section with instructions for the pharmacist, which occasionally causes confusion.

Also, because not all pharmacies are able to accept e-prescribing, there still some manual work that has to happen. Fortunately, our e-prescribing system knows which pharmacies cannot accept e-prescribing and will then revert to the old-fashioned way of faxing the prescription. This has definitely improved over the two years we’ve been e-prescribing -- more pharmacies than ever accept e-prescribing -- but there are still some that do not. It gets easier each year to e-prescribe.

Overall, the e-prescribing process was very easy to implement and its benefits have outweighed the minimal downsides we’ve experienced. We’re extremely happy e-prescribing, and so are our patients.

Has anyone else experienced the challenge with noting the dosages? How have you addressed?

But most likely you still won’t be, even though the Centers for Medicare and Medicaid Services (CMS) last week released a proposal that would add new hardship exemptions to the program. The proposal would exempt some practitioners from the 2012 Medicare penalty that will be levied against those who are not e-prescribing by June 30. The proposal would create new categories for hardship exemptions, making the total list of exemptions as follows:

• Individual practices in rural areas without high speed internet access
• Individual practices in areas without sufficient available pharmacies for electronic prescribing
• Practitioners who have registered to participate in the Medicare or Medicaid EHR Incentive Program and have adopted certified EHR technology
• Practitioners who are unable to electronically prescribe due to local, state, or federal law or regulation. (This proposed exemption is designed to address practitioners who prescribe controlled substances.)
• Practitioners who infrequently prescribe. (For 2012, this means a practitioner must not have had the opportunity to e-prescribe at least 10 times between January and the end of June 2011 in order to qualify for the exemption.)
• Practitioners who have had insufficient opportunities to report the e-prescribing measure due to program limitations

Under the proposal, practitioners would have until Oct. 1 to claim a hardship exemption. This new proposal comes after months of pressure from the ACC, AMA and other physician organizations. The College will be commenting on the proposal, particularly on the provisions of the e-prescribing program the new proposal does not address, such as the June 30 deadline and the narrowness of the proposed infrequent prescriber exemption.

In sum, while this is good news for some providers who qualify under the new hardship exemptions, most are still going to need to demonstrate that they are e-prescribing by June 30 to miss getting a 1% penalty in their Medicare payments.

More detailed information is posted at CardioSource.org/healthIT.

As part of ACC’s ongoing series on e-prescribing, ACC staff interviewed South Denver Cardiology CEO Brenda Lambert, RN, AACC, and Amy Hurley, RN, Director of Clinical Services at South Denver, about their experiences with e-prescribing and how it has affected their practice. The deadline to demonstrate successful e-prescribing under the Medicare E-Prescribing Incentive Program is June 30, 2011. Health care providers who cannot demonstrate successful e-prescribing by June 30 will have their 2012 Medicare payments penalized by 1 percent.

1.      What does e-prescribing mean to you? What are some of the benefits you’ve seen?

Lambert: We embraced e-prescribing as soon as we could with our electronic medical record (EMR) system. It’s been up for a year and was quite easy to do. So for us it was an easy implementation.

Some important things it’s meant to us: We always had a difficult time when patient called in for a prescription to make sure they had been seen in our office in the past year. We now know when their last visit was and if we can go ahead and e-prescribe or need to have them make an appointment.  If a patient or pharmacy contacts us we know if they’ve been seen all in the matter of less than a minute. We’ve increased efficiency and maximized patient care.

It has also help with legibility – I’ve personally experienced poor signatures or poor writing and the pharmacy would have to call back and double check what the prescription says. With e-prescribing it does improve patient safety as well.

We’d like to see a bidirectional piece added where we can see if the patient hasn’t picked up the prescription yet so we can do some follow-up, but that’s not in place at this time.

Hurley: It is also very convenient for the patient; if they’re in the office their prescriptions are ready for them at the pharmacy by the time they get there. Also, there’s a large database in our e-prescribing system that allows us to have access to all of the pharmacies in our area, so if the patient doesn’t know the information, we have it.

2.      Are there any downsides? What challenges have you had to overcome to implement e-prescribing?

Lambert:  More on our EMR side, there are times when meds aren’t used as much as others and you have to tweak dosages but it’s just a matter of identifying that and having it changed. Just like any system there are things that have to be improved.

We have had some problems for in-person pharmacy pick-up in terms of liability for payment. For example, if we e-prescribe to Walgreens and the patient decides between here and there they don’t want the medication, then that’s the end of it – they haven’t paid anything.

With mail in, once we click that button, the patient is liable for paying for the meds and can’t return it. Because of e-prescribing we’ve had multiple problems with patients saying they don’t want to take the medication anymore and wondering who will pay for what was delivered. We tell them they do.

3.      Are there any stories or reasons why e-prescribing has worked for you and your practice?

Lambert: There are many comments from patients saying how nice it is that they don’t have to wait at the pharmacy when they get there: once they arrive, the prescription is there and it’s correct. It’s been a huge patient-pleaser. It’s funny how you get used to it – I went to the doctor and he didn’t e-prescribe and I was surprised. I thought our physicians would resist, but it went as smooth as silk. Our physicians took to it immediately.  

Hurley: It’s a lot more efficient and more organized and cuts down on paper. We all know patients who lose a piece of paper no matter what it is – this is a slick, efficient way of doing things.

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Resources are available at cardiosource.org/HealthIT to help ACC members learn more about e-prescribing.  

Past ACC President Ralph Brindis, MACC, et al., was published in BMJ recently on the need for international collaboration in device clinical standards. Brindis and the other authors discuss differences in the stringency of the approval process between Europe and other parts of the world and stress that patients around the world should be protected by similar requirements for device safety. The authors discuss the recommendations of the Global Harmonization Task Force, which includes representatives of regulatory agencies in Europe, North American, Japan and Australia, to promote common principles for evaluating devices. The authors write:

"…it would be inappropriate for higher levels of evidence to be required in Europe and North American than in parts of Africa and Asia. There should be no ‘region of least resistance’ where devices could be approved more rapidly and on the basis of less evidence. Rather, efforts should be concentrated on developing a global approach. For each type of high risk device, this should include a specific determination of how safe is ‘safe enough’ relative to its therapeutic benefit."

Their recommendations make sense, although I think it might be difficult to implement in reality. Additionally, I would argue that the U.S. process is too burdensome, and we could stand to learn something from Europe. However, any loosening in pre-market requirements must be made up by post-market surveillance, which we do poorly now. We can use the ACC’s NCDR and other registries to uplevel post-market surveillance, accelerate speed of products to market, and improve the safety profile of such products. This is promoting innovation -- it’s heading offshore unless we get more proactive here.

Thirty-four percent of all office-based prescribers were using e-prescribing by the end of 2010. Cardiologists had the highest adoption rates (49%) followed by family physicians (47%). Providers created 326 million e-prescriptions in 2010, up from 190 million in 2009. Wow!

If 49% of cardiologists ARE e-prescribing, that means that 51% still AREN’T e-prescribing. Since we’re just a month and a half away from providers being penalized for not e-prescribing, this is not good. If you aren’t e-prescribing by June 30, your Medicare professional fee reimbursements will be cut by 1% in 2012. This requirement applies to ALL health providers participating in Medicare who are eligible for billing numbers: physicians, nurse practitioners, physician assistants, etc.

There’s still time to get an e-prescribing system set up and complete the requisite number of e-prescriptions before the deadline. Check out http://www.cardiosource.org/healthIT for more resources on how to get started. Also, check out the other posts on this blog about e-prescribing. This deadline is real and quickly approaching. If you don’t want to take the 1% cut in pay, you’ll need to get started now.

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.

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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.